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## Complete Summary

#### GUIDELINE TITLE

Chronic ankle pain.

#### BIBLIOGRAPHIC SOURCE(S)

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. \[55 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology
(ACR), Expert Panel on Musculoskeletal Imaging. Chronic ankle pain.
Reston (VA): American College of Radiology (ACR); 2002. 12 p. (ACR
appropriateness criteria).

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

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Chronic ankle pain

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Nuclear Medicine\
Orthopedic Surgery\
Podiatry\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

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

#### TARGET POPULATION

Patients with chronic ankle pain

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray

    -   Anterior-posterior (AP) view

    -   Lateral view

    -   Mortise view

    -   Stress films\--with manual stressing

    -   Stress films\--stress using biomechanical device

    -   Stress films\--manual stress while under general anesthesia

2.  Nuclear medicine (NUC), bone scan

3.  Ultrasound (US)

4.  Magnetic resonance imaging (MRI)

5.  Computed tomography (CT)

6.  Conventional arthrography

7.  CT arthrography

8.  Magnetic resonance (MR) arthrography

9.  Tenography

10. Diagnostic injection of anesthetic

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

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

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1 to 9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by this Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

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

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

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

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Chronic Ankle Pain**

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

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, ankle, AP,    9                    
  lateral, and mortise                     
  views                                    

  X-ray, ankle, stress 2                    
  films \-- with                           
  manual stressing                         

  X-ray, ankle, stress 2                    
  films \-- stress                         
  using biomechanical                      
  device                                   

  X-ray, ankle, stress 2                    
  films - manual                           
  stress while under                       
  general anesthesia                       

  NUC, bone scan       2                    

  US, ankle            2                    

  MRI, ankle           2                    

  CT, ankle            2                    

  Conventional         2                    
  arthrography, ankle                      

  CT arthrography,     2                    
  ankle                                    

  MR arthrography,     2                    
  ankle                                    

  Tenography, ankle    2                    

  Diagnostic injection 2                    
  of anesthetic                            

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

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

**Variant 2: Suspected osteochondral injury, ankle radiographs normal.
Next study.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, ankle           9                    

  US, ankle            2                    

  CT, ankle            2                   If MRI not available.

  X-ray, ankle, stress 2                    
  films - with manual                      
  stressing                                

  X-ray, ankle, stress 2                    
  films - stress using                     
  biomechanical device                     

  X-ray, ankle, stress 2                    
  films - manual                           
  stress while under                       
  general anesthesia                       

  NUC, bone scan       2                    

  Conventional         2                    
  arthrography, ankle                      

  CT arthrography,     2                    
  ankle                                    

  MR arthrography,     2                    
  ankle                                    

  Tenography, ankle    2                    

  Diagnostic injection 2                    
  of anesthetic, ankle                     

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

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

**Variant 3: Suspected tendinopathy, ankle radiographs normal. Next
study.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, ankle           9                    

  US, ankle            6                   Only if experienced examiner
                                           available

  CT, ankle            2                    

  X-ray, ankle, stress 2                    
  films - with manual                      
  stressing                                

  X-ray, ankle, stress 2                    
  films - stress using                     
  biomechanical device                     

  X-ray, ankle, stress 2                    
  films - manual                           
  stress while under                       
  general anesthesia                       

  NUC, bone scan       2                    

  Conventional         2                    
  arthrography, ankle                      

  CT arthrography,     2                    
  ankle                                    

  MR arthrography,     2                    
  ankle                                    

  Tenography, ankle    2                    

  Diagnostic injection 2                    
  of anesthetic, ankle                     

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

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

**Variant 4: Suspected ankle instability, ankle radiographs normal. Next
study.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, ankle           3                    

  US, ankle            2                    

  CT, ankle            2                    

  X-ray, ankle, stress 2                    
  films - with manual                      
  stressing                                

  X-ray, ankle, stress 2                    
  films - stress using                     
  biomechanical device                     

  X-ray, ankle, stress 2                    
  films - manual                           
  stress while under                       
  general anesthesia                       

  NUC, bone scan       2                    

  Conventional         2                    
  arthrography, ankle                      

  CT arthrography,     2                    
  ankle                                    

  MR arthrography,     2                    
  ankle                                    

  Tenography, ankle    2                    

  Diagnostic injection 2                    
  of anesthetic, ankle                     

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

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

**Variant 5: Pain of uncertain etiology, ankle radiographs normal. Next
study.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, ankle           6                   If patient needs an imaging study,
                                           it should be MRI.

  Diagnostic injection 5                   Depending on clinical implication
  of anesthetic, ankle                     and severity of pain

  US, ankle            2                    

  CT, ankle            2                    

  Conventional         2                    
  arthrography, ankle                      

  CT arthrography,     2                    
  ankle                                    

  MR arthrography,     2                    
  ankle                                    

  Tenography, ankle    2                    

  X-ray, ankle, stress 2                    
  films - with manual                      
  stressing                                

  X-ray, ankle, stress 2                    
  films - stress using                     
  biomechanical device                     

  X-ray, ankle, stress 2                    
  films - manual                           
  stress while under                       
  general anesthesia                       

  NUC, bone scan       2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

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

**Variant 6: Multiple sites of degenerative joint disease (DJD) by ankle
radiographs, operative candidate. Next study.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  Diagnostic injection 6                    
  of anesthetic, ankle                     

  Conventional         2                    
  arthrography, ankle                      

  CT arthrography,     2                    
  ankle                                    

  MR arthrography,     2                    
  ankle                                    

  Tenography, ankle    2                    

  X-ray, ankle, stress 2                    
  films - with manual                      
  stressing                                

  X-ray, ankle, stress 2                    
  films - stress using                     
  biomechanical device                     

  X-ray, ankle, stress 2                    
  films - manual                           
  stress while under                       
  general anesthesia                       

  NUC, bone scan       2                    

  US, ankle            2                    

  MRI, ankle           2                    

  CT, ankle            2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

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

**Variant 7: Suspected ankle impingement syndrome, initial ankle
radiographs normal. Next study.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, ankle           8                    

  MR arthrography,     8                    
  ankle                                    

  CT arthrography,     4                    
  ankle                                    

  Diagnostic injection 4                    
  of anesthetic in the                     
  ankle                                    

  NUC, bone scan       2                    

  US, ankle            2                    

  CT, ankle            2                    

  Conventional         2                    
  arthrography, ankle                      

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

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

For assessing chronic ankle pain, there are multiple imaging options,
including stress radiography, radionuclide bone scanning, ultrasound
(US), computed tomography (CT), magnetic resonance imaging (MRI), and
injection procedures. Injection procedures include arthrography, CT
arthrography, magnetic resonance (MR) arthrography, and diagnostic
injection with anesthetics. There have been no studies specifically
addressing the value of radiographs in assessing chronic ankle pain.
However, radiographs are routinely obtained as the first option to
exclude arthritis, infection, fracture, or neoplasm.

Ankle instability has traditionally been imaged using radiographs
obtained with varus, valgus, or anterior stress on the ankle. However,
recent studies have questioned the value of stress radiographs. Even
with a mechanical stress device, there is overlap between stable and
unstable ankles. Patients may have successful surgery for clinically
unstable ankles even if the stress radiographs are normal. One study
found that stress radiographs obtained preoperatively were not as
accurate as intraoperative stress films while the patient is under
general anesthesia. Another study found that MR arthrography was
significantly more accurate than stress radiography in detecting chronic
tears of the ankle ligaments. A review of eight prospective clinical
series using stress radiography for assessment of chronic instability
concluded that \"the large variability in talar tilt and anterior draw
values in both injured and noninjured ankles precludes their routine
use.\" More recently, a comparison of stress radiography and stress
radiostereometry for assessing syndesmotic injuries in a cadaver model
concluded that stress radiography is not reliable for assessing these
injuries. However another study reported that both stress radiography
and MRI were both accurate in diagnosing the extent of both lateral
ligament and syndesmosis injuries. The accuracy of MRI for diagnosing
tibiofibular syndesmotic injuries was also confirmed in a study
comparing routine radiography and MRI with ankle arthroscopy. 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.

Radionuclide bone scanning, CT, and MRI have been used to assess the
ankle joint for osteochondral injuries. Two studies reported that ankle
CT is useful in assessing persistent ankle pain after trauma. One study
used CT to evaluate 31 consecutive patients with chronic ankle pain
after an injury. Thirteen of these 31 patients had normal radiographs
but had occult intra-articular or juxta-articular fractures noted on CT.
In one study, four of 32 osteochondral lesions of the talus were occult
by radiographs but identified on direct coronal CT scanning. Another
study reviewed 92 patients with talar osteochondral lesions. Although
they did not report the accuracy for occult lesions alone, only 66% of
the osteochondral lesions were seen on radiographs, but the sensitivity
was 99% with bone scanning and 98% with CT. There have been no reports
on the accuracy of CT arthrography for detecting osteochondral fractures
in the ankle. However, case reports suggest that CT arthrography can
help detect intra-articular loose bodies and assess the stability of
osteochondritis dissecans.

MRI can be used to assess osteochondritis dissecans of the talus with a
high accuracy in determining lesion stability. In a multimodality study,
17 cases of occult osteochondral fractures were found in 30 patients
with normal radiographs and posttraumatic chronic ankle pain. MRI
detected all occult osteochondral injuries, bone scanning missed one,
and CT missed four. Radiography has also been shown to be unreliable for
detecting osteochondritis dissecans of the tibial plafond. The accuracy
of MRI and its ability to stage osteochondritis dissecans of the talar
dome have also been assessed in a study of 54 patients who had operative
confirmation of the presence and stage of their lesions. MRI may also
have a role in monitoring the healing of an osteochondral lesion after
surgery.

Ankle tendon pathology has been studied using tenography, CT, MRI, and
US. Tenography uniquely demonstrates the configuration of the tendon
sheath and can identify tenosynovial irregularity and focal stenosis.
One study found that five patients with tenographic evidence of moderate
to severe tenosynovitis failed conservative treatment but that three
patients with normal or minimally abnormal tenograms responded to
conservative treatment. However, another study reported a series of 111
patients who had tenography and injection of anesthetic and
corticosteroid. They found that 47% of patients who had been previously
refractory to treatment had prolonged relief after injection. The degree
of tenosynovitis on tenography did not correlate with the therapeutic
response. Other authors found peroneal stenosing tenosynovitis in ten
patients with prior calcaneal fractures.

Both CT and MRI can be used to identify tendon pathology. The greater
tissue contrast of MRI and its sensitivity to fluid allow easier and
more specific diagnosis of chronic tendinitis and partial and complete
tendon tears. Rosenberg et al found a slightly lower accuracy for CT
than MRI in distinguishing an intact from a torn ankle tendon. However,
MRI was significantly more accurate than CT in staging the severity of
the tendon injury. One report found that MRI staging was more accurate
in predicting patient outcome after tendon reconstruction than
intraoperative staging. MRI is also useful for diagnosing injuries of
the superior peroneal retinaculum.

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 accurate in diagnosing anterolateral impingement
syndrome when compared to arthroscopy. 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 of patients with anterolateral impingement and 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
patients with anterolateral impingement and control ankles. 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.

Recently, US has been used in assessing ankle tendon pathology. Although
a limitation of US is the dependence on operator skill, several studies
have reported a high degree of accuracy. In one series in which 54
tendons were examined by US and surgery, the sensitivity and specificity
of US for tendon tears were 100% and 88%, respectively. In another
series with surgical correlation, One study found that the sensitivity
and specificity for detection of ankle tendon pathology were 100% and
89.9% for US and 23.4% and 100% for MRI. However, the sensitivity of MRI
for tendon pathology in this study was much lower than the 92 to 95%
previously reported. Sonography of posterior tibial tendinopathy was
found to have a sensitivity of 80% and specificity of 90% when MRI was
used as the gold standard. A unique advantage of sonography when
compared to CT and MRI is the ability to perform dynamic imaging for
conditions such as subluxation of the peroneal tendons and identify
causes of tendon impingement.

Injection procedures include CT arthrography, MR arthrography, and
tenography as discussed above, as well as conventional arthrography and
diagnostic injections with anesthetic. Another study performed
arthrograms to assess the ankle ligaments in 61 patients with chronic
ankle instability and noted 20 true-positive, one false-positive, and
four false-negative arthrograms in 25 patients who underwent surgery.
Ankle arthrography is also useful to diagnose adhesive capsulitis after
ankle trauma. The importance of post-traumatic adhesive capsulitis has
not been determined.

Although anesthetic injection has been shown to be useful in assessment
of hindfoot pain, the value of this technique has not been studied in
the ankle joint itself. One report states that Xylocaine injection into
the peroneal tendon sheaths of ten patients helped to confirm that the
patients\' pain was due to tendon pathology.

**Abbreviations**

-   AP, anterior-posterior

-   CT, computed tomography

-   MR, magnetic resonance

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

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

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

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. \[55 references\]

#### ADAPTATION

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

#### DATE RELEASED

1998 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

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

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Musculoskeletal
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Arthur A. DeSmet, MD (*Principal Author*); Murray K.
Dalinka, MD (*Panel Chair*); Richard H. Daffner, MD; George Y.
El-Khoury, MD; John B. Kneeland, MD; B.J. Manaster, MD, PhD; William B.
Morrison, MD; Helene Pavlov, MD; David A. Rubin, MD; Robert Schneider,
MD; Lynne S. Steinbach, MD; Barbara N. Weissman, MD; Robert H. Haralson
III, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology
(ACR), Expert Panel on Musculoskeletal Imaging. Chronic ankle pain.
Reston (VA): American College of Radiology (ACR); 2002. 12 p. (ACR
appropriateness criteria).

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

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ChronicAnklePainDoc5.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

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

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. 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](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

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.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

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Date Modified: 11/3/2008