This is the current release of the guideline.

This guideline updates a previous version: DeSmet AA, Dalinka MK, Daffner RH, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin DA, Schneider R, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Chronic ankle pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 8 p. [55 references]

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

Chronic ankle pain

To evaluate the appropriateness of radiologic examinations for patients with chronic ankle pain

Patients with chronic ankle 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 "Availability of Companion Documents" field).

Modified Delphi Technique

When the data available from existing scientific studies are insufficient, the American College of Radiology Appropriateness Criteria (ACR AC) employs systematic consensus techniques to determine appropriateness. The ACR AC panels use a modified Delphi technique to determine the rating for a specific procedure. A series of surveys are conducted to elicit each individual panelist's expert opinion of the appropriateness of an imaging or therapeutic procedure for a specific clinical scenario based on the available data. ACR staff distributes surveys to the panelists along with the evidence table and narrative. Each panelist interprets the available evidence and rates each procedure. Voting surveys are completed by panelists without consulting other panelists. The ratings are integers on a scale between 1 and 9, where 1 means the panel member feels the procedure is "least appropriate" and 9 means the panel member feels the procedure is "most appropriate." Each panel member has one vote per round to assign a rating. The surveys are collected and de-identified and the results are tabulated 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. If eighty percent (80%) of the panel members agree on a single rating or one of two consecutive ratings, the final rating is determined by the rating that is closest to the median of all the ratings. Up to three voting rounds are conducted to achieve consensus.

If consensus is not reached through the modified Delphi technique, the panel is convened by conference call. The strengths and weaknesses of each imaging examination or procedure 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, "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.

Note from the American College of Radiology (ACR) and the National Guideline Clearinghouse (NGC): ACR has updated its Relative Radiation Level categories and Rating Scale. The Rating Scale now includes categories (1,2,3 = Usually not appropriate; 4,5,6 = May be appropriate; 7,8,9 = Usually appropriate). See the original guideline document for details.

ACR Appropriateness Criteria®

Clinical Condition: Chronic Ankle Pain

Variant 1: Chronic ankle pain of any origin, best initial study.

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

Variant 2: Multiple sites of degenerative joint disease by ankle radiographs. Next study.

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

Variant 3: Ankle radiographs normal, suspected osteochondral injury. Next study.

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

Variant 4: Ankle radiographs normal, suspected tendon abnormality. Next study.

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

Variant 5: Ankle radiographs normal, suspected ankle instability. Next study.

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

Variant 6: Ankle radiographs normal, suspected ankle impingement syndrome. Next study.

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

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

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

Summary of Literature Review

For assessing chronic ankle pain, there are multiple imaging options, including radiography, stress radiography, radionuclide bone scanning, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and various injection procedures. Injection procedures include arthrography, CT arthrography, magnetic resonance (MR) arthrography, tenography, and diagnostic injection with anesthetic agents. While there are numerous causes for chronic ankle pain, common etiologies can include osteoarthritis, osteochondral injury, tendon abnormalities, ligament abnormalities and instability, and impingement.

Chronic Ankle Pain of Any Origin — Best Initial Study

Radiography should be considered as the initial imaging study to evaluate chronic ankle pain. Radiographs may reveal osteoarthritis, calcified or ossified intra-articular bodies, osteochondral abnormalities, and evidence of prior trauma. Ankle effusions may also be identified in the anterior ankle joint recess by radiography with 53% to 74% accuracy. They are often associated with ligamentous injury or fracture. The presence of ossific fragments can indicate ligamentous injury or retinaculum avulsion, while periostitis can occur adjacent to tenosynovitis. Radiographs can also identify synovial osteochondromatosis and erosions from chronic synovitis. Routine radiographs of the ankle typically include anteroposterior, lateral, and mortise views, the latter obtained by internally rotating the foot 15 to 20 degrees.

Multiple Sites of Degenerative Joint Disease Seen on Ankle Radiographs

When degenerative changes affect the ankle joint, MRI may be considered to evaluate cartilage integrity and associated soft tissues, such as ligaments and tendons, if this information is needed. However, when multiple sites of osteoarthrosis are present, it may be important to determine which joint is the cause of symptoms. Several reports have indicated the effectiveness of fluoroscopically guided anesthetic and corticosteroid injection of joints and tendon sheaths to identify a source of pain, which aided in surgical planning.

Suspected Osteochondral Injury with Normal Ankle Radiographs

Osteochondral injuries may involve the talar dome and uncommonly the tibial plafond. If associated with fracture, osseous cyst, or osteochondral defect, radiography (and bone scan) may show the abnormality; however, radiography often fails to show the extent of the osteochondral injury and will be initially negative if the injury is limited to the articular hyaline cartilage. One multimodality study showed that 41% of osteochondral abnormalities of the ankle were missed on radiography, while CT (noncontrast, multidetector with multiplanar reformatted images) and routine MRI performed similar to arthroscopy; MRI had the highest sensitivity at 0.96, but CT was more specific at 0.99. MRI is also effective in determining if an osteochondral lesion is unstable (sensitivity 0.97), most commonly appearing as a high signal line deep to the osteochondral lesion on T2-weighted images, or less commonly a focal defect, an articular fracture, or an adjacent cyst. MRI has also been used to assess osteochondral abnormalities after cartilage repair. While comparison studies evaluating MR arthrography and CT arthrography for talus osteochondral abnormalities are lacking, the introduction of contrast into the ankle joint prior to MRI or CT will outline a cartilage surface defect.

Suspected Tendon Abnormality with Normal Ankle Radiographs

Possible tendon abnormalities include tenosynovitis, tendinopathy, tendon tear (partial or complete), and tendon subluxation or dislocation. Both MRI and US can effectively demonstrate ankle tendon abnormalities, although US results are more dependent on operator skill and expertise. It is generally accepted that MRI can achieve high sensitivities (>90%) in the diagnosis of ankle tendon tears; however, US can produce similar results, with one study showing that it had a sensitivity of 100% and an accuracy of 93% in diagnosing ankle tendon tears compared to surgical findings. With regard to the tibialis posterior tendon, one study evaluating tendon pathology showed that US was slightly less sensitive than MRI but without affecting clinical management. With regard to peroneal tendon tears, one study of 14 suspected tendon tears on MRI revealed two false-positive and one false-negative result compared to surgical findings, while another study using US showed 100% sensitivity and 90% accuracy in diagnosing peroneal tendon tears. With regard to chronic Achilles tendinopathy, US detected 21/26 and MRI 26/27 cases of tendinosis and partial rupture compared to surgery, and another study showed that US can differentiate full-thickness from partial-thickness Achilles tears with 92% accuracy compared to surgical findings.

One significant advantage of US over MRI is in the dynamic assessment for tendon subluxation and dislocation, with a reported positive predictive value of 100% compared to surgical findings. Diagnostic and therapeutic ankle tenography has also been used, with one study reporting that 47% of patients had prolonged relief of symptoms.

Suspected Ankle Instability with Normal Ankle Radiographs

In the absence of findings on routine radiography, imaging options to evaluate ligamentous integrity include stress radiography, MRI, MR arthrography, and US. One study has shown that MR arthrography was more accurate (100%) in diagnosing chronic anterior talofibular and calcaneofibular ligament tears than MRI (59% to 63%) and stress radiography (65%). This is in contrast to MRI evaluation of acute lateral ankle ligament tears where accuracy has been reported as 94%. US has also been shown to be effective in evaluating acute lateral ankle ligament tears, with accuracy of 100% for anterior talofibular and 92% for calcaneofibular ligament tears proven at surgery. With regard to tears of the tibiofibular ligaments of the tibiofibular syndesmosis, MRI has a reported accuracy of 100%. While MRI can also demonstrate interosseous membrane tears, US has a proven sensitivity of 89% and specificity of 94.5% in diagnosing interosseous membrane tears shown at surgery. When compared to stress radiography, MRI offers the additional advantage of evaluating for injuries associated with or mimicking lateral instability such as tenosynovitis, tendon injury, and osteochondral lesions. MRI may also be used to evaluate the ankle after lateral ligament reconstruction.

Suspected Ankle Impingement Syndrome with Normal Ankle Radiographs

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. In one study, CT arthrography was found to be more accurate than arthroscopy in diagnosing anterolateral impingement syndrome. Studies on the accuracy of MRI in diagnosing anterolateral impingement syndrome have drawn different conclusions. While one study found considerable overlap in the MRI findings in patients with anterolateral impingement and in control individuals, another found that MRI was useful when an ankle effusion was present, and a third found no overlap in the MRI appearance of ankles with anterolateral impingement and control ankles. US also showed abnormal soft tissues in anterolateral impingement with a reported accuracy of 100% in one study. 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 well established. MR arthrography has been found to be an accurate method for assessing both anterolateral and anteromedial impingement with the advantage of joint capsule distention by intra-articular contrast injection. US guided injection has been shown as an effective treatment with posteromedial ankle impingement.

Pain of Uncertain Etiology with Normal Ankle Radiographs

When chronic ankle pain is of unclear etiology, normal ankle radiographs can be followed by other imaging tests, primarily directed by clinical findings. If the patient has a focal soft-tissue abnormality, both US and MRI can be considered. Peripheral nerve-related symptoms can be evaluated with US or MRI; however, US has the benefit of higher resolution. If symptoms are believed to originate from osseous structures, MRI or possibly bone scan can be considered, as well as CT if there is concern for fracture. CT has been shown to be superior to radiography for fracture detection. MRI is effective in detecting osseous stress injuries. Overall, MRI is the imaging test that globally evaluates all anatomic structures, including bone marrow. US with dynamic evaluation should be considered when symptoms are only present during specific movements or positions.

Summary

• Initial evaluation of chronic ankle pain should begin with radiography.
• With multiple sites of degenerative change, pain relief after fluoroscopically guided anesthetic joint injection can indicate which joint is the source of symptoms.
• If there is concern for focal soft-tissue abnormality, such as tendon or ligament abnormality, MRI or US may be considered, with the latter requiring an experienced operator for optimal accuracy.
• Dynamic US should be considered with any soft-tissue abnormality that requires specific joint movement or positioning to produce symptoms, such as with tendon subluxation.
• For suspected osseous abnormality, MRI, CT, and possibly bone scan can be used.
• Overall, MRI is the imaging method that globally evaluates all structures of the ankle.
• If there is concern for an intra-articular process such as osteochondral abnormality or ankle impingement, MR arthrography or MRI may be used, with the latter more effective in the presence of a joint effusion than when no effusion is present.

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 ACR Manual on Contrast Media (see the "Availability of Companion Documents" field).

Abbreviations

• CT, computed tomography
• Med, medium
• Min, minimal
• MR, magnetic resonance
• MRI, magnetic resonance imaging
• NS, not specified
• Tc, technetium
• US, ultrasound

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 ankle pain

Magnetic resonance imaging (MRI) may render false-positive or false-negative results.

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 ACR Manual on Contrast Media (see "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, an 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. Additional information regarding radiation dose assessment for imaging examinations can be found in the American College of Radiology (ACR) Appropriateness Criteria® Radiation Dose Assessment Introduction document (see "Availability of Companion Documents" field).

The 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: Jon A. Jacobson, MD (Principal Author); Richard H. Daffner, MD (Panel Chair); Barbara N. Weissman, MD (Panel Vice-Chair); Erin Arnold, MD; Laura Bancroft, MD; D. Lee Bennett, MD; Judy S. Blebea, MD; Michael A. Bruno, MD; Ian Blair Fries, MD; Jonathan S. Luchs, MD; William B. Morrison, MD; William K. Payne, MD; Charles S. Resnik, MD; Catherine C. Roberts, MD; Mark E. Schweitzer, MD; Leanne L. Seeger, MD; Mihra Taljanovic, MD; James N. Wise, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: DeSmet AA, Dalinka MK, Daffner RH, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Pavlov H, Rubin DA, Schneider R, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Chronic ankle pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 8 p. [55 references]

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 May 22, 2003. The information was verified by the guideline developer on June 23, 2003. This NGC summary was updated by ECRI on January 5, 2006. The updated information was verified by the guideline developer on January 19, 2006. This NGC summary was updated by ECRI Institute on May 18, 2010. 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.

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