Chronic Elbow Pain

Variant: 1 Chronic elbow pain. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography elbow	Usually Appropriate	☢
US elbow	Usually Not Appropriate	O
MR arthrography elbow	Usually Not Appropriate	O
MRI elbow without and with IV contrast	Usually Not Appropriate	O
MRI elbow without IV contrast	Usually Not Appropriate	O
CT arthrography elbow	Usually Not Appropriate	☢☢
CT elbow with IV contrast	Usually Not Appropriate	☢☢
CT elbow without and with IV contrast	Usually Not Appropriate	☢☢
CT elbow without IV contrast	Usually Not Appropriate	☢☢
3-phase bone scan elbow	Usually Not Appropriate	☢☢☢

Variant: 2 Chronic elbow pain with mechanical symptoms such as locking, clicking, or limited range of motion. Suspect intra-articular pathology such as osteocartilaginous body, osteochondral lesion, or synovial abnormality. Radiographs normal or nonspecific. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MR arthrography elbow	Usually Appropriate	O
MRI elbow without IV contrast	Usually Appropriate	O
CT arthrography elbow	Usually Appropriate	☢☢
CT elbow without IV contrast	Usually Appropriate	☢☢
US elbow	Usually Not Appropriate	O
MRI elbow without and with IV contrast	Usually Not Appropriate	O
CT elbow with IV contrast	Usually Not Appropriate	☢☢
CT elbow without and with IV contrast	Usually Not Appropriate	☢☢
3-phase bone scan elbow	Usually Not Appropriate	☢☢☢

Variant: 3 Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI elbow without IV contrast	Usually Appropriate	O
CT elbow without IV contrast	Usually Appropriate	☢☢
3-phase bone scan elbow	May Be Appropriate (Disagreement)	☢☢☢
US elbow	Usually Not Appropriate	O
MR arthrography elbow	Usually Not Appropriate	O
MRI elbow without and with IV contrast	Usually Not Appropriate	O
CT arthrography elbow	Usually Not Appropriate	☢☢
CT elbow with IV contrast	Usually Not Appropriate	☢☢
CT elbow without and with IV contrast	Usually Not Appropriate	☢☢

Variant: 4 Chronic elbow pain. Suspect chronic epicondylalgia or tendon tear. Refractory to empirical treatment. Radiographs normal or nonspecific. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
US elbow	Usually Appropriate	O
MRI elbow without IV contrast	Usually Appropriate	O
MR arthrography elbow	Usually Not Appropriate	O
MRI elbow without and with IV contrast	Usually Not Appropriate	O
CT arthrography elbow	Usually Not Appropriate	☢☢
CT elbow with IV contrast	Usually Not Appropriate	☢☢
CT elbow without and with IV contrast	Usually Not Appropriate	☢☢
CT elbow without IV contrast	Usually Not Appropriate	☢☢
3-phase bone scan elbow	Usually Not Appropriate	☢☢☢

Variant: 5 Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
US elbow	Usually Appropriate	O
MR arthrography elbow	Usually Appropriate	O
MRI elbow without IV contrast	Usually Appropriate	O
CT arthrography elbow	Usually Appropriate	☢☢
Radiography elbow stress views	May Be Appropriate	☢
MRI elbow without and with IV contrast	Usually Not Appropriate	O
CT elbow with IV contrast	Usually Not Appropriate	☢☢
CT elbow without and with IV contrast	Usually Not Appropriate	☢☢
CT elbow without IV contrast	Usually Not Appropriate	☢☢
3-phase bone scan elbow	Usually Not Appropriate	☢☢☢

Variant: 6 Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
US elbow	Usually Appropriate	O
MRI elbow without IV contrast	Usually Appropriate	O
CT elbow without IV contrast	May Be Appropriate	☢☢
MR arthrography elbow	Usually Not Appropriate	O
MRI elbow without and with IV contrast	Usually Not Appropriate	O
CT arthrography elbow	Usually Not Appropriate	☢☢
CT elbow with IV contrast	Usually Not Appropriate	☢☢
CT elbow without and with IV contrast	Usually Not Appropriate	☢☢
3-phase bone scan elbow	Usually Not Appropriate	☢☢☢

Panel Members

Jonelle M. Thomas, MD, MPH^a; Eric Y. Chang, MD^b; Alice S. Ha, MD, MS^c; Roger J. Bartolotta, MD^d; Matthew D. Bucknor, MD^e; Jamie T. Caracciolo, MD, MBA^f; Karen C. Chen, MD^g; Jonathan Flug, MD, MBA^h; Manickam Kumaravel, MDⁱ; Noah M. Raizman, MD^j; Andrew B. Ross, MD, MPH^k; Matthew L. Silvis, MD^l; Devaki Shilpa Surasi, MD^m; Francesca D. Beaman, MDⁿ.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Chronic elbow pain. Initial imaging.

Variant 1: Chronic elbow pain. Initial imaging.
A. 3-phase bone scan elbow

Variant 1: Chronic elbow pain. Initial imaging.
B. CT arthrography elbow

Variant 1: Chronic elbow pain. Initial imaging.
C. CT elbow

Variant 1: Chronic elbow pain. Initial imaging.
D. MR arthrography elbow

Variant 1: Chronic elbow pain. Initial imaging.
E. MRI elbow

Variant 1: Chronic elbow pain. Initial imaging.
F. Radiography elbow

Variant 1: Chronic elbow pain. Initial imaging.
G. US elbow

Variant 2: Chronic elbow pain with mechanical symptoms such as locking, clicking, or limited range of motion. Suspect intra-articular pathology such as osteocartilaginous body, osteochondral lesion, or synovial abnormality. Radiographs normal or nonspecific. Next imaging study.

Variant 3: Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. Next imaging study.

Variant 3: Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. Next imaging study.
A. 3-phase bone scan elbow

Variant 3: Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. Next imaging study.
B. CT arthrography elbow

Variant 3: Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. Next imaging study.
C. CT elbow

Variant 3: Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. Next imaging study.
D. MR arthrography elbow

Variant 3: Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. Next imaging study.
E. MRI elbow

Variant 3: Chronic elbow pain. Suspect occult stress fracture or other bone abnormality. Radiographs normal or nonspecific. Next imaging study.
F. US elbow

Variant 4: Chronic elbow pain. Suspect chronic epicondylalgia or tendon tear. Refractory to empirical treatment. Radiographs normal or nonspecific. Next imaging study.

Variant 4: Chronic elbow pain. Suspect chronic epicondylalgia or tendon tear. Refractory to empirical treatment. Radiographs normal or nonspecific. Next imaging study.
A. 3-phase bone scan elbow

Variant 4: Chronic elbow pain. Suspect chronic epicondylalgia or tendon tear. Refractory to empirical treatment. Radiographs normal or nonspecific. Next imaging study.
C. CT elbow

Variant 4: Chronic elbow pain. Suspect chronic epicondylalgia or tendon tear. Refractory to empirical treatment. Radiographs normal or nonspecific. Next imaging study.
E. MRI elbow

Variant 4: Chronic elbow pain. Suspect chronic epicondylalgia or tendon tear. Refractory to empirical treatment. Radiographs normal or nonspecific. Next imaging study.
F. US elbow

Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study.

Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study.
A. 3-phase bone scan elbow

Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study.
B. CT arthrography elbow

Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study.
C. CT elbow

Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study.
D. MR arthrography elbow

Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study.
E. MRI elbow

Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study.
F. Radiography elbow stress views

Variant 5: Chronic elbow pain. Suspect collateral ligament tear. Radiographs normal or nonspecific. Next imaging study.
G. US elbow

Variant 6: Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. Next imaging study.

Variant 6: Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. Next imaging study.
A. 3-phase bone scan elbow

Variant 6: Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. Next imaging study.
B. CT arthrography elbow

Variant 6: Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. Next imaging study.
C. CT elbow

Variant 6: Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. Next imaging study.
D. MR arthrography elbow

Variant 6: Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. Next imaging study.
E. MRI elbow

Variant 6: Chronic elbow pain. Suspect nerve abnormality. Radiographs normal or nonspecific. Next imaging study.
F. US elbow

Summary of Highlights

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.