American College of Radiology
ACR Appropriateness Criteria®

Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae

Variant 1: Suspected stress (fatigue) fracture, excluding vertebrae. First imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Varies Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body with SPECT area of interest Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Suspected stress (fatigue) fracture, hip. Negative radiographs. 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 IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body with SPECT hip May be appropriate ☢☢☢ 1-10 mSv 6 n/a 0 0 0 0 0 0 0 0 0
CT hip without IV contrast May be appropriate ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
Radiography hip repeat in 10-14 days May be appropriate ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
MRI hip without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT hip without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT hip with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US hip Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Suspected stress (fatigue) fracture, excluding hip and vertebrae. Negative radiographs. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest repeat in 10-14 days Usually appropriate Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body with SPECT area of interest May be appropriate ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Suspected stress (fatigue) fracture, excluding vertebrae. Negative radiographs. Immediate “need-to-know” diagnosis. 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 area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body with SPECT area of interest May be appropriate ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Radiography area of interest Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Confirmed stress (fatigue) fracture, excluding vertebrae. Follow-up imaging study for “return-to-play” evaluation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
DXA total body composition May be appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies Varies 4 n/a 0 0 0 0 0 0 0 0 0
Radiography area of interest repeat in 10-14 days Usually not appropriate Varies Varies 3 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body with SPECT area of interest Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Suspected stress (insufficiency) fracture, pelvis or hip. First imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Varies Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body with SPECT area of interest Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Suspected stress (insufficiency) fracture, pelvis or hip. Negative radiographs. 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 area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast Usually appropriate Varies Varies Varies Varies 7 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body with SPECT area of interest May be appropriate ☢☢☢ 1-10 mSv 6 n/a 0 0 0 0 0 0 0 0 0
Radiography area of interest repeat in 10-14 days May be appropriate Varies Varies 4 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 8: Suspected stress (insufficiency) fracture of lower extremity, excluding pelvis and hip. First imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography lower extremity area of interest (not pelvis or hip) Usually appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
US lower extremity area of interest (not pelvis or hip) Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI lower extremity area of interest (not pelvis or hip) without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI lower extremity area of interest (not pelvis or hip) without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT lower extremity area of interest (not pelvis or hip) without IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT lower extremity area of interest (not pelvis or hip) without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT lower extremity area of interest (not pelvis or hip) with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body with SPECT lower extremity area of interest Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 9: Suspected stress (insufficiency) fracture of lower extremity, excluding pelvis and hip. Negative radiographs. 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 lower extremity area of interest (not pelvis or hip) without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Radiography lower extremity area of interest (not pelvis or hip) repeat in 10-14 days Usually appropriate ☢ <0.1 mSv 7 n/a 0 0 0 0 0 0 0 0 0
CT lower extremity area of interest (not pelvis or hip) without IV contrast May be appropriate Varies Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body with SPECT lower extremity area of interest May be appropriate ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
US lower extremity area of interest (not pelvis or hip) Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI lower extremity area of interest (not pelvis or hip) without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT lower extremity area of interest (not pelvis or hip) without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT lower extremity area of interest (not pelvis or hip) with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Variant 10: Follow-up imaging study for characterizing nonspecific focal uptake on Tc-99m MDP bone scintigraphy, suspected to be a stress fracture.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Varies Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast May be appropriate Varies Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies Varies 2 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 11: Suspect stress (fatigue or insufficiency) fracture, pelvis or hip or sacrum. Pregnant patient.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
Radiography area of interest May be appropriate Varies Varies Varies Varies 4 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body with SPECT area of interest Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 12: Suspect stress (fatigue or insufficiency) fracture of the long bones. Pregnant patient.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Varies Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Varies Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US area of interest Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.