This is the current release of the guideline.

This guideline updates a previous version: Jacobson JA, Daffner RH, Weissman BN, Bennett DL, Blebea JS, Morrison WB, Resnik CS, Roberts CC, Rubin DA, Schweitzer ME, Seeger LL, Taljanovic M, Wise JN, Haralson RH III, Payne WK, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic elbow pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 8 p.

The appropriateness criteria are reviewed biennially and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Chronic elbow pain

To evaluate the appropriateness of initial radiologic examinations for chronic elbow pain

Patients with chronic elbow pain

Utility of radiologic examinations in differential diagnosis

Literature Search Procedure

The Medline literature search is based on keywords provided by the topic author. The two general classes of keywords are those related to the condition (e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic intervention of interest (e.g., mammography, MRI).

The search terms and parameters are manipulated to produce the most relevant, current evidence to address the American College of Radiology Appropriateness Criteria (ACR AC) topic being reviewed or developed. Combining the clinical conditions and diagnostic modalities or therapeutic procedures narrows the search to be relevant to the topic. Exploding the term "diagnostic imaging" captures relevant results for diagnostic topics.

The following criteria/limits are used in the searches.

1. Articles that have abstracts available and are concerned with humans.
2. Restrict the search to the year prior to the last topic update or in some cases the author of the topic may specify which year range to use in the search. For new topics, the year range is restricted to the last 5 years unless the topic author provides other instructions.
3. May restrict the search to Adults only or Pediatrics only.
4. Articles consisting of only summaries or case reports are often excluded from final results.

The search strategy may be revised to improve the output as needed.

The total number of source documents identified as the result of the literature search is not known.

Strength of Evidence Key

Category 1 - The conclusions of the study are valid and strongly supported by study design, analysis and results.

Category 2 - The conclusions of the study are likely valid, but study design does not permit certainty.

Category 3 - The conclusions of the study may be valid but the evidence supporting the conclusions is inconclusive or equivocal.

Category 4 - The conclusions of the study may not be valid because the evidence may not be reliable given the study design or analysis.

The topic author drafts or revises the narrative text summarizing the evidence found in the literature. American College of Radiology (ACR) staff draft an evidence table based on the analysis of the selected literature. These tables rate the strength of the evidence for all articles included in the narrative text.

The expert panel reviews the narrative text, evidence table, and the supporting literature for each of the topic-variant combinations and assigns an appropriateness rating for each procedure listed in the table. Each individual panel member forms his/her own opinion based on his/her interpretation of the available evidence.

More information about the evidence table development process can be found in the ACR Appropriateness Criteria® Evidence Table Development document (see the "Availability of Companion Documents" field).

Modified Delphi Technique

The appropriateness ratings for each of the procedures included in the Appropriateness Criteria topics are determined using a modified Delphi methodology. A series of surveys are conducted to elicit each panelist's expert interpretation of the evidence, based on the available data, regarding the appropriateness of an imaging or therapeutic procedure for a specific clinical scenario. American College of Radiology (ACR) staff distributes surveys to the panelists along with the evidence table and narrative. Each panelist interprets the available evidence and rates each procedure. The surveys are completed by panelists without consulting other panelists. The ratings are a scale between 1 and 9, which is further divided into three categories: 1, 2, or 3 is defined as "usually not appropriate"; 4, 5, or 6 is defined as "may be appropriate"; and 7, 8, or 9 is defined as "usually appropriate." Each panel member assigns one rating for each procedure per survey round. The surveys are collected and the results are tabulated, de-identified and redistributed after each round. A maximum of three rounds are conducted. The modified Delphi technique enables each panelist to express individual interpretations of the evidence and his or her expert opinion without excessive bias from fellow panelists in a simple, standardized and economical process.

Consensus among the panel members must be achieved to determine the final rating for each procedure. Consensus is defined as eighty percent (80%) agreement within a rating category. The final rating is determined by the median of all the ratings once consensus has been reached. Up to three rating rounds are conducted to achieve consensus.

If consensus is not reached, the panel is convened by conference call. The strengths and weaknesses of each imaging procedure that has not reached consensus are discussed and a final rating is proposed. If the panelists on the call agree, the rating is accepted as the panel's consensus. The document is circulated to all the panelists to make the final determination. If consensus cannot be reached on the call or when the document is circulated, "No consensus" appears in the rating column and the reasons for this decision are added to the comment sections.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

ACR Appropriateness Criteria®

Clinical Condition: Chronic Elbow Pain

Variant 1: Evaluation for chronic elbow pain. First test.

Radiologic Procedure	Rating	Comments	RRL*
X-ray elbow	9
MRI elbow without contrast	1		O
MR arthrography elbow	1		O
CT elbow without contrast	1
CT arthrography elbow	1
US elbow	1		O
Tc-99m bone scan elbow	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 2: Suspect intra-articular osteocartilaginous body; radiographs nondiagnostic.

Radiologic Procedure	Rating	Comments	RRL*
MRI elbow without contrast	9	Either routine MRI or MR arthrogram is appropriate. Depends on availability, expertise, and local conditions. If effusion is present, without contrast is preferred.	O
MR arthrography elbow	9	Either routine MRI or MR arthrogram is appropriate. Depends on availability, expertise, and local conditions. See statement regarding contrast in text under "Anticipated Exceptions."	O
CT elbow without contrast	8
CT arthrography elbow	8	If double contrast is used, dose should be less than 0.5 cc.
US elbow	6	With appropriate expertise.	O
Tc-99m bone scan elbow	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 3: Suspect occult injury; (e.g., osteochondral injury); radiographs nondiagnostic.

Radiologic Procedure	Rating	Comments	RRL*
MRI elbow without contrast	9		O
CT elbow without contrast	2
MR arthrography elbow	2		O
CT arthrography elbow	2
Tc-99m bone scan elbow	2
US elbow	1		O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 4: Suspect unstable osteochondral injury; radiographs nondiagnostic.

Radiologic Procedure	Rating	Comments	RRL*
MRI elbow without contrast	9	Either routine MRI or MR arthrogram is appropriate. Depends on availability, expertise, and local conditions.	O
MR arthrography elbow	9	Either routine MRI or MR arthrogram is appropriate. Depends on availability, expertise, and local conditions. See statement regarding contrast in text under "Anticipated Exceptions."	O
CT arthrography elbow	8	If MR is contraindicated or not available.
CT elbow without contrast	2
US elbow	1		O
Tc-99m bone scan elbow	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 5: Suspect soft-tissue mass; radiographs nondiagnostic.

Radiologic Procedure	Rating	Comments	RRL*
MRI elbow without and with contrast	9	Contrast may not be necessary in all cases. See statement regarding contrast in text under "Anticipated Exceptions."	O
US elbow	5	With appropriate expertise.	O
Tc-99m bone scan elbow	2
CT elbow without and with contrast	2
CT arthrography elbow	1
MR arthrography elbow	1		O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 6: Suspect chronic epicondylitis; radiographs nondiagnostic.

Radiologic Procedure	Rating	Comments	RRL*
MRI elbow without contrast	9		O
US elbow	8	An alternative to MRI if expertise is available	O
MR arthrography elbow	2		O
CT elbow without contrast	1
CT arthrography elbow	1
Tc-99m bone scan elbow	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 7: Suspect collateral ligament tear; radiographs nondiagnostic.

Radiologic Procedure	Rating	Comments	RRL*
MR arthrography elbow	9	Either routine MRI or MR arthrogram is appropriate. Depends on availability, expertise, and local conditions. See statement regarding contrast in text under "Anticipated Exceptions."	O
MRI elbow without contrast	9	Either routine MRI or MR arthrogram is appropriate. Depends on availability, expertise, and local conditions.	O
US elbow	6	With appropriate expertise.	O
CT arthrography elbow	5
CT elbow without contrast	2
Tc-99m bone scan elbow	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 8: Suspect biceps tendon tear and/or bursitis; radiographs nondiagnostic.

Radiologic Procedure	Rating	Comments	RRL*
MRI elbow without contrast	9		O
US elbow	8	An alternative to MRI if expertise is available.	O
MR arthrography elbow	1		O
CT elbow without contrast	1
CT arthrography elbow	1
Tc-99m bone scan elbow	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 9: Suspect nerve abnormality; radiographs nondiagnostic.

Radiologic Procedure	Rating	Comments	RRL*
MRI elbow without contrast	9		O
US elbow	8	An alternative to MRI if expertise is available. Dynamic US is ideal for assessing ulnar nerve dislocation and snapping triceps syndrome.	O
MR arthrography elbow	1		O
CT elbow without contrast	1
CT arthrography elbow	1
Tc-99m bone scan elbow	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 10: Elbow stiffness; suspect heterotopic ossification/osteophytosis by radiograph. Next test.

Radiologic Procedure	Rating	Comments	RRL*
CT elbow without contrast	9
MRI elbow without contrast	5		O
US elbow	1		O
MR arthrography elbow	1		O
CT arthrography elbow	1
Tc-99m bone scan elbow	1
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 11: Suspect osseous tumor per radiographs. Next test.

Radiologic Procedure	Rating	Comments	RRL*
MRI elbow without and with contrast	9		O
CT elbow with or without contrast	5
US elbow	1		O
MR arthrography elbow	1		O
CT arthrography elbow	1
Tc-99m bone scan elbow	1	If multifocal disease suspected.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Summary of Literature Review

Chronic elbow pain may be caused by a variety of osseous abnormalities, soft-tissue abnormalities, or both. Exclusion of an osseous abnormality with radiographs may be helpful when conservative therapy is planned. In some cases, radiographs may reveal the cause of the problem (e.g., intra-articular osteocartilaginous body, osteophytes, heterotopic ossification, or calcification in and around the joint in the form of hydroxyapatite deposition or calcium pyrophosphate crystal deposition). When the etiology of the chronic pain is uncertain and the patient has failed appropriate conservative therapeutic trials (e.g., anti-inflammatory medication, physical therapy, and/or corticosteroid injection), other imaging studies may be considered. While computed tomography (CT) and ultrasound (US) may be used for specific indications, magnetic resonance imaging (MRI) can be used to display most abnormalities in the elbow. The success of US varies depending on the training and experience of the person performing the examination, as well as the US equipment. Imaging choices will be considered for a variety of clinical conditions.

Osteochondral Lesion or Intra-articular Body

Radiographs are required before other imaging studies and may be diagnostic for fracture, osteochondritis dissecans, and osteocartilaginous intra-articular body (IAB). CT and CT arthrography with single-contrast (iodinated contrast or air) and double-contrast (iodinated contrast and air) techniques are superior to radiography for detecting a chondral or osteochondral lesion or IAB. All of these studies have limitations; a small IAB may be obscured by contrast or confused with air bubbles (double-contrast arthrography). A CT air arthrogram can avoid confusion of air bubbles with IABs. MRI has been advocated as the initial study for suspected osteochondral fracture or IAB. Regardless of method, detection of an IAB is limited by its size and location within the elbow joint, although detection is enhanced by the presence of joint effusion. Both CT and MRI can assess for osteochondral fragment stability. MRI following direct intra-articular contrast administration is preferred to routine MRI for diagnosing IAB and may also play a role in improving diagnosis of stability of an osteochondral lesion. While US may show osteochondral abnormalities in some situations, MRI offers a more comprehensive evaluation of them.

Other Osseous Abnormalities

There are a number of other osseous abnormalities about the elbow that may cause chronic elbow pain. Initial evaluation should begin with radiography. Both traumatic and stress fractures may be identified with MRI and bone scan. CT is superior to radiography in the preoperative assessment of osteophytosis or heterotopic ossification in the patient with symptomatic stiff elbow. Primary bone tumors are characterized with radiography, CT, and MRI before and after intravenous gadolinium administration. While the whole-body extent of osseous metastatic disease is assessed with bone scan, MRI will evaluate local extent.

Tendon, Ligament, Muscle, Nerve, or Other Soft-Tissue Abnormality

MRI may provide important diagnostic information for evaluating the elbow in many different conditions, including collateral ligament injury, epicondylitis, injury to the biceps and triceps tendons, and abnormality of the ulnar, radial, or median nerve, and for evaluating masses about the elbow joint. There is a lack of studies showing the sensitivity and specificity of MRI in many of these conditions; most of the studies demonstrate MRI findings in patients either known or highly likely to have a specific condition. US has been shown to be helpful for diagnosing abnormalities of the distal biceps tendon, flexor and extensor tendons, and ligaments, providing an alternative to MRI.

Radiographs can be useful to identify heterotopic calcification (ossification) of the ulnar collateral ligament. This finding may be associated with partial or complete tears of that structure. Avulsion of the ulnar collateral ligament at the insertion site on the ulna is a source of chronic medial elbow pain in the throwing athlete. While US has been shown to detect medial epicondylar fragmentation of the humerus in throwing athletes, this finding is optimally evaluated with a combination of radiographs and coronal MRI. MR arthrography has been advocated to distinguish complete tears from partial tears of the ulnar collateral ligament.

With use of appropriate pulse sequences, MRI is an effective tool in the preoperative diagnosis of posterolateral rotatory instability. This includes assessment of the ulnar band of the lateral collateral ligament. Epicondylitis—caused by tendon degeneration and tear of the common extensor tendon laterally ("tennis elbow") or the common flexor tendon medially (in pitchers, golfers, and tennis players)—is a common clinical diagnosis, and imaging is usually not necessary. MRI or US may be useful for confirming the diagnosis in refractory cases and to exclude associated tendon and ligament tear.

Bicipitoradial and interosseous bursitis around the distal biceps tendon is a source of elbow pain that can be assessed with MRI or US. MRI also demonstrates the effects of the bursa on adjacent structures, including the posterior interosseous and median nerves. MRI effectively characterizes a soft-tissue mass, showing its extent and differentiating between intra-articular mass, lymph node (as in cat scratch disease), pseudomass from tendon tear, and other soft-tissue masses.

The ulnar nerve is particularly vulnerable to trauma from a direct blow in the region of its superficial location in the restricted space of the cubital tunnel. Anatomic variations of the cubital tunnel retinaculum may contribute to ulnar neuropathy. Axial T1-weighted MR images have been shown to depict the size and shape of the nerve, and axial T2-weighted or short tau inversion recovery (STIR) images may show increased signal in the presence of neuritis, and both are more sensitive than conventional nerve conduction studies. US may also show ulnar nerve enlargement and when added to electrodiagnostic tests, increases sensitivity for the diagnosis of ulnar neuropathy at the elbow from 78% to 98%. A snapping of the medial head of the triceps can cause recurrent dislocation of the ulnar nerve. This diagnosis can be confirmed with MRI or CT using axial images with the elbow in flexion and extension. US is ideal for dynamic assessment of ulnar nerve subluxation and dislocation, as well as for confirmation of snapping triceps syndrome. Radial nerve and median nerve entrapment syndromes may also be evaluated with MRI.

Chronic elbow pain may also be caused by a number of joint-related processes, such as inflammatory arthritis (and chronic infection), as well as other synovial proliferative disorders. Evaluation begins with radiography to assess for joint distention and erosions. MRI can also show erosions, and is effective in characterizing synovitis (low signal suggests hemosiderin) and the extent and activity of disease. In the setting of rheumatoid arthritis, US can be used to detect joint effusion, synovitis, and erosions.

Summary

• Initial evaluation of chronic elbow pain should begin with radiography.
• Chondral and osteochondral abnormalities can be further evaluated with MRI or CT. The addition of arthrography is helpful, especially for detecting intra-articular bodies.
• Radiographically occult bone abnormalities can be detected with MRI.
• Soft-tissue abnormalities (tendon, ligament, nerve, joint recess) are well-demonstrated with MRI or US.
• Dynamic assessment with US is effective for diagnosing nerve or muscle subluxation.

Anticipated Exceptions

Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rate (GFR) (i.e., <30 mL/min/1.73 m²), and almost never in other patients. There is growing literature regarding NSF. Although some controversy and lack of clarity remain, there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1.73 m². For more information, please see the American College of Radiology (ACR) Manual on Contrast Media (see the "Availability of Companion Documents" field).

Abbreviations

• CT, computed tomography
• MR, magnetic resonance
• MRI, magnetic resonance imaging
• Tc, technetium
• US, ultrasound

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 NS (not specified).

Algorithms were not developed from criteria guidelines.

The recommendations are based on analysis of the current literature and expert panel consensus.

Selection of appropriate radiologic imaging procedures for evaluation of patients with chronic elbow pain

Gadolinium-Based Contrast Agents

Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rate (GFR) (i.e., <30 mL/min/1.73 m²), and almost never in other patients. Although some controversy and lack of clarity remain, there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1.73 m². For more information, please see the American College of Radiology (ACR) Manual on Contrast Media (see the "Availability of Companion Documents" field).

Relative Radiation Level (RRL)

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 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, both because of 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 to those specified for adults. Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document (see the "Availability of Companion Documents" field).

An American College of Radiology (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 exams 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 U.S. Food and Drug Administration (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.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Musculoskeletal Imaging

Panel Members: Curtis W. Hayes, MD (Principal Author); Richard H. Daffner, MD (Panel Chair); Barbara N. Weissman, MD (Panel Vice-chair); Erin Arnold, MD; Laura W. Bancroft, MD; D. Lee Bennett, MD, MA; Judy S. Blebea, MD; Michael A. Bruno, MD; Ian Blair Fries, MD; Mark J. Kransdorf, MD; Jonathan S. Luchs, MD; William B. Morrison, MD; Christopher J. Palestro, MD; Catherine C. Roberts, MD; David W. Stoller, MD; Mihra S. Taljanovic, MD; Michael J. Tuite, MD; Robert J. Ward, MD; James N. Wise, MD; Adam C. Zoga, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Jacobson JA, Daffner RH, Weissman BN, Bennett DL, Blebea JS, Morrison WB, Resnik CS, Roberts CC, Rubin DA, Schweitzer ME, Seeger LL, Taljanovic M, Wise JN, Haralson RH III, Payne WK, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic elbow pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 8 p.

The appropriateness criteria are reviewed biennially and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site.

Print copies: Available from the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

The following are available:

• ACR Appropriateness Criteria®. Overview. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site.
• ACR Appropriateness Criteria®. Literature search process. Reston (VA): American College of Radiology; 1 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.
• ACR Appropriateness Criteria®. Evidence table development. Reston (VA): American College of Radiology; 4 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.
• ACR Appropriateness Criteria®. Radiation dose assessment introduction. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site.
• ACR Appropriateness Criteria® Manual on contrast media. Reston (VA): American College of Radiology; 90 p. Electronic copies: Available in PDF from the ACR Web site.

None available

This summary was completed by ECRI on May 6, 2001. The information was verified by the guideline developer as of June 29, 2001. This summary was updated by ECRI on July 31, 2002. The updated information was verified by the guideline developer on October 1, 2002. This NGC summary was updated by ECRI on January 4, 2006. The updated information was verified by the guideline developer on January 19, 2006. This summary was updated by ECRI Institute on June 25, 2009. This summary was updated by ECRI Institute on January 13, 2011 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents. This NGC summary was updated by ECRI Institute on February 28, 2012.

Instructions for downloading, use, and reproduction of the American College of Radiology (ACR) Appropriateness Criteria® may be found on the ACR Web site .