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Variant 1: Chronic hip pain. Initial Imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography pelvis Usually appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 9 9 0 0 0 0 0 0 0 6 9
References Study Quality
15 (11567537) 4
14 (12578996) 4
13 (22915391) 4
12 (12783223) 3
Radiography hip Usually appropriate Limited ☢☢☢ 1-10 mSv 9 9 0 0 0 0 0 0 0 2 13
References Study Quality
15 (11567537) 4
14 (12578996) 4
13 (22915391) 4
12 (12783223) 3
US hip Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 1 1 2 0 0 0 0
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures Usually not appropriate Expert Consensus Varies Varies 1 1 14 1 0 0 0 0 0 0 0
MR arthrography hip Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 1 0 0 0 0
MRI hip without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 0 1 0 0 0 0 0
MRI hip without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 1 0 0 0 0
Bone scan hip Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 0 0 0 0 0 0 0
CT arthrography hip Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
CT hip with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 0 0 0 0 0 0 0
CT hip without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
CT hip without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 2 0 0 0 0 0 0
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 15 0 0 0 0 0 0 0 0
Variant 2: Chronic hip pain. Suspect noninfectious extra-articular abnormality, such as tendonitis or bursitis. Radiographs negative or nondiagnostic. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US hip Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 5 2 4 2 2
References Study Quality
23 (22038311) M
38 (8596860) 4
39 (21136580) 4
40 (18287424) 4
41 (21381497) 3
MRI hip without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 1 12
References Study Quality
23 (22038311) M
24 (31243547) 2
25 (16275576) 4
26 (16275579) 4
27 (16275574) 4
28 (16275584) 4
29 (16275577) 4
30 (19887296) 4
31 (16275583) 4
32 (16275580) 4
33 (16275578) 4
34 (16275571) 4
35 (22403167) 2
36 (33474984) 4
37 (26102391) 3
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures May be appropriate Moderate Varies Varies 5 5 0 0 0 1 9 2 2 0 1
References Study Quality
19 (16177412) 4
20 (-3195116) 4
21 (15494331) 3
22 (23852899) 2
MR arthrography hip Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 2 0 2 1 0 0 0
MRI hip without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 1 1 3 1 0 0 0
Bone scan hip Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
CT arthrography hip Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 9 1 2 0 2 1 0 0 0
References Study Quality
16 (20716653) 3
17 (24071389) 2
18 (21298428) 2
CT hip with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 4 1 0 0 0 0 0 0
CT hip without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 2 0 0 0 0 0 0 0
CT hip without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 7 2 4 2 0 0 0 0 0
References Study Quality
18 (21298428) 2
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 1 0 0 0 0 0 0 0
Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR arthrography hip Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 3 7 5
References Study Quality
70 (16530634) 4
69 (16530635) 4
68 (17114529) 2
67 (21048174) 2
66 (20872764) 2
65 (22933489) 3
72 (31633993) 2
71 (30048144) 3
53 (31023206) 3
52 (24656977) 2
55 (24370140) 2
54 (25022979) 2
56 (20859632) M
18 (21298428) 2
16 (20716653) 3
59 (22878728) 2
58 (15800516) 2
57 (23073899) 2
60 (19455497) 3
MRI hip without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 2 8 5
References Study Quality
58 (15800516) 2
68 (17114529) 2
69 (16530635) 4
70 (16530634) 4
64 (22907475) 2
65 (22933489) 3
71 (30048144) 3
72 (31633993) 2
44 (23395032) 4
45 (22985733) 2
43 (16721954) 4
42 (16211385) 4
46 (22492172) 4
48 (25558377) 3
47 (18984718) 4
Radiography hip additional views May be appropriate Limited ☢☢ 0.1-1mSv 6 6 0 0 0 2 3 3 1 0 6
References Study Quality
47 (18984718) 4
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures May be appropriate Moderate Varies Varies 5 5 0 0 2 0 11 2 0 0 0
References Study Quality
19 (16177412) 4
20 (-3195116) 4
21 (15494331) 3
22 (23852899) 2
CT arthrography hip May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 0 1 12 2 0 0 0
References Study Quality
42 (16211385) 4
43 (16721954) 4
44 (23395032) 4
17 (24071389) 2
16 (20716653) 3
CT hip without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 1 0 1 6 3 2 1 1
References Study Quality
42 (16211385) 4
43 (16721954) 4
44 (23395032) 4
62 (8451409) 4
45 (22985733) 2
46 (22492172) 4
48 (25558377) 3
47 (18984718) 4
49 (29406341) 4
US hip Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 4 3 2 2 3 0 1 0 0
References Study Quality
17 (24071389) 2
41 (21381497) 3
39 (21136580) 4
73 (27405494) 2
MRI hip without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 8 2 5 0 0 0 0 0 0
References Study Quality
34 (16275571) 4
61 (8657921) 3
62 (8451409) 4
63 (12606867) 4
64 (22907475) 2
65 (22933489) 3
66 (20872764) 2
67 (21048174) 2
Bone scan hip Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
CT hip with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 1 1 1 0 0 0 0 0
References Study Quality
42 (16211385) 4
43 (16721954) 4
44 (23395032) 4
CT hip without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 2 1 0 0 0 0 0 0
References Study Quality
42 (16211385) 4
43 (16721954) 4
44 (23395032) 4
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 12 1 2 0 0 0 0 0 0
References Study Quality
50 (26745810) 4
51 (31470763) 4
Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR arthrography hip Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 2 11
References Study Quality
80 (19380568) 3
79 (17712555) 4
78 (11479747) 4
77 (17383908) 3
76 (10430132) 2
75 (22865251) 2
82 (16857978) 2
81 (15972331) 4
52 (24656977) 2
18 (21298428) 2
16 (20716653) 3
59 (22878728) 2
58 (15800516) 2
57 (23073899) 2
56 (20859632) M
MRI hip without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 3 6 6
References Study Quality
85 (29843749) 2
79 (17712555) 4
78 (11479747) 4
77 (17383908) 3
76 (10430132) 2
70 (16530634) 4
69 (16530635) 4
86 (16436825) 4
58 (15800516) 2
68 (17114529) 2
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures May be appropriate Moderate Varies Varies 5 5 0 0 0 2 12 1 0 0 0
References Study Quality
22 (23852899) 2
21 (15494331) 3
20 (-3195116) 4
CT arthrography hip May be appropriate Strong ☢☢☢ 1-10 mSv 6 6 0 0 0 0 6 3 4 1 1
References Study Quality
18 (21298428) 2
17 (24071389) 2
74 (30838104) 3
US hip Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 6 3 2 2 1 0 1 0 0
References Study Quality
88 (19421915) 1
87 (30203593) 3
17 (24071389) 2
41 (21381497) 3
39 (21136580) 4
MRI hip without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 2 3 0 2 0 0 0 0
References Study Quality
34 (16275571) 4
63 (12606867) 4
62 (8451409) 4
61 (8657921) 3
84 (20173149) 3
83 (25277527) 3
Bone scan hip Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
CT hip with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 3 0 1 0 0 0 0 0
CT hip without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 1 0 0 0 0 0 0
CT hip without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 1 1 0 0 0 0 0
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 15 0 0 0 0 0 0 0 0
Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR arthrography hip Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 0 0 2 3 9
References Study Quality
89 (21822939) 4
95 (26001258) 4
55 (24370140) 2
52 (24656977) 2
MRI hip without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 4 8
References Study Quality
18 (21298428) 2
85 (29843749) 2
89 (21822939) 4
98 (27325163) 4
93 (25352941) 3
91 (16037508) 1
CT arthrography hip May be appropriate Strong ☢☢☢ 1-10 mSv 6 6 0 0 0 2 2 4 2 3 2
References Study Quality
89 (21822939) 4
18 (21298428) 2
93 (25352941) 3
92 (16990027) 2
91 (16037508) 1
90 (16242374) 3
US hip Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 3 1 1 0 0 0 0 0
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures Usually not appropriate Limited Varies Varies 2 2 7 1 2 2 1 1 0 1 0
References Study Quality
94 (30415421) 4
MRI hip without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 2 4 0 0 0 0 0 0
References Study Quality
97 (26304042) 3
96 (28209142) Inadequate
Bone scan hip Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
CT hip with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 0 1 0 0 0 0 0
CT hip without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 2 0 0 0 0 0 0 0
CT hip without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 2 0 1 0 0 0 0 0
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 15 0 0 0 0 0 0 0 0
Variant 6: Chronic hip pain. Radiographs suspicious for intra-articular synovial hyperplasia or neoplasia, including nodular synovitis, diffuse tenosynovial giant cell tumor, osteochondromatosis, other synovial neoplasm. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI hip without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 0 1 1 0 2 1 4 6
MRI hip without IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 1 8 5
CT arthrography hip May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 4 4 1 1 3 4 5 0 0 0 1
US hip Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 2 1 0 0 1 0 0
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures Usually not appropriate Expert Consensus Varies Varies 1 1 14 0 1 0 0 0 0 0 0
Image-guided aspiration hip Usually not appropriate Limited Varies Varies 3 3 6 0 2 3 4 0 0 0 0
References Study Quality
100 (2383449) 4
99 (2845469) 4
MR arthrography hip Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 2 5 1 0 0 0 0 0
Bone scan hip Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 0 0 0 0 0 0 0
CT hip with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 0 2 0 0 0 0 0
CT hip without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 0 3 0 0 0 1 0 1
CT hip without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 3 3 4 3 4 2 2 0 0 0 0
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 13 0 0 1 0 0 1 0 0
Variant 7: Chronic hip pain with low back or knee pathology or pain. Radiographs demonstrate hip osteoarthritis. Want to quantify amount of pain related to the hip. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures Usually appropriate Moderate Varies Varies 9 9 0 0 0 0 2 1 0 3 9
References Study Quality
22 (23852899) 2
21 (15494331) 3
20 (-3195116) 4
19 (16177412) 4
US hip Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 1 0 1 0 0 0 0
MR arthrography hip Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 1 1 2 1 0 0 0 0
References Study Quality
13 (22915391) 4
MRI hip without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 1 0 1 1 0 0 0
MRI hip without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 2 0 0 0 0 0 0
Bone scan hip Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 0 1 1 0 0 0 0 1
CT arthrography hip Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 11 2 2 0 0 0 0 0 0
References Study Quality
18 (21298428) 2
93 (25352941) 3
92 (16990027) 2
91 (16037508) 1
90 (16242374) 3
13 (22915391) 4
CT hip with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 0 0 0 0 0 0 0
CT hip without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 0 0 0 0 0 0 0
CT hip without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 0 0 1 0 0 0
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 0 0 0 0 0 0 0 1
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.