Microsoft Word Chronic Ankle Pain AC FINAL 2017

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1 Revised 2017 American College of Radiology ® ACR Appropriateness Criteria Chronic Ankle Pain Chronic ankle pain. Initial imaging. Variant 1: Procedure Appropriateness Category Relative Radiation Level X-ray ankle Usually Appropriate ☢ Tc-99m bone scan ankle Usually Not Appropriate ☢☢☢ US ankle Usually Not Appropriate O CT ankle without IV contrast Usually Not Appropriate ☢ CT ankle with IV contrast Usually Not Appropriate ☢ Usually Not Appropriate CT ankle without and with IV contrast ☢ MRI ankle without IV contrast O Usually Not Appropriate MRI ankle without and with IV contrast Usually Not Appropriate O Variant 2: Chronic ankle pain. Multiple sites of dege nerative joint disease in the hindfoot detected by ankle radiographs. Next study. Appropriateness Category Relative Radiation Level Procedure Image-guided anesthetic injection ankle and May Be Appropriate Varies hindfoot May Be Appropriate without IV contrast foot ankle and hind O MRI ankle and hindfoot without IV co ntrast May Be Appropriate CT ☢ with CT ankle and hindfoot Usually Not Appropriate IV contrast ☢ CT ankle and hindfoot withou t and with IV ☢ Usually Not Appropriate contrast without and with IV ankle and hindfoot MRI O Usually Not Appropriate contrast Tc-99m bone scan ankle and hindfoot Usually Not Appropriate ☢☢☢ Usually Not Appropriate O US ankle and hin dfoot e Usually Not Appropriate foot CT arthrography ankle and hind ☢ O Usually Not Appropriate d hindfoot ankle an MR arthrography Usually Not Appropriate ankle and hindfoot X-ray arthrography ☢ ® Ankle Pain 1 Chronic ACR Appropriateness Criteria

2 Variant 3: Chronic ankle pain. Ankle radiographs no rmal, suspected osteochondral lesion. Next study. Relative Radiation Level Procedure Appropriateness Category Usually Appropriate O MRI ankle without IV contrast CT arthrography ankle May Be Appropriate ☢ May Be Appropriate O MR arthrography ankle Tc-99m bone scan with SPECT/CT ankle May Be Appropriate (Disagreement) ☢☢☢ CT ankle without IV contrast May Be Appropriate ☢ MRI ankle without and with IV contrast Usually Not Appropriate O Usually Not Appropriate CT ankle with IV contrast ☢ CT ankle without and with IV contrast Usually Not Appropriate ☢ X-ray ankle stress views Usually Not Appropriate ☢ US ankle Usually Not Appropriate O X-ray arthrography ankle Usually Not Appropriate ☢ Varies Image-guided anesthetic injection ankle Usually Not Appropriate Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study. Procedure Relative Radiation Level Appropriateness Category MRI ankle without IV contrast O Usually Appropriate US ankle Usually Appropriate O US-guided anesthetic injection ankle tendon O May Be Appropriate sheath MRI ankle without and with IV contrast Usually Not Appropriate O X-ray ankle stress views Usually Not Appropriate ☢ Tc-99m bone scan ankle Usually Not Appropriate ☢☢☢ CT ankle without IV contrast Usually Not Appropriate ☢ CT ankle with IV contrast Usually Not Appropriate ☢ CT ankle without and with IV contrast Usually Not Appropriate ☢ CT arthrography ankle Usually Not Appropriate ☢ MR arthrography ankle Usually Not Appropriate O X-ray tenography ankle Usually Not Appropriate ☢ Usually Not Appropriate X-ray arthrography ankle ☢ ® Chronic Ankle Pain 2 ACR Appropriateness Criteria

3 Variant 5: Chronic ankle pain. Ankle radiographs no rmal or nonspecific, suspected ankle instability. Next study. Procedure Relative Radiation Level Appropriateness Category MRI ankle without IV contrast Usually Appropriate O MR arthrography ankle O Usually Appropriate US ankle May Be Appropriate O X-ray ankle stress views May Be Appropriate ☢ CT arthrography ankle May Be Appropriate ☢ Usually Not Appropriate O MRI ankle without and with IV contrast Tc-99m bone scan ankle Usually Not Appropriate ☢☢☢ CT ankle without IV contrast Usually Not Appropriate ☢ CT ankle with IV contrast Usually Not Appropriate ☢ CT ankle without and with IV contrast Usually Not Appropriate ☢ X-ray arthrography ankle Usually Not Appropriate ☢ Image-guided anesthetic injection ankle Varies Usually Not Appropriate Variant 6: rmal or nonspecific, suspected ankle impingement Chronic ankle pain. Ankle radiographs no syndrome. 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 ☢ Image-guided anesthetic injection ankle Varies May Be Appropriate (Disagreement) US ankle May Be Appropriate O MRI ankle without and with IV contrast Usually Not Appropriate O Tc-99m 3-phase bone scan with SPECT/CT Usually Not Appropriate ☢☢☢ ankle CT ankle with IV contrast Usually Not Appropriate ☢ CT ankle without and with IV contrast Usually Not Appropriate ☢ X-ray ankle stress views Usually Not Appropriate ☢ Usually Not Appropriate X-ray arthrography ankle ☢ ® Chronic Ankle Pain 3 ACR Appropriateness Criteria

4 pain. Ankle radiographs normal, pain of uncertain etiology. Next study. Chronic ankle Variant 7: Procedure Appropriateness Category Relative Radiation Level MRI ankle without IV contrast Usually Appropriate O CT ankle without IV contrast May Be Appropriate ☢ Tc-99m bone scan with SPECT/CT ankle May Be Appropriate (Disagreement) ☢☢☢ Varies Image-guided anesthetic injection ankle May Be Appropriate US ankle May Be Appropriate O Usually Not Appropriate CT ankle with IV contrast ☢ CT ankle without and with IV contrast Usually Not Appropriate ☢ Usually Not Appropriate CT arthrography ankle ☢ MR arthrography ankle Usually Not Appropriate O MRI ankle without and with IV contrast Usually Not Appropriate O X-ray ankle stress views Usually Not Appropriate ☢ Usually Not Appropriate X-ray arthrography ankle ☢ ® Chronic Ankle Pain 4 ACR Appropriateness Criteria

5 CHRONIC ANKLE PAIN a b Expert Panel on Musculoskeletal Imaging: Eric Y. Chang, MD ; ; Anthony S. Tadros, MD d e f c Behrang Amini, MD, PhD ; ; Stephanie A. Bernard, MD ; Angela M. Bell, MD ; Michael G. Fox, MD, MBA h g i j Tetyana Gorbachova, MD ; Alice S. Ha, MD ; Kenneth S. Lee, MD, MBA ; ; Darlene F. Metter, MD n k l m Pekka A. Mooar, MD ; Adam D. Singer, MD ; Stacy E. Smith, MD ; Nehal A. Shah, MD ; o p q Mihra S. Taljanovic, MD ; Mark J. Kransdorf, MD. ; Ralf Thiele, MD Summary of Literature Review Introduction/Background >6 weeks. Chronic ankle pain can be caused by a variety Ankle pain is considered chronic when symptoms persist in combination. For assessing chronic ankle pain, there are of osseous or soft-tissue abnormalities, either alone or multiple imaging options, including radiography, stress radiography, computed tomography (CT) radionuclide bone scanning, ultrasound (US), magnetic resonance imaging (MRI), and various injection procedures. Injection procedures include arthrography, CT arthrography, MR arthrography, and diagnostic injection with anesthetic agents. Although there are numerous causes for chronic ankle pain, common etiologies include osteoarthritis, osteochondral injury, tendon abnormalities, ligament abnormalities and instability, and impingement. Overview of Imaging Modalities Radiography Radiographs can provide information about the osseous and soft-tissue structures about the ankle. Routine radiographs of the ankle typically include anteroposteri or, lateral, and mortise views, the latter obtained by internally rotating the foot 15 to 20 degrees. Stress ra diographs can be used to assess ankle instability [1,2]; however, some have questioned their accuracy [3,4]. CT CT is not routinely used as a first-line imaging tool in chronic ankle pain, but it is more sensitive than radiographs, particularly for osseous abnormalities [5]. CT arthrography may be more accurate than MR arthrography for the identification of osteochondral abnormalities [6]. Bone Scan Conventional planar bone scintigraphy can assess osseous pathology. More recently, single-photon emission computed tomography (SPECT) combined with CT has b een shown to provide additional information compared with clinical diagnosis and conventi onal bone scintigraphy for the evaluation of impingement syndromes and soft- tissue pathology [7]. In addition, SPECT/CT abnormalities have been shown to significantl y correlate with pain in osteochondral lesions [8]. US and ligament tears. In inflammatory US can be used to evaluate for soft -tissue abnormalities, including tendon and severity as well as detect subclinical pathology in arthritis, it can help in the assessment of disease activity early disease or after treatment [9]. US is ideal for dyna mic assessment of peroneal tendon instability [10] and can be used to guide interventions [11]. Compared with some other modalities, US is less prone to artifacts, such as susceptibility, motion, magic angle, and streak artifact, but dynamic assessment may be limited in cases of pain. MRI anatomic structures, including ligaments, tendons, cartilage, MRI is the imaging test that globally evaluates all and bone [12,13]. Most studies have shown that MRI is highly accurate for evaluation of ligament, tendon, and b a ego Healthcare System, San Diego, California. Research Author, University of California San Diego Medical Principal Author and Panel Chair, VA San Di c d Rush University Medical Center, Chicago, Illinois; University of Texas MD Anderson Cancer Center, Houston, Texas. Center, San Diego, California. e f g Penn State Milton S. Hershey Medica Mayo Clinic Arizona, Phoenix, Arizona. l Center, Hershey, Pennsylvania. Albert American College of Physicians. h i University of Washington, Seattle, Washington. University of Wisconsin Hospital & Clinics, Einstein College of Medicine, Philadelphia, Pennsylvania. j k Temple University Hospital, Philadelphi a, Pennsylvania; American Academy of UT Health San Antonio, San Antonio, Texas. Madison, Wisconsin. m n l Brigham & Women’s Hospital, Boston, Massachusetts. Emory University School of Medicine, Atlanta, Georgia. Brigham & Orthopaedic Surgeons. p o University of Arizona, Tucson, Arizona. University of Rochester School of Women’s Hospital & Harvard Medical School, Boston, Massachusetts. q Specialty Chair, Mayo Clinic, Phoenix, Arizona. Medicine and Dentistry, Rochester, New York; American College of Rheumatology. The American College of Radiology seeks and encourages collabor ation with other organizations on the development of the ACR Ap propriateness Criteria through society representation on expert panels. Particip ation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endor sement of the final document. Reprint requests to: [email protected] ® Chronic Ankle Pain 5 ACR Appropriateness Criteria

6 osteochondral abnormalities [14-16], alt hough one study found statistically si gnificant lower sensitivity for these MRI can identify synovitis and impingement lesions, abnormalities on MRI as compared to arthroscopy [17]. which can contribute to patient symptoms [18]. Discussion of Procedures by Variant Variant 1: Chronic ankle pain. Initial imaging. Radiography y. Radiographs may reveal osteoarthritis, calcified or Radiography should be considered as the initial imaging stud ossified intra-articular bodies, osteochondral abnormalities, stress fractures, or evidence of prior trauma. Ankle effusions may also be identified in the anterior ankle joint recess by radiography with 53% to 74% accuracy [19]. They are often associated with ligament ous injury or fracture [19]. The presen ce of ossific fragments can indicate ligamentous injury or retinaculum avulsion [20], wh adjacent to tenosynovitis. ereas periostitis can occur Radiographs can also identify synovial osteochondr omatosis and erosions from chronic synovitis. CT CT is not routinely used as the first stud y for the evaluation of chronic ankle pain. MRI MRI is not routinely used as the first stud y for the evaluation of chronic ankle pain. US US is not routinely used as the first stud y for the evaluation of chronic ankle pain. Bone Scan udy for the evaluation of chronic ankle pain. Bone scan is not routinely used as the first st Variant 2: Chronic ankle pain. Multiple sites of degen erative joint disease in the hindfoot detected by ankle radiographs. Next study. important to determine which joint is the cause of When multiple sites of osteoarthritis are present, it may be symptoms. Image-guided Anesthetic Injection Several reports have indicated the effectiveness of fluorosc opic, CT, or US-guided anesthetic [11] with or without corticosteroid injection of joints to identify a so urce of pain, which aids in surgical planning [21-25]. MRI When degenerative changes of the ankle joint are diagno sed based on radiographs, MRI may be considered as the next best examination to evaluate cartilage integrity, bone marrow, and associated soft tissues, such as ligaments and tendons, if these injuries are clinically suspected [13-15]. CT CT without contrast may be helpful to visualize subchondral cysts [5]. US aluation of degenerative joint disease. US is not routinely used for the ev Bone Scan Bone scan is not routinely used for th e evaluation of degenerative joint disease. Arthrography Arthrography is not routinely used for th e evaluation of degenerative joint disease. MR Arthrography MR arthrography is not routinely used for the evaluation of degenerative joint disease. CT Arthrography CT arthrography is not routinely used for the evaluation of degenerative joint disease. Variant 3: Chronic ankle pain. Ankle radiographs no rmal, suspected osteochondral lesion. Next study. Osteochondral injuries may involve the talar dome and, less commonly, the tibial plafond and tarsal navicular bone [5,26,27]. If this injury is associated with fractur e, osseous cyst, or osteochondral defect, radiography may show the abnormality; however, radiography often fails to s how the extent of the osteochondral injury and will be ® Chronic Ankle Pain 6 ACR Appropriateness Criteria

7 initially negative if the injury is limited to the articular hyaline cartilage. One multimodality study [5] showed that e ankle were missed on radiography. 41% of osteochondral abnormalities of th MRI In one multimodality study, MRI performed similarly to arthroscopy for the evaluation of osteochondral abnormalities of the ankle [5]. Although MRI had the highest ess specific than CT [5]. sensitivity (96%), it was l MRI is effective in determining oste ochondral injury instability (sensitivity 97%), most commonly appearing as a eighted images or less commonly as a focal defect, an high signal line deep to the osteochondral lesion on T2-w [28]. MRI has also been u sed to stage these lesions preoperatively with an articular fracture, or an adjacent cyst accuracy of 81% [29] and to assess osteochondral abnorma lities after cartilage repair [30]. Although MRI may be less reliable than CT arthrography for talar cartilagi nous lesions (accuracy between 76% to 88%) [6], high- resolution MRI using a microscopy coil (eg, a 4-cm receive-only surface coil) can assist in detecting small, clinically relevant features of ta missed on standard MRI, including lar osteochondral lesions that may be osteochondral junction separation due to focal collapse of the subchondral b one, reparative cartilage hypertrophy, and bone separation in the absence of cartilage fracture [31]. CT Arthrography The introduction of contrast into the ankle joint prior to CT will outline a cartilage su rface defect, assisting in lesion detection and assessment for instability. One study comparing CT arthrography and MR arthrography for talar cartilaginous lesions found an acc uracy between 76% to 88% using MR arthrography compared to 90% to 92% for CT arthrography, suggesting that CT arthrography may be more reliable [6]. MR Arthrography to MRI will outline a cartilage surface defect, assisting in The introduction of contrast into the ankle joint prior lesion detection and assessment for instability. One study comparing CT arthrography and MR arthrography for talar cartilaginous lesions found an acc uracy between 76% to 88% using MR arthrography compared to 90% to 92% for CT arthrography, suggesting that CT arthrography may be more reliable [6]. CT In one multimodality study, CT (noncontrast, multidetect or with multiplanar reformatted images) performed similarly to arthroscopy for the evaluation of osteochondr al abnormalities of the ankle [5]. However, CT was more specific (99%) but less sensitive then MRI [5]. Bone Scan with SPECT/CT When osteochondral injuries are associated with fracture, osseous cyst, or osteochondral defect, bone scans may show the abnormality. One study evaluating the role of SPECT/CT in assessing osteochondral defects in the ankle found that this study affected the surgeon’s ultimate d ecision regarding treatment in 48% to 52% of cases, as it allowed for improved evaluation of the subchondral bone and subchondral bone plate [32]. SPECT/CT abnormalities have also been shown to significantly correlate with pain in the setting of osteochondral lesions [8] and to precisely localize the painful regions in the setting of multiple lesions [33,34]. US US is not routinely used for the evaluation of osteochondral lesions in the ankle. Radiography Stress views are not routinely used for the eval uation of osteochondral lesions in the ankle. Arthrography Arthrography is not routinely used for the evaluation of osteochondral lesions in the ankle. Image-guided Anesthetic Injection Image-guided anesthetic injections may be helpful to asse ss whether an osteochondral lesion in the ankle is the source of the patient’s pain [8]. Variant 4: Chronic ankle pain. Ankle radiographs norm al or nonspecific, suspected tendon abnormality. Next study. Possible tendon abnormalities include tenosynovitis, tendino pathy, tendon tear (partial or complete), and tendon subluxation or dislocation. Both MRI and US can ef fectively demonstrate ankle tendon abnormalities, although US results are more dependent on operator skill and expe rtise [10,35]. For the assessment, it is assumed the interpreted by an expert. procedure is performed and ® Chronic Ankle Pain 7 ACR Appropriateness Criteria

8 US US can be used to evaluate for soft -tissue abnormalities, including tendon and ligament tears. It has been shown tendon tears, although US results are more dependent on to produce similar results as MRI in diagnosing ankle med that the procedure is performed and interpreted by operator skill and expertise [10,35]. In this case, it is assu an expert. One study showed that it had a sensitivity of 100% and an accuracy of 93% compared to surgical findings [36]. With regard to the tibialis posterior te ndon, one study evaluating tendon pathology showed that US was slightly less sensitive than MRI; however, this diffe rence did not significantly affect clinical management [37]. One study using US showed 100% sensitivity and 90% accuracy in diagnosing peroneal tendon tears [38]; suggesting that US may be more useful than MRI. With regard to chronic Achilles tendinopathy, US detected 21 of 26 cases of tendinosis and partial r upture [39], and another study showed that US can differentiate full- thickness from partial-thickness Achilles tears with 92% accuracy [40]. In addition to the diagnostic capabilities of US, when a tendon abnormality is detected, it can be used to guide interventions such as concurrent performance of US-guided intrasheath anesthetic injections [11]. It can also be used for direct intratendinous biologic injection and dry needling [41-43]. One significant advantage of US is in the dynamic assessment for tendon subluxati on (including intrasheath subluxation) and dislocation, with a reported positive predictive value of 100% compared to surgical findings [44,45]. US-guided sheath injections are more accurate than pa lpation guided and allow fo r precise positioning of the needle tip in the sheath rather than the tendon substan ce because a large volume intratendinous injection of corticosteroids or local anesthetic can result in a split tear [46]. fascia in spondyloarthritis, US can detect intratendinous tophi in gout, enthesitis of the Achilles tendon or plantar and tenosynovitis in spondyloarthritis and rheumatoid arthritis [47]. MRI sitivities (>90%) in diagnosing ankle tendon tears [16]. It is generally accepted that MRI can achieve high sen Regarding tibialis posterior tendon, MRI is more sensitive than US; however, this difference did not significantly affect clinical management [37]. With regard to peroneal tendinopathy and tendon tear, one study found the sensitivities and specificities of MRI to be 83.9% and 74.5%, respectively, for te ndinopathy and 54.5% and 88.7%, respectively, for tendon tears [48]. With regard to chronic Achilles tendinopathy, MRI detected 26 of 27 cases of tendinosis and partial rupture [39]. MRI re ported a 66% accuracy rate for assessment for tendon subluxation and dislocation [44,45]. MRI evidence of per oneal tendon pathology should be treated with caution because up to 34% of asymptomatic patients may have a tear of the peroneus brevis tendon [49]. One study showed that MRI evidence of peron eal tendon pathology had a 48% positive pr edictive value for clinical findings, highlighting the importance of clinical examination [50]. Image-guided Anesthetic Injection es of US, when a tendon abnormality is detected, a fluoroscopic or US- In addition to the diagnostic capabiliti guided intrasheath anesthetic injection can be concurrently performed [11]. Tenography Diagnostic and therapeutic ankle tenography can also be c onsidered for evaluation, with one study reporting that 47% of patients had prolonge d relief of symptoms [51]. CT CT is not routinely used for the evaluation of suspected tendon abnormality. Bone Scan Bone scan is not routinely used for th e evaluation of suspected tendon abnormality. CT Arthrography CT arthrography is not routinely used fo r the evaluation of suspected tendon abnormality. MR Arthrography r the evaluation of suspected tendon abnormality. MR arthrography is not routinely used fo Arthrography e evaluation of suspected tendon abnormality. Arthrography is not routinely used for th ® Chronic Ankle Pain 8 ACR Appropriateness Criteria

9 Radiography Stress views are not routinely used for th e evaluation of suspected tendon abnormality. or nonspecific, suspected ankle instability. Next Variant 5: Chronic ankle pain. Ankle radiographs normal study. In the absence of findings on routine radiography, imaging op tions to evaluate ligamentous integrity include stress radiography, MRI, MR arthrography, CT arthrography, and US. MRI ry demonstrated a diagnostic accuracy of 97% for MRI One study evaluating anterior talofibular ligament inju when compared to arthroscopic findings. Additionally, MR I identified the exact location of the injury in 93% of the cases [15]. Comparing MRI with arthroscopy, studies ha ve shown a range of accuracies of chronic lateral ligament tearing (either partial or complete), ranging fro m 77% to 92% for the anterior talofibular ligament and 88% to 92% for the calcaneofibular ligament [14,52]. For the evaluation of deep deltoid ligament tears, MRI is both sensitive and specific compared with arthroscopy, w ith reported values of 96% and 98%, respectively [53]. With regard to tears of the tibiofibular ligaments of th e tibiofibular syndesmosis, MRI has a reported accuracy of 100% [54]. Additionally, MRI can also demonstrate intero sseous membrane tears [55]. MRI offers the advantage of evaluating for injuries associated wi th or mimicking lateral instability that may not be diagnosed on stress radiography such as tenosynovitis, tendon injury, and oste ochondral lesions [56]. MRI may also be used to evaluate the ankle after lateral ligament reconstruction [57]. MR Arthrography MR arthrography can be helpful for th e assessment of chronic ankle instabilit y due to lateral collateral ligament injuries [12]. US One study evaluating anterior talofibula nostic accuracy of 91% for US when r ligament injury demonstrated a diag compared to arthroscopic findings. Additionally, US iden tified the exact location of the injury in 63% of cases r the diagnosis of anterior talofibular ligament injury [15]. Another study comparing US and CT arthrography fo showed an accuracy of 61% using US and 71% for CT ar thrography [58]. US also has the dynamic capability of stressing the ligament and looking for laxity or frank separation of the injured ligament [1,59]. With regard to interosseous membrane tears, US has a proven sensitivity of 89% and specificity of 94.5% in tears shown at surgery [55,60]. diagnosing interosseous membrane Radiography Stress radiographs can be used to assess ankle instability [1,2]; however, some have questioned their accuracy [3,4]. One study evaluating anterior talofibular ligamen t injury demonstrated a diagnostic accuracy of 67% for stress radiography [15]. Oae et al [15] compared stress radiography to arthroscopic fi ndings and found the former has an accuracy of 67% for ev ries. Subtalar stress radiography using aluating anterior talofibular ligament inju forced dorsiflexion and supination [4] or talar rotati on [61] can be used to evaluate subtalar laxity. CT Arthrography CT arthrography showed an accuracy of 71% for di agnosing anterior talofibul ar ligament injury [58]. CT CT is not routinely used for the evaluation of ligamentous integrity. Arthrography . Arthrography is not routinely used for the evaluation of ligamentous integrity Image-guided Anesthetic Injection sed for the evaluation of ligamentous integrity. Image-guided anesthetic injection is not routinely u Bone Scan e evaluation of ligamentous integrity. Bone scan is not routinely used for th ® Chronic Ankle Pain 9 ACR Appropriateness Criteria

10 Variant 6: Chronic ankle pain. Ankle radiographs no rmal or nonspecific, suspected ankle impingement syndrome. Next study. Imaging can also be used to diagnose ankle impingement syndromes, which can occur in the anterolateral, anterior, anteromedial, posteromedial, and posterior aspects of the ankle joint [62-71]. MR Arthrography be an accurate method for assessing both anterolateral and anteromedial MR arthrography has been found to ention by intra-articular contrast injection [68,69]. impingement with the advantage of joint capsule dist US One study involving anterolateral ankle impingement comp ared US to arthroscopic findings. The study found US had a sensitivity and specificity of 77% and 57%, respec tively [70]. US also showed abnormal soft tissues in anterolateral impingement, with a reporte d accuracy of 100% in one study [72]. MRI lateral impingement syndrome have drawn varying Studies on the accuracy of MRI in diagnosing antero conclusions, which may be related to varying MRI magnet strengths and inc onsistent protocols [73]. Comparing MRI with surgical findings, studies have shown sensitiviti es between 75% to 83% and sp ecificity between 75% to 100% for the diagnosis of antero lateral impingement [73,74]. One study found that, when compared with arthroscopy, fat-suppressed, IV contrast-enhanced, 3-D gradient- recalled echo imaging was sensitive for the evaluation of sy novitis of the ankle associated with trauma (92%), whereas it was specific for soft-tissue impingement eval uation (97%) when the ankle was divided into four gutter, anterior recess, and posterior recess [75]. compartments: the anterolateral gutter, anteromedial MRI is useful in confirming the diagnosis, evaluating pa tients with an uncertain clinical diagnosis, and planning surgery. Additionally, it can help exclude other pathol ogic entities that may mimic or coexist with impingement syndromes. However, MRI features suppor tive of impingement may be present in asymptomatic individuals, and an accurate diagnosis requires careful correlation of imag ing features findings with clinical findings [76]. There are only limited reports on the use of MRI for the other forms of ankle impingement syndrome, so its accuracy in these conditions is not we ll established [62,64,67,68]. CT Arthrography One study involving anterolateral ankle impingement compared CT arthrography to arthroscopic findings. The study found that CT arthrography had a sensitivity an d specificity of 97% and 71%, respectively [77]. Image-guided Anesthetic Injection as an effective treatment for some ankle impingement Fluoroscopic or US-guided injections have been shown syndromes [78,79]. Bone Scan with SPECT/CT ovide additional information compared with clinical Recently, SPECT combined with CT has been shown to pr diagnosis and conventional bone scintigraphy for the evaluation of impingement syndromes and soft-tissue pathology [7]. One study found that SPECT/CT provided information not suspected on clinical diagnosis in 56% of cases with impingement syndromes or soft-tissue pathology [7]. CT CT may be useful for depiction of osseous causes of impingement, such as chronic abnormalities between the talus and an os trigonum or fractures of the latera l tubercle of the talus or os trigonum [62]. Arthrography Arthrography is not routinely used for th e evaluation of ankle impingement syndromes. Radiography evaluation of ankle impingement syndromes. Stress views are not routinely used for the Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study. When chronic ankle pain is of unclear etiology, normal ankle radiographs can be followed by other imaging tests, primarily directed by clinical findings. ® Chronic Ankle Pain 10 ACR Appropriateness Criteria

11 MRI If the patient has a focal soft-tissue abnormality, MRI can nerve-related symptoms can be considered. Peripheral nefit of higher resolution. If symptoms are believed to be evaluated with US or MRI; however, US has the be originate from osseous structures, MRI can be considered if there is concern for an initially missed fracture [80]. Overall, MRI is the imaging test that globally evaluates MRI is effective in detecting osseous stress injuries [81]. all anatomic structures, including bone marrow [13,82]. US US is best used as a focal examination and should not be used for comprehensive evaluation of the ankle when no particular pathology is suspected. If the patient has a focal soft-tissue abnormality, US can be considered. ever, US has the benefit of higher Peripheral nerve-related symptoms can be evaluated with US or MRI; how resolution. US with dynamic evaluation should be considered when symptoms are only present during specific movements or positions [83,84]. CT If symptoms are believed to originate from osseous structur es, CT can be considered if there is concern for an superior to radiography for fracture detection [85]. initially missed fracture [80]. CT has been shown to be Bone Scan with SPECT/CT SPECT/CT is an emerging imaging modality for evaluati on of ankle pathology and can detect osteochondral lesions, osteoarthritis, tarsal coalition, oc cult fractures, or painful accessory bones [86]. Arthrography Arthrography is not routinely used for the evaluation of pain of unknown etiology in the ankle. CT Arthrography CT arthrography is not routinely used for the evaluation of pain of unknown etiology in the ankle. MR Arthrography MR arthrography is not routinely used for the evaluation of pain of unknown etiology in the ankle. Image-guided Anesthetic Injection US-guided nerve blocks have been re ported to be helpful for diagnostic purposes and to plan for surgical or procedural intervention [87-89]. Radiography Stress views are not routinely used for the evalua tion of pain of unknown etiology in the ankle. Other Causes of Chronic Ankle Pain Tarsal tunnel syndrome ® onic ankle pain. See the ACR Appropriateness Criteria Tarsal tunnel syndrome can also be a cause of chr topic on “ Chronic Foot Pain ” [90]. Suspected stress fracture ® Stress fractures can also be a cause of chronic ankle pain. See the ACR Appropriateness Criteria topic on “ Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae ” [91]. Tarsal coalition ® Tarsal coalition can also be a cause of chroni c ankle pain. See the ACR Appropriateness Criteria topic on “ ” [90]. Chronic Foot Pain Suspected tumor ® Tumors can also be a cause of chronic ankl e pain. See the ACR Appropriateness Criteria topics on “ Primary Bone Tumors ” [92], “ Metastatic Bone Disease ” [93], and “ Soft-Tissue Masses ” [94]. Inflammatory arthritis or crystal deposition Inflammatory arthritis or crystal deposition can also be a cause of chronic ankle pain. See the ACR ® Appropriateness Criteria Chronic Extremity Joint Pain-Sus ” [95]. pected Inflammatory Arthritis topic on “ ® Chronic Ankle Pain 11 ACR Appropriateness Criteria

12 Summary of Recommendations  Radiograph of the ankle is the most appropriate initial imaging study.  Image-guided anesthetic injection ankle and hindfoot, MRI ank le and hindfoot without IV contrast, or CT ankle and hindfoot without IV con trast may be appro priate as the next study for degenerative joint d isease in the hin dfoot detected by ankle radiographs. MRI ankle without IV contrast should be the next imaging study when ankle radiographs are normal for  suspected osteochondral lesion. Either MRI ankle without IV contrast or US ankle should be ordered when tendon abnormality is suspected  and ankle radiographs are normal. Either MRI ankle without IV contrast or MR arthr  ography of the ankle should be ordered when ankle instability is suspected and ankle radiographs are normal. ankle impingement syndrome is suspected and ankle  MRI ankle without IV contrast should be ordered when radiographs are normal.  MRI ankle without IV contrast should be ordered as the next study after radiographs when there is pain of uncertain etiology and ankle radiographs are normal. Summary of Evidence ® Of the 96 references cited in the ACR Appropriateness Criteria Chronic Ankle Pain document, 5 are categorized and 3 good-quality studies. Additionally, 91references as therapeutic references including 1 well-designed study ll-designed study, 10 good-quality studies, and 41 quality are categorized as diagnostic references including 1 we studies that may have design limitations. There are 40 refe rences that may not be useful as primary evidence. ® ACR Appropriateness Criteria The 96 references cited in the Chronic Ankle Pain document were published from 1988-2017. ith design limitations, 15 well-designed or good-quality Although there are references that report on studies w studies provide good evidence. Appropriateness Category Names and Definitions Appropriateness Appropriateness Category Name Appropriateness Category Definition Rating The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk- Usually Appropriate 7, 8, or 9 benefit ratio for patients. The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with May Be Appropriate 4, 5, or 6 it ratio, or the risk-benefit a more favorable risk-benef ratio for patients is equivocal. The individual ratings are too dispersed from the panel median. The different label provides May Be Appropriate transparency regarding the panel’s recommendation. 5 (Disagreement) “May be appropriate” is the rating category and a rating of 5 is assigned. The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the 1, 2, or 3 Usually Not Appropriate risk-benefit ratio for patients is likely to be unfavorable. ® nkle Pain A Chronic 12 ACR Appropriateness Criteria

13 Relative Radiation Level Information Potential adverse health eff ects associated with radiation exposure are an important factor to consider when a wide range of radiation exposures associated with selecting the appropriate imaging procedure. Because there is different diagnostic procedures, a relative radiation le vel (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 imagi ng procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of orga n 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 to those specified for adults (see Table below). Additional information regarding radiation dose assessment fo r imaging examinations can be found in the ACR ® Appropriateness Criteria Radiation Dose Assessment Introduction document [96]. Relative Radiation Level Designations Adult Effective Dose Estimate Pediatric Effective Dose Estimate Relative Radiation Level* Range Range 0 mSv 0 mSv O <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 examin ations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies”. Supporting Documents For additional information on the Appropriateness Crite ria methodology and other supporting documents go to www.acr.org/ac. References ultrasound for the diagnosis of YU. Value of stress 1. Cho JH, Lee DH, Song HK, Bang JY, Lee KT, Park gnetic resonance chronic ankle instability compared to manual anterior drawer test, stress radiography, ma 2016;24(4):1022-1028. Knee Surg Sports Traumatol Arthrosc. maging, and arthroscopy. i with 2. Dowling LB, Giakoumis M, Ryan JD. Narrowing the normal range for lateral ankle ligament stability adiography. J Foot Ankle Surg. 2014;53(3):269-273. stress r 3. Hoffman E, Paller D, Koruprolu S, et al. Accuracy of plain radiographs versus 3D analys is of ankle stress le Int. 2011;32(10):994-999. test. Foot Ank 4. ich therapeutic Tourne Y, Besse JL, Mabit C. Chronic ankle instability. Which tests to assess the lesions? Wh options 2010;96(4):433-446. ? Orthop Traumatol Surg Res. Verhagen RA, Maas M, Dijkgraaf MG, Tol JL, Krips R, van Dijk CN. Prospective study on diagnostic 5. strategies in Br. J Bone Joint Surg talus. Is MRI superior to helical CT? osteochondral lesions of the 87(1):41-46. 2005; Schmid MR, Pfirrmann CW, Hodler J, Vienne P, Zanetti M. Cartilage lesions in the ankle joint: comparison 6. Skeletal Radiol. 2003;32(5):259-265. of MR arthrography and CT arthrography. Chicklore S, Gnanasegaran G, V ijayanathan S, Fogelman I. Poten tial role of multislice SPECT/CT 7. in pingement syndrome and soft-tissue pathology of the ankle and foot. Nucl Med Commun. 2013;34(2):130- im 139. 8. Wiewiorski M, Pagenstert G, Rasch H, Jacob AL, Valderrabano V. Pain in osteochondral lesions. Foot An kle 1;4(2):92-99. Spec. 201 Ultrasound of the ankle and foot in rheumatology. Me 9. Micu MC, Nestorova R, Petranova T, et al. d Ultrason. 2012; 14(1):34-41. ® Ankle Pain Chronic 13 ACR Appropriateness Criteria

14 10. Lee SJ, Jacobson JA, Kim SM, et al. Ultrasound and MR I of the peroneal tendons and associated pathology. 2013;42(9):1191-1200. Skeletal Radiol. Semin Musculoskelet Radiol. 11. Yablon CM. Ultrasound-guided interv entions of the foot and ankle. 2013;17(1):60-68. uation of traumatic ligamentous injuries of the ankle 12. Nazarenko A, Beltran LS, Bencardino JT. Imaging eval Radiol Clin North Am. 2013;51(3):455-478. and foot. 13. Weishaupt D, Schweitzer ME. MR imaging of th e foot and ankle: patterns of bone marrow signal Eur Radiol. 2002;12(2):416-426. abnormalities. 14. Joshy S, Abdulkadir U, Chaganti S, Sullivan B, Hari haran K. Accuracy of MRI scan in the diagnosis of 2010;16(2):78-80. Foot Ankle Surg. ligamentous and chondral pathology in the ankle. 15. Oae K, Takao M, Uchio Y, Ochi M. Evaluation of ante rior talofibular ligament injury with stress radiography, ultrasonography and MR imaging. Skeletal Radiol. 2010;39(1):41-47. 16. Rosenberg ZS, Cheung Y, Jahss MH, Noto AM, Norman A, Leeds NE. Rupture of posterior tibial tendon: CT Radiology. and MR imaging with surgical correlation. 1988;169(1):229-235. 17. Cha SD, Kim HS, Chung ST, et al. Intra-articular lesi ons in chronic lateral ankle instability: comparison of Clin Orthop Surg. arthroscopy with magnetic resonance imaging findings. 2012;4(4):293-299. 18. Singleton TJ, Hutchinson B, Ford L. Arth roscopic treatment of ankle osteochondral lesions. Clin Podiatr Med Surg. 2011;28(3):481-490. 19. Karchevsky M, Schweitzer ME. Accuracy of plain film s, and the effect of experience, in the assessment of Skeletal Radiol. 2004;33(12):719-724. ankle effusions. roneal Tendon Instability in Intra-Articular Calcaneus 20. Ketz JP, Maceroli M, Shields E, Sanders RW. Pe J Orthop Trauma. Fractures: A Retrospective Comparative Study and a New Surgical Technique. 2016;30(3):e82-87. 21. Khoury NJ, el-Khoury GY, Saltzman CL, Brandser EA. In traarticular foot and ankle injections to identify AJR Am J Roentgenol. 1996;167(3):669-673. source of pain before arthrodesis. 22. Lucas PE, Hurwitz SR, Kaplan PA, Dussault RG, Maurer EJ . Fluoroscopically guided injections into the foot and ankle: localization of the source of pain as a guide to treatment--prospective study. Radiology. 1997;204(2):411-415. 23. Henning PT. Ultrasound-Guided Foot and Ankle Procedures. 2016;27(3):649- Phys Med Rehabil Clin N Am. 671. 24. Reach JS, Easley ME, Chuckpaiwong B, Nunley JA, 2nd. Accuracy of ultrasound guided injections in the 2009;30(3):239-242. foot and ankle. Foot Ankle Int. 25. Smith J, Maida E, Murthy NS, Kissin EY, Jacobson JA. Sonographically guided posterior subtalar joint injections via the sinus tarsi approach. J Ultrasound Med. 2015;34(1):83-93. FS, Rogers LF, Lenchi 26. Bui-Mansfield LT, Kline M, Chew k L. Osteochondritis dissecans of the tibial plafond: imaging characteristics and a review of the literature. 2000;175(5):1305-1308. AJR Am J Roentgenol. Rogers LF, Chew FS, Boles CA, Kline M. Osteochondritis dissecans of the 27. Bui-Mansfield LT, Lenchik L, J Comput Assist Tomogr. 2000;24(5):744-747. tarsal navicular bone: imaging findings in four patients. 28. De Smet AA, Ilahi OA, Graf BK. Reassessment of th e MR criteria for stability of osteochondritis dissecans in the knee and ankle. Skeletal Radiol. 1996;25(2):159-163. 29. Lee KB, Bai LB, Park JG, Yoon TR. A comparison of arthroscopic and MRI findings in staging of Knee Surg Sports Traumatol Arthrosc. osteochondral lesions of the talus. 2008;16(11):1047-1051. 30. Choi YS, Potter HG, Chun TJ. MR imaging of cartilage repair in the knee and ankle. Radiographics. 2008;28(4):1043-1059. tion MR imaging of talar osteochondral lesions with 31. Griffith JF, Lau DT, Yeung DK, Wong MW. High-resolu new classification. Skeletal Radiol. 2012;41(4):387-399. 32. Leumann A, Valderrabano V, Plaass C, et al. A novel imaging method for osteochondral lesions of the talus-- comparison of SPECT-CT with MRI. 2011;39(5):1095-1101. Am J Sports Med. 33. Meftah M, Katchis SD, Scharf SC, Mintz DN, Klein DA, Weiner LS. SPECT/CT in the management of osteochondral lesions of the talus. Foot Ankle Int. 2011;32(3):233-238. 34. Tamam C, Tamam MO, Yildirim D, Mulazimoglu M. Diagnostic value of single-photon emission computed tomography combined with computed tomography in relation to MRI on osteochondral lesions of the talus. Nucl Med Commun. 2015;36(8):808-814. 35. Ng JM, Rosenberg ZS, Bencardino JT, Restrepo-Velez Z, Ciavarra GA, Adler RS. US and MR imaging of the extensor compartment of the ankle. 2013;33(7):2047-2064. Radiographics. ® Chronic Ankle Pain 14 ACR Appropriateness Criteria

15 36. Waitches GM, Rockett M, Brage M, Sudakoff G. Ultr asonographic-surgical correlation of ankle tendon tears. 1998;17(4):249-256. J Ultrasound Med. 37. Nallamshetty L, Nazarian LN, Schw eitzer ME, et al. Evaluation of posterior tibial pathology: comparison of 2005;34(7):375-380. Skeletal Radiol. sonography and MR imaging. 38. Grant TH, Kelikian AS, Jereb SE, McCarthy RJ. Ultr asound diagnosis of peroneal tendon tears. A surgical correlation. J Bone Joint Surg Am. 2005;87(8):1788-1794. Rausing A, Sjoberg S, Westlin N. Im aging in chronic achilles tendinopathy: 39. Astrom M, Gentz CF, Nilsson P, imaging and surgical findings in 27 histologically a comparison of ultrasonography, magnetic resonance Skeletal Radiol. verified cases. 1996;25(7):615-620. on JA, van Holsbeeck MT. Full- vers us partial-thickness Achilles tendon 40. Hartgerink P, Fessell DP, Jacobs Radiology. tears: sonographic accuracy and characterization in 26 cases with surgical correlation. 2001;220(2):406-412. 41. Guelfi M, Pantalone A, Vanni D, Abate M, Guelfi MG , Salini V. Long-term beneficial effects of platelet-rich plasma for non-insertional Achilles tendinopathy. Foot Ankle Surg. 2015;21(3):178-181. 42. Owens RF, Jr., Ginnetti J, Conti SF, Latona C. Clin ical and magnetic resonance imaging outcomes following Foot Ankle Int. platelet rich plasma injection for chronic midsubstance Achilles tendinopathy. 2011;32(11):1032-1039. 43. Yeo A, Kendall N, Jayaraman S. Ultrasound-guided dr ous paratenon decompression y needling with percutane for chronic Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc. 2016;24(7):2112-2118. 44. Neustadter J, Raikin SM, Nazarian LN. Dynami c sonographic evaluation of peroneal tendon subluxation. AJR Am J Roentgenol. 2004;183(4):985-988. 45. Roth JA, Taylor WC, Whalen J. Peroneal tendon subluxation: the other lateral ankle injury. Br J Sports Med. 2010;44(14):1047-1053. 46. Muir JJ, Curtiss HM, Hollman J, Smith J, Finnoff JT. The accuracy of ultrasound-guided and palpation- guided peroneal tendon sheath injections. Am J Phys Med Rehabil. 2011;90(7):564-571. 47. Wilkinson VH, Rowbotham EL, Grainger AJ . Imaging in Foot and Ankle Arthritis. Semin Musculoskelet 2016;20(2):167-174. Radiol. 48. Park HJ, Cha SD, Kim HS, et al. Reliability of MRI fi ndings of peroneal tendinopath y in patients with lateral chronic ankle instability. Clin Orthop Surg. 2010;2(4):237-243. resonance imaging and inci 49. Saxena A, Luhadiya A, Ewen B, Goumas C. Magnetic dental findings of lateral J Foot Ankle Surg. 2011;50(4):413-415. ankle pathologic features with asymptomatic ankles. er JC. A clinical and radiological study of peroneal 50. Giza E, Mak W, Wong SE, Roper G, Campanelli V, Hunt tendon pathology. Foot Ankle Spec. 2013;6(6):417-421. 51. Jaffee NW, Gilula LA, Wissman RD, Johnson JE. Di agnostic and therapeutic ankle tenography: outcomes and complications. 2001;176(2):365-371. AJR Am J Roentgenol. 52. Park HJ, Cha SD, Kim SS, et al. Accuracy of MR I findings in chronic lateral ankle ligament injury: comparison with surgical findings. Clin Radiol. 2012;67(4):313-318. 53. Crim J, Longenecker LG. MRI and surg ical findings in deltoid ligament tears. AJR Am J Roentgenol. 2015;204(1):W63-69. 54. Oae K, Takao M, Naito K, et al. Injury of the tibio fibular syndesmosis: value of MR imaging for diagnosis. 2003;227(1):155-161. Radiology. 55. Nielson JH, Sallis JG, Potter HG, Helfet DL, Lorich DG. Correlation of interosseous membrane tears to the J Orthop Trauma. level of the fibular fracture. 2004;18(2):68-74. 56. DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ. Associated injuries found in chronic lateral ankle Foot Ankle Int. instability. 2000;21(10):809-815. 57. Chien AJ, Jacobson JA, Jamadar DA, Brigido MK, Fe mino JE, Hayes CW. Imaging appearances of lateral ankle ligament reconstruction. Radiographics. 2004;24(4):999-1008. 58. Guillodo Y, Varache S, Saraux A. Value of ultrasonogr aphy for detecting ligament damage in athletes with chronic ankle instability compared to computed arthrotomography. 2010;3(6):331-334. Foot Ankle Spec. 59. Lee KT, Park YU, Jegal H, Park JW, Choi JP, Kim JS. New method of diagnosis for chronic ankle instability: comparison of manual anterior drawer test, stress radiography and stress ultrasound. Knee Surg Sports Traumatol Arthrosc. 2014;22(7):1701-1707. 60. Christodoulou G, Korovessis P, Giarmenitis S, Di mopoulos P, Sdougos G. Th e use of sonography for J tibiofibular interosseous membrane in ankle fractures. evaluation of the integrity and healing process of the Orthop Trauma. 1995;9(2):98-106. ® Chronic Ankle Pain 15 ACR Appropriateness Criteria

16 61. Lee BH, Choi KH, Seo DY, Choi SM, Kim GL. Diagnos tic validity of alternative manual stress radiographic with concomitant ankle instability. Knee Surg Sports Traumatol technique detecting subtalar instability Arthrosc. 2016;24(4):1029-1039. 62. Bureau NJ, Cardinal E, Hobden R, Aubin B. Poster ior ankle impingement syndrome: MR imaging findings in seven patients. 2000;215(2):497-503. Radiology. 63. Farooki S, Yao L, Seeger LL. An terolateral impingement of the ankl e: effectiveness of MR imaging. Radiology. 1998;207(2):357-360. 64. Fiorella D, Helms CA, Nunley JA posterior intermalleolar ligament in , 2nd. The MR imaging features of the Skeletal Radiol. 1999;28(10):573-576. patients with posterior impingement syndrome of the ankle. ard F. Anterolateral compartment of the ankle in the 65. Hauger O, Moinard M, Lasalarie JC, Chauveaux D, Di lateral impingement syndrome: appearance on CT arthrography. AJR Am J Roentgenol. 1999;173(3):685-690. 66. Jordan LK, 3rd, Helms CA, Cooperman AE, Speer KP . Magnetic resonance imaging findings in anterolateral impingement of the ankle. Skeletal Radiol. 2000;29(1):34-39. of posterior ankle impingement syndrome in ballet 67. Peace KA, Hillier JC, Hulme A, Healy JC. MRI features dancers: a review of 25 cases. Clin Radiol. 2004;59(11):1025-1033. 68. Robinson P, White LM, Salonen D, Ogilvie-Harris D. Anteromedial impingement of the ankle: using MR arthrography to assess the anteromedial recess. AJR Am J Roentgenol. 2002;178(3):601-604. 69. Robinson P, White LM, Salonen DC, Daniels TR, Og ilvie-Harris D. Anterolateral ankle impingement: mr arthrographic assessment of the anterolateral recess. 2001;221(1):186-190. Radiology. 70. Rubin DA, Tishkoff NW, Britton CA, Conti SF, Towers JD. Anterolateral soft-tissue impingement in the ankle: diagnosis using MR imaging. AJR Am J Roentgenol. 1997;169(3):829-835. 71. Schaffler GJ, Tirman PF, Stoller DW, Genant HK, Ceballos C, Dillingham MF. Impingement syndrome of the ankle following supination external rotation trauma: MR imaging findings with arthroscopic correlation. Eur Radiol. 2003;13(6):1357-1362. l ankle impingement: findings and diagnostic accuracy 72. McCarthy CL, Wilson DJ, Coltman TP. Anterolatera Skeletal Radiol. 2008;37(3):209-216. with ultrasound imaging. 73. Duncan D, Mologne T, Hildebrand H, Stanley M, Sc hreckengaust R, Sitler D. The usefulness of magnetic terolateral impingement of the ankle. resonance imaging in the diagnosis of an J Foot Ankle Surg. 2006;45(5):304-307. I evaluation of anterolateral soft tissue impingement 74. Ferkel RD, Tyorkin M, Applegate GR, Heinen GT. MR Foot Ankle Int. 2010;31(8):655-661. of the ankle. 75. Huh YM, Suh JS, Lee JW, Song HT. Synovitis and soft tissue impingement of the ankle: assessment with enhanced three-dimensional FSPGR MR imaging. J Magn Reson Imaging. 2004;19(1):108-116. 76. Donovan A, Rosenberg ZS. MRI of ankle AJR Am J and lateral hindfoot impingement syndromes. Roentgenol. 2010;195(3):595-604. 77. Cochet H, Pele E, Amoretti N, Brunot S, Lafenetre O, Hauger O. Ante rolateral ankle impingement: diagnostic performance of MDCT arthrography and sonography. AJR Am J Roentgenol. 2010;194(6):1575-1580. 78. Messiou C, Robinson P, O'Connor PJ, Grainger A. S ubacute posteromedial impingement of the ankle in on and ultrasound guided therapy. athletes: MR imaging evaluati Skeletal Radiol. 2006;35(2):88-94. 79. Jones DM, Saltzman CL, El-Khoury G. The diagnosis of the os trigonum syndrome with a fluoroscopically controlled injection of local anesthetic. Iowa Orthop J. 1999;19:122-126. 80. Rodop O, Mahirogullari M, Akyuz M, Sonmez G, Tur gut H, Kuskucu M. Missed talar neck fractures in ankle Acta Orthop Traumatol Turc. distortions. 2010;44(5):392-396. 81. Niva MH, Sormaala MJ, Kiuru MJ, Haataja R, Ahovuo JA , Pihlajamaki HK. Bone stress injuries of the ankle and foot: an 86-month magnetic resonance imaging- based study of physically active young adults. Am J Sports Med. 2007;35(4):643-649. 82. Sormaala MJ, Niva MH, Kiuru MJ, Mattila VM, Pihlaj amaki HK. Stress injuries of the calcaneus detected with magnetic resonance imaging in military recruits. J Bone Joint Surg Am. 2006;88(10):2237-2242. 83. Khoury V, Cardinal E, Bureau NJ. Musculoskel etal sonography: a dynamic tool for usual and unusual disorders. AJR Am J Roentgenol. 2007;188(1):W63-73. 84. Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am. 2008;90(5):992-999. and foot injuries: analysis of MDCT findings. AJR Am J 85. Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle 2004;183(3):615-622. Roentgenol. ® Chronic Ankle Pain 16 ACR Appropriateness Criteria

17 86. Hirschmann MT, Davda K, Rasch H, Arnold MP, Friede rich NF. Clinical value of combined single photon mputer tomography (SPECT/CT) in sports medicine. emission computerized tomography and conventional co 2011;19(2):174-181. Sports Med Arthrosc. 87. Chin KJ, Wong NW, Macfarlane AJ, Chan VW. Ultr asound-guided versus anatomic landmark-guided ankle Reg Anesth Pain Med. blocks: a 6-year retrospective review. 2011;36(6):611-618. 88. Redborg KE, Antonakakis JG, Beach ML, Chinn CD, Sites BD. Ultrasound improves the success rate of a tibial nerve block at the ankle. Reg Anesth Pain Med. 2009;34(3):256-260. 89. Redborg KE, Sites BD, Chinn CD, et al. Ultrasound im proves the success rate of a sural nerve block at the ankle. Reg Anesth Pain Med. 2009;34(1):24-28. 90. American College of Radiology. ACR Appropriate ness Criteria®: Chronic Foot Pain. Available at: https://acsearch.acr.org/docs/69424/Narrativ e/. Accessed December 4, 2017. 91. Bencardino JT, Stone TJ, Roberts CC, et al. ACR Appropriateness Criteria(R) Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. J Am Coll Radiol. 2017;14(5S):S293-S306. 92. American College of Radiology. ACR Appropriate ness Criteria®: Primary Bone Tumors. Available at: https://acsearch.acr.org/docs/69421/Narrativ e/. Accessed December 4, 2017. 93. American College of Radiology. ACR Appropriateness Criteria®: Metastatic Bone Disease. Available at: https://acsearch.acr.org/docs/69431/Narrativ e/. Accessed December 4, 2017. teness Criteria®: Soft-Tissue Masses. Available at: 94. American College of Radiology. ACR Appropria https://acsearch.acr.org/docs/69434/Narrativ e/. Accessed December 4, 2017. 95. Jacobson JA, Roberts CC, Bencardino JT, et al. ACR Appropriateness Criteria(R) Chronic Extremity Joint J Am Coll Radiol. 2017;14(5S):S81-S89. Pain-Suspected Inflammatory Arthritis. ® 96. American College of Radiol ogy. ACR Appropriateness Criteria Radiation Dose Assessment Introduction. Available at: http://www.acr.org/~/media/ACR/Document s/AppCriteria/RadiationDoseAssessmentIntro.pdf. Accessed December 4, 2017. The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for dete rmining appropriate imaging examinations for s, radiation oncolog diagnosis and treatment of specified medi cal condition(s). These criteria are intende d to guide radiologist ists and referring physicians in making decisions regarding radiologic imag and severity of a patient’s clinical condition should dictate the ing and treatment. Generally, the complexity selection of appropriate imaging procedures or treatments. Only those examinations generally us ed for evaluation of the patient ’s condition are ranked. Other imaging studies necessary to evaluate other co-existent di seases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of a ppropriate imaging procedures or treatment s. Imaging techniques classified as investigational by the FDA have not been consider ed in developing these criteria; however, study of new equipment and applications should made by the referring of any specific radiologic examination or treatment must be be encouraged. The ultimate decision regarding the appropriateness stances presented in an individual examination. physician and radiologist in light of all the circum ® Chronic Ankle Pain 17 ACR Appropriateness Criteria

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