This is the current release of the guideline.

This guideline updates a previous version: El-Khoury GY, Bennett DL, Dalinka MK, Daffner RH, DeSmet AA, 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 foot pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 7 p. [58 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 foot pain

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

Patients with chronic foot 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 Foot Pain

Variant 1: Child or adolescent with painful rigid flat foot. Rule out tarsal coalition.

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

Variant 2: To rule out reflex sympathetic dystrophy.

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

Variant 3: Pain and tenderness over head of second metatarsal. Rule out Freiberg's disease.

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

Variant 4: Pain and tenderness over the navicular tuberosity, unresponsive to conservative therapy. Radiographs showed accessory navicular.

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

Variant 5: Evaluation for inflammatory arthropathy, including rheumatoid arthritis and seronegative arthritis.

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

Variant 6: Young athlete presenting with localized pain at the plantar aspect of the heel. Plantar fasciitis is suspected clinically.

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

Variant 7: Middle-aged woman with burning pain and paresthesias along the plantar surface of the foot and toes. Clinically, the patient is suspected of having tarsal tunnel syndrome.

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

Variant 8: Patient is complaining of pain in the 3-4 web space with radiation to the toes. Morton's neuroma is clinically suspected.

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

Variant 9: Athlete with pain and tenderness over tarsal navicular; radiographs are unremarkable.

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

Variant 10: Evaluation for suspected tendinopathy.

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

Summary of the Literature Review

Many conditions can affect the foot and cause chronic foot pain. Some of these conditions and techniques to image them are reviewed here.

Tarsal Coalition

Tarsal coalition is a congenital abnormality resulting from fibrous, cartilaginous, or osseous union of two or more tarsal bones. Calcaneonavicular and middle-facet talocalcaneal coalitions are the most common. In about half the patients the coalition is bilateral. Calcaneonavicular coalition is easily detected on oblique radiographs of the foot and confirmed by computed tomography (CT). Talocalcaneal (subtalar) coalition is often associated with severe valgus deformity of the hind foot, rigid painful flat foot, and restricted subtalar motion. It is frequently overlooked on standard foot radiographs because of overlapping structures; however, secondary signs on the lateral view could be suggestive of a subtalar coalition. These signs include talar beaking, flattening and broadening of the lateral talar process, positive C-sign, and narrowing of the posterior talocalcaneal joint. A well-penetrated axial view (Harris-Beath view) can demonstrate the posterior and middle subtalar joints.

CT of the subtalar joint is usually diagnostic. Magnetic resonance imaging (MRI) has been shown to be effective in depicting all types of coalition. Inversion-recovery MRI may reveal bone marrow edema along the margins of the abnormal articulation, which is an important clue to the diagnosis.

Reflex Sympathetic Dystrophy

Reflex sympathetic dystrophy (RSD), also called complex regional pain syndrome type I (CRPS I), is characterized clinically by pain, tenderness, swelling, diminished motor function, and vasomotor instability. Conditions associated with RSD of the foot include fractures and other trauma, central nervous system (CNS) and spinal disorders, and peripheral nerve injury. RSD has also been described in children; the patients are predominantly girls. Early diagnosis favorably affects outcome. Diffuse osteopenia of the involved part is seen in 69% of patients with RSD. The osteopenia patterns are not pathognomonic and can be seen as a result of disuse. Three-phase radionuclide scans have been used to diagnose RSD. One study reported a characteristic delayed bone scan pattern consisting of diffuse increased tracer throughout the foot, with juxta-articular accentuation of tracer uptake. Overall sensitivity in this study was 100%, specificity 80%, positive predictive value 54%, and negative predictive value 100%. There are no specific findings on MRI in patients with RSD. Using power Doppler sonography, patients with RSD of the lower extremity have increased power Doppler flow compared with asymptomatic control subjects.

Avascular Necrosis of the Metatarsal Head (Freiberg's Disease)

This disease is characterized by pain, tenderness, swelling, and limitation of motion in the affected metatarsophalangeal (MTP) joint. The disease is usually detected in adolescents, and adolescent girls predominate about three or four to one. Radiographic changes are characteristic, and they show increased density of the metatarsal head, and flattening, collapse, cystic changes, and widening of the MTP joint. The second metatarsal is most commonly affected, although the third and fourth can also be occasionally involved.

Painful Accessory Bones

Potentially painful normal variants such as accessory navicular and os trigonum have been described. Pain in the presence of an accessory navicular has been attributed to traumatic or degenerative changes at the synchondrosis or to soft-tissue inflammation. Symptomatic accessory navicular bones have been studied with radionuclide bone scans and MRI. Symptomatic lesions are reported to show increased radiotracer uptake or marrow edema across the synchondrosis.

For a painful os trigonum, selective arthrography of the synchondrosis followed by local anesthetic injection localizes the source of pain.

Arthritis

All the common forms of arthritis, including rheumatoid and seronegative arthritis, affect the feet and can cause chronic foot pain. Most of the arthritides are best evaluated with plain radiography. Charcot changes are still best detected and followed by plain radiography also. There is now evidence that gadolinium-enhanced MRI can be helpful in detecting early rheumatoid arthritis and seronegative arthritis.

Chronic heel pain can be caused by calcaneal stress fractures, tarsal tunnel syndrome, and plantar fasciitis. When the heel pain is bilateral, the seronegative arthritides warrant consideration.

Plantar Fasciitis

Plantar fasciitis is the most common cause of plantar heel pain. It may occur in isolation or as a manifestation of a systemic disease such as the seronegative spondyloarthropathies, rheumatoid arthritis, gout, or systemic lupus erythematosus (SLE). In athletes, plantar fasciitis is a common cause of foot pain and it is attributed to mechanical stresses, presumably due to repetitive trauma causing microtearing of the plantar fascia at its origin as well as fascial and perifascial inflammation. Plantar fasciitis is also common in obese patients and in patients with flat feet. Typically radiography is insensitive to fasciitis, but it should be the initial study. Bone scintigraphy and MRI have been shown to be helpful in arriving at a diagnosis. Ultrasonography (US) has been shown by one study to be effective in differentiating normal plantar fascia from those involved with plantar fasciitis.

Tarsal Tunnel Syndrome

This syndrome is a compressive neuropathy of the posterior tibial nerve or one of its branches. Patients typically complain of poorly localized burning pain and paresthesias along the plantar surface of the foot and toes. Inflammatory processes or mass lesions in the tarsal tunnel are described as the cause for this syndrome in most patients with this syndrome. Such lesions are best imaged by MRI.

Interdigital (Morton's) Neuroma

Morton's neuroma is a nonneoplastic perineural fibrous proliferation involving a plantar digital nerve. Clinical symptoms include pain in the involved web space that often radiates to the toes. It is frequently asymptomatic. These neuromas are seen more often in women and typically involve the three-four or less commonly the two-three intermetatarsal space. They are best detected on MRI using T1-weighted or T1-weighted, fat-suppressed images with gadolinium enhancement and T2-weighted images. The diagnosis of Morton's neuroma at MRI becomes relevant only when the transverse diameter of the lesion is 5 mm or more and can be correlated with the clinical findings. High-resolution ultrasound has been used successfully to diagnose Morton's neuromas. US may approach the sensitivity of MRI in detecting Morton's neuromas with appropriate expertise.

Tendinopathies

Tendinopathies, ranging from tendinosis to complete tear, in and around the foot can result in significant foot pain and disabilities. The most commonly affected tendons are the Achilles tendon, posterior tibial tendon, and peroneal tendons. Tendon dysfunction is best imaged with MRI and US.

Hallux Valgus

Hallux valgus is a common foot disorder resulting in significant morbidity. Preoperative evaluation and measurements and postoperative follow-up are best performed with weight-bearing posteroanterior and lateral radiographs of the feet.

Neoplasm

Neoplasm is another cause of chronic foot pain, and (diagnostically) these lesions in the foot can be approached as other neoplasms in the musculoskeletal system are (see the National Guideline Clearinghouse [NGC] summary of the ACR Appropriateness Criteria® on Soft Tissue Masses and Bone Tumors).

Stress Fractures

Stress fractures can also be a cause of chronic foot pain (see the NGC summary of the ACR Appropriateness Criteria® on Stress/Insufficiency Fracture, Including Sacrum, Excluding Other Vertebrae).

Osteomyelitis

Osteomyelitis can be a cause of chronic foot pain (see the NGC summary ACR Appropriateness Criteria® suspected osteomyelitis in patients with diabetes mellitus).

Summary

• Radiography is the foundation for imaging chronic foot pain. It is the initial study or the first step in the imaging algorithm for evaluating pedal pathology.
• CT is the secondary modality of choice to evaluate for tarsal coalition if radiographs are equivocal or unremarkable and clinical concern warrants further imaging evaluation.
• Tc-99m-labeled methylene diphosphonate (MDP) bone scan is the modality of choice for evaluating RSD if radiographs are equivocal or unremarkable and clinical concern warrants further imaging evaluation.
• MRI or US (if local expertise allows) is complementary to radiography.
• In evaluating for inflammatory arthropathy, plantar fasciitis, tarsal tunnel syndrome, interdigital (Morton's) neuroma, and/or tendinopathy, MRI or US is indicated if the initial radiograph is equivocal or unremarkable and clinical concern warrants further imaging.

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 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).

Abbreviations

• AP, anteroposterior
• CT, computed tomography
• Med, medium
• Min, minimal
• MRI, magnetic resonance imaging
• 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 foot 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 "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 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: James N. Wise, MD (Principal Author); Richard H. Daffner, MD (Panel Chair); Barbara N. Weissman, MD (Panel Vice-Chair); Erin Arnold, MD; D. Lee Bennett, MD, MA; Judy S. Blebea, MD; Jon A. Jacobson, MD; William B. Morrison, MD; William K. Payne III, MD, MPH; Charles S. Resnik, MD; Catherine C. Roberts, MD; Mark E. Schweitzer, MD; Leanne L. Seeger, MD; Mihra S. Taljanovic, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: El-Khoury GY, Bennett DL, Dalinka MK, Daffner RH, DeSmet AA, 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 foot pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. 7 p. [58 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 summary was updated by ECRI Institute on May 17, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Gadolinium-based contrast agents. This summary was updated by ECRI Institute on June 20, 2007 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents. This summary was updated by ECRI Institute on May 19, 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 .