Chronic Ankle Pain

Variant: 1 Chronic ankle pain. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography ankle	Usually Appropriate	☢
US ankle	Usually Not Appropriate	O
MRI ankle without and with IV contrast	Usually Not Appropriate	O
MRI ankle without IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
CT ankle without IV contrast	Usually Not Appropriate	☢
Bone scan ankle	Usually Not Appropriate	☢☢☢

Variant: 2 Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
Image-guided anesthetic injection ankle and hindfoot	May Be Appropriate	Varies
MRI ankle and hindfoot without IV contrast	May Be Appropriate	O
CT ankle and hindfoot without IV contrast	May Be Appropriate	☢
US ankle and hindfoot	Usually Not Appropriate	O
Radiographic arthrography ankle and hindfoot	Usually Not Appropriate	☢
MR arthrography ankle and hindfoot	Usually Not Appropriate	O
MRI ankle and hindfoot without and with IV contrast	Usually Not Appropriate	O
CT ankle and hindfoot with IV contrast	Usually Not Appropriate	☢
CT ankle and hindfoot without and with IV contrast	Usually Not Appropriate	☢
CT arthrography ankle and hindfoot	Usually Not Appropriate	☢
Bone scan hindfoot/ankle	Usually Not Appropriate	☢☢☢

Variant: 3 Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI ankle without IV contrast	Usually Appropriate	O
MR arthrography ankle	May Be Appropriate	O
CT ankle without IV contrast	May Be Appropriate	☢
CT arthrography ankle	May Be Appropriate	☢
Bone scan with SPECT or SPECT/CT ankle	May Be Appropriate (Disagreement)	☢☢☢
US ankle	Usually Not Appropriate	O
Radiographic arthrography ankle	Usually Not Appropriate	☢
Radiography ankle stress views	Usually Not Appropriate	☢
Image-guided anesthetic injection ankle	Usually Not Appropriate	Varies
MRI ankle without and with IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢

Variant: 4 Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
US ankle	Usually Appropriate	O
MRI ankle without IV contrast	Usually Appropriate	O
US-guided anesthetic injection ankle tendon sheath	May Be Appropriate	O
Fluoroscopy tenography ankle	Usually Not Appropriate	☢
Radiographic arthrography ankle	Usually Not Appropriate	☢
Radiography ankle stress views	Usually Not Appropriate	☢
MR arthrography ankle	Usually Not Appropriate	O
MRI ankle without and with IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
CT ankle without IV contrast	Usually Not Appropriate	☢
CT arthrography ankle	Usually Not Appropriate	☢
Bone scan ankle	Usually Not Appropriate	☢☢☢

Variant: 5 Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MR arthrography ankle	Usually Appropriate	O
MRI ankle without IV contrast	Usually Appropriate	O
US ankle	May Be Appropriate	O
Radiography ankle stress views	May Be Appropriate	☢
CT arthrography ankle	May Be Appropriate	☢
Radiographic arthrography ankle	Usually Not Appropriate	☢
Image-guided anesthetic injection ankle	Usually Not Appropriate	Varies
MRI ankle without and with IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
CT ankle without IV contrast	Usually Not Appropriate	☢
Bone scan ankle	Usually Not Appropriate	☢☢☢

Variant: 6 Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI ankle without IV contrast	Usually Appropriate	O
US ankle	May Be Appropriate	O
Image-guided anesthetic injection ankle	May Be Appropriate (Disagreement)	Varies
MR arthrography ankle	May Be Appropriate	O
CT ankle without IV contrast	May Be Appropriate	☢
CT arthrography ankle	May Be Appropriate	☢
Radiographic arthrography ankle	Usually Not Appropriate	☢
Radiography ankle stress views	Usually Not Appropriate	☢
MRI ankle without and with IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
3-phase bone scan with SPECT or SPECT/CT ankle	Usually Not Appropriate	☢☢☢

Variant: 7 Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI ankle without IV contrast	Usually Appropriate	O
US ankle	May Be Appropriate	O
Image-guided anesthetic injection ankle	May Be Appropriate	Varies
CT ankle without IV contrast	May Be Appropriate	☢
Bone scan with SPECT or SPECT/CT ankle	May Be Appropriate (Disagreement)	☢☢☢
Radiographic arthrography ankle	Usually Not Appropriate	☢
Radiography ankle stress views	Usually Not Appropriate	☢
MR arthrography ankle	Usually Not Appropriate	O
MRI ankle without and with IV contrast	Usually Not Appropriate	O
CT ankle with IV contrast	Usually Not Appropriate	☢
CT ankle without and with IV contrast	Usually Not Appropriate	☢
CT arthrography ankle	Usually Not Appropriate	☢

Panel Members

Eric Y. Chang, MD^a; Anthony S. Tadros, MD^b; Behrang Amini, MD, PhD^c; Angela M. Bell, MD^d; Stephanie A. Bernard, MD^e; Michael G. Fox, MD, MBA^f; Tetyana Gorbachova, MD^g; Alice S. Ha, MD^h; Kenneth S. Lee, MD, MBAⁱ; Darlene F. Metter, MD^j; Pekka A. Mooar, MD^k; Nehal A. Shah, MD^l; Adam D. Singer, MD^m; Stacy E. Smith, MDⁿ; Mihra S. Taljanovic, MD^o; Ralf Thiele, MD^p; Mark J. Kransdorf, MD^q.

Summary of Literature Review

Introduction/Background

Overview of Imaging Modalities

Discussion of Procedures by Variant

Variant 1: Chronic ankle pain. Initial imaging.

Variant 1: Chronic ankle pain. Initial imaging.
A. Radiography

Variant 1: Chronic ankle pain. Initial imaging.
B. CT

Variant 1: Chronic ankle pain. Initial imaging.
C. MRI

Variant 1: Chronic ankle pain. Initial imaging.
D. US

Variant 1: Chronic ankle pain. Initial imaging.
E. Bone Scan

Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.

Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.
A. Image-guided Anesthetic Injection

Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.
B. MRI

Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.
C. CT

Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.
D. US

Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.
E. Bone Scan

Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.
F. Arthrography

Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.
G. MR Arthrography

Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study.
H. CT Arthrography

Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.

Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
A. MRI

Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
B. CT Arthrography

Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
C. MR Arthrography

Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
D. CT

Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
E. Bone Scan with SPECT or SPECT/CT

Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
F. US

Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
G. Radiography

Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
H. Arthrography

Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study.
I. Image-guided Anesthetic Injection

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
A. US

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
B. MRI

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
C. Image-guided Anesthetic Injection

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
D. Tenography

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
E. CT

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
F. Bone Scan

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
G. CT Arthrography

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
H. MR Arthrography

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
I. Arthrography

Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study.
J. Radiography

Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.

Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
A. MRI

Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
B. MR Arthrography

Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
C. US

Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
D. Radiography

Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
E. CT Arthrography

Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
F. CT

Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
G. Arthrography

Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
H. Image-guided Anesthetic Injection

Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study.
I. Bone Scan

Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.

Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
A. MR Arthrography

Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
B. US

Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
C. MRI

Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
D. CT Arthrography

Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
E. Image-guided Anesthetic Injection

Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
F. Bone Scan with SPECT or SPECT/CT

Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
G. CT

Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
H. Arthrography

Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study.
I. Radiography

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
A. MRI

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
B. US

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
C. CT

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
D. Bone Scan with SPECT or SPECT/CT

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
E. Arthrography

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
F. CT Arthrography

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
G. MR Arthrography

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
H. Image-guided Anesthetic Injection

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
I. Radiography

Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study.
J. Other Causes of Chronic Ankle Pain

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.