Supraspinatus pathology on MRI is associated with degree of weakness on dynamic clinical strength testing.

OBJECTIVE: To analyze shoulder strength and function in patients presenting with possible supraspinatus pathology and to ascertain if these clinical findings are associated with severity of supraspinatus pathology on MRI. MATERIALS AND METHODS: In total, 171 patients with presumptive rotator cuff pathology and with preserved strength on standard rotator cuff examination were prospectively recruited. Patients were subjected to bilateral shoulder strength testing employing dynamometry; this included isometric strength testing at 90° of abduction, followed by eccentric assessment of isotonic strength from full abduction through the full range of motion until the arm rested at the patient's side. We calculated absolute strength and symptomatic-to-asymptomatic arm (S/A) strength ratios. On subsequent shoulder MRI, supraspinatus pathology was designated into one of seven categories. The association between strength measurements and MRI findings was analyzed. RESULTS: Increasing lesion severity on MRI was associated with both decreasing absolute strength (no tear [59.9 N] to full-thickness tear [44.2 N]; P = 0.036) and decreasing S/A strength ratios during isotonic testing (no tear [91.9%] to full-thickness tear [65.3%]; P = 0.022). In contrast, there were no significant relationships between imaging severity and absolute strength or S/A strength ratios on isometric testing. CONCLUSION: Severity of supraspinatus pathology on MRI was associated with dynamic clinical function. These results validate the clinical correlation between MRI designations of supraspinatus pathology and function and suggest the need for future work to investigate utility of dynamic (versus isometric) rotator cuff physical examination maneuvers.

Imaging of meniscal allograft transplantation: what the radiologist needs to know.

Meniscal allograft transplantation is an emerging surgical option for younger patients with symptomatic meniscal deficiency, which aims to restore anatomic biomechanics and load distribution in the knee joint, and by so doing to potentially delay accelerated osteoarthritis. In this review article, we summarize the structure and biomechanics of the native meniscus, describe indications and procedure technique for meniscal allograft transplantation, and demonstrate the spectrum of expected postoperative imaging and role of imaging to identify potential complications.

Coracoid graft union: a quantitative assessment by computed tomography in primary and revision Latarjet procedure.

BACKGROUND: The goal of the Latarjet procedure is restoration of shoulder stability enabled by accurate graft positioning and union. This study aimed to establish a reproducible method of quantitatively assessing coracoid graft osseous union percentage (OUP) using computed tomography (CT) scans and to determine the effect of other factors on the OUP. MATERIALS AND METHODS: Postoperative CT scans of 41 consecutive patients treated with the open Latarjet procedure (37% primary, 63% revision) for anterior glenohumeral instability were analyzed for the OUP, position of the graft, and screw type and angle. Two musculoskeletal radiologists independently examined the images 2 times, and intraobserver and interobserver reliability was calculated using intraclass correlation coefficient (ICC). RESULTS: Mean OUP was 66% (range, 0%-94%) using quantitate methods, with good intraobserver reliability (ICC = 0.795) and interobserver reliability (ICC = 0.797). Nonunion and significant graft resorption was found in 2 patients. No significant difference was found in the mean OUP in the primary (63%) vs. revision Latarjet procedure (67%). Grafts were flush in 39%, medial in 36%, and lateral in 8%. The medial and neutral graft position was associated with slightly higher OUP (72% and 69%) compared with lateral (65%). OUP was higher when the superior screw angle was less than 17° and the inferior screw angle was less than 24°. This difference did not reach statistical significance. Screw type was not associated with significant difference in OUP. CONCLUSION: Quantitative assessment of osseous union of the graft using a reproducible method that we introduced showed similar OUP in the primary and revision Latarjet procedure.

Imaging Evaluation of Nonacute Shoulder Pain.

OBJECTIVE: A variety of radiographic views have been described in the literature for the initial imaging of nonacute shoulder pain. Multiple articles have also discussed the best next imaging test if radiographs do not show the diagnosis, especially the use of unenhanced MRI, MR arthrography, CT arthrography, and ultrasound. The purpose of this article is to examine the evidence for the most helpful radiographic views and the best imaging test after radiographs for different clinical presentations of chronic shoulder pain. CONCLUSION: The recommended radiographic views and best next imaging test after the radiograph depends on the clinical diagnosis. Ultrasound is generally preferred over MRI for evaluating chronic rotator cuff pain, whereas MR arthrography, preferably with abducted and externally rotated images, is most accurate for imaging chronic symptoms from a suspected labral tear or instability.

Morphology of the Lesser Tuberosity and Intertubercular Groove in Patients With Arthroscopically Confirmed Subscapularis and Biceps Tendon Pathology.

PURPOSE: To evaluate for an association between the morphology of the lesser tuberosity and intertubercular groove and subscapularis tendon tears and biceps tendon pathology. METHODS: Sixty-six patients with arthroscopically confirmed subscapularis tendon tears were compared with 59 demographically matched control patients who underwent magnetic resonance imaging or computed tomography arthrography examination of the shoulder. Measurements of the lesser tuberosity and intertubercular groove included maximum depth of the intertubercular groove, intertubercular groove depth at the midpoint of the glenoid, lesser tuberosity length, length from the top of the humeral head to the point of maximum depth of the intertubercular groove, length from the top of the humeral head to the top of the lesser tuberosity, and medial wall angle and depth. RESULTS: Patients with subscapularis tears showed a significantly decreased depth of the intertubercular groove at the mid glenoid (P = .01), shorter length of the lesser tuberosity (P = .002), and greater distance from the top of the humeral head to the top of the lesser tuberosity (P = .02). There was a trend toward a decreased medial wall angle (P = .07) and greater distance from the top of the humeral head to the point of maximum intertubercular groove depth (P = .06). Patients with biceps tendon pathology showed a significantly decreased depth of the intertubercular groove at the mid glenoid (P = .001), shorter length of the lesser tuberosity (P = .0003), greater distance from the top of the humeral head to the top of the lesser tuberosity (P = .01), and decreased medial wall angle (P = .01) and depth (P = .03). CONCLUSIONS: There are several morphologic factors related to the lesser tuberosity and intertubercular groove that are associated with both subscapularis tendon tears and biceps tendon pathology. LEVEL OF EVIDENCE: Level III, case-control study.

Imaging characteristics of lesser tuberosity osteotomy after total shoulder replacement: a study of 220 patients.

BACKGROUND: The lesser tuberosity osteotomy (LTO) has been gaining popularity as a method of exposing the glenohumeral joint during total shoulder replacement, whereby a small fragment of bone is removed from the lesser tuberosity, thus preserving the subscapularis tendon. To date, no large, randomized studies have reported evaluations of LTO healing and healing rates. METHODS: We reviewed the radiographs and available computed tomography images of 362 patients who underwent a total shoulder arthroplasty by the same surgeon between 2006 and 2012. The integrity of the LTO site was graded as not seen, bony union, nondisplaced nonunion, and displaced nonunion. The smoking status of patients was also assessed. RESULTS: Of 362 patients investigated, 220 had a minimum of 6 months of radiographic follow-up. The LTO site was not seen in 37 patients; of the remaining 183, 159 patients (86.89%) demonstrated bony union, 8.80% of whom were smokers; 16 patients (8.74%) demonstrated nondisplaced nonunion, 6.3% of whom were smokers; and 8 patients (4.3%) demonstrated displaced nonunion, 25.0% of whom were smokers. Overall, 19 of the 24 nonunions were in male patients (79.1%) and 5 were in female patients (20.8%). CONCLUSIONS: This is the first large-scale study to report the healing rate of LTOs. LTO healing is best assessed on radiographs; if nondisplaced or displaced nonunions are suspected, computed tomography can be a helpful additional examination. The number of radiographs where there is a lack of adequate visualization of the LTO site raises important questions about definitive radiographic evaluation using current techniques.

Diagnostic Features of Emphysematous Osteomyelitis.

Emphysematous osteomyelitis (EO) is a rare, aggressive, and potentially fatal variant of osteomyelitis related to gas-forming organisms. Imaging plays a vital role in diagnosis. The purpose of this study was to describe a novel and distinct imaging sign of EO, by analysis of the imaging characteristics of 3 newly identified cases of EO as well as all reported cases in the literature. Literature review and retrospective study in 2 tertiary care medical centers was conducted. During the course of clinical care over the last year, we have observed 2 cases of EO. An Institutional Review Board approved 1-year systematic retrospective review of our institutional radiology information system identified 1 additional case of EO. We conducted a MEDLINE literature search to identify all published EO case reports using key phrases. The imaging in all published cases was reviewed. To address the specificity of imaging characteristics, we identified cases demonstrating variants of intraosseous gas that were not caused by EO. We found 31 individual case reports of EO via MEDLINE search. Of the published cases, 25 of the 31 cases contained images of sufficient extent and quality for image analysis. Including our 3 cases, a total of 34 cases were identified. Of the 34 cases, 28 had images of sufficient quality and extent to determine the presence or absence of the "pumice stone" pattern. The "pumice stone" sign was identified in 27 of 28 cases (96%). The most commonly affected sites of infection include the pelvic bones (38%; 13 of 34), vertebral bodies (32%; 11 of 34), and femurs (24%; 8 of 34). Adjacent soft tissue inflammation and emphysema was evident in 23 of 29 cases (79%). Cortical destruction, a key diagnostic feature of traditional osteomyelitis, was absent in 79% of cases of EO. We describe the "pumice stone sign" as a radiological sign to identify EO. We found it present in 96% of all currently known cases of EO. EO commonly involves the pelvic bones (38%), vertebral bodies (32%), and femur (24%). Key features also include adjacent soft tissue emphysema (79%) and absence of cortical destruction (79%).

Standardized Classification of Lumbar Spine Degeneration on Magnetic Resonance Imaging Reduces Intra- and Inter-subspecialty Variability.

BACKGROUND AND PURPOSE: To determine the efficacy of standardized definitions of degenerative change in reducing variability in interpretation of lumbar spine magnetic resonance imaging within and between groups of subspecialty-trained neuroradiologists (NR) and musculoskeletal radiologists (MSK). MATERIALS AND METHODS: Six radiologists, three from both NR and MSK groups were trained on a standardized classification system of degenerative change. After an 11-month washout period, they independently re-interpreted fifty exams at the L4-L5 and L5-S1 levels. Responses were converted to a six-point ordinal scale for the assessment of neural foraminal stenosis and spinal canal stenosis (SCS), three-point scale for lateral recess stenosis, and four-point scale for facet osteoarthritis (FO). Intra-subspecialty and inter-subspecialty analysis was performed using the weighted Cohen's kappa with a binary matrix of all reader pairs. RESULTS: Inter-subspecialty agreement improved from k=0.527 (moderate) to k=0.602 (substantial) for neural foraminal stenosis, from k=0.540 (moderate) to k=0.652 (substantial) for SCS, from k=0.0818 (slight) to k=0.337 (fair) for lateral recess stenosis, and from k=0.176 (slight) to k=0.495 (moderate) for FO. The NR group demonstrated improved intra-subspecialty agreement for the assessment of SCS, from k=0.368 (fair) to k=0.638 (substantial). The MSK group demonstrated improved intra-subspecialty agreement for the assessment of FO, from k=0.134 (slight) to k=0.413 (moderate). Intra-subspecialty agreement was similar for other parameters before and after training. CONCLUSIONS: As result of the standardized definitions training, the NR and MSK groups each improved in one of the four parameters, while inter-subspecialty variability improved in all four parameters. These definitions may be useful in clinical practice across radiology subspecialties.

Association of markers of patellofemoral maltracking to cartilage damage and bone marrow lesions on MRI: Data from the 2016 Olympic Games of Rio De Janeiro.

BACKGROUND: Patellofemoral joint (PFJ) disease is a common ailment in elite athletes. Our aim is to report the frequency of superolateral Hoffa's fat pad (SHFP) edema, and PFJ cartilage damage and bone marrow lesions (BML), among Olympian athletes, and to study the association between measurements of trochlear morphology and vertical patellar position and a) PFJ cartilage damage or BML, and b) SHFP edema. METHODS: All knee MRI, performed in the Olympic Village and polyclinics, of participating athletes in the 2016 Olympic Games of Rio de Janeiro were included. MRI were scored for PFJ cartilage damage and BML, and SHFP edema. Trochlear morphology measurements included sulcus angle, trochlear angle, lateral trochlear inclination, and medial trochlear inclination. Insall-Salvati ratio was also assessed. RESULTS: One hundred twenty-one knee MRIs were included (62 female, 51.2 %). The highest frequencies of PFJ cartilage damage, combination of PFJ cartilage damage and BML, and SHFP edema were found among Beach Volleyball and Volleyball athletes. SHFP edema was more common among female compared to male Olympian athletes. We found no statistically significant associations between different measurements of trochlear morphology/vertical patellar position, and 1. SHFP edema, and 2. PFJ cartilage damage/BML. CONCLUSION: SHFP edema and the combination of PFJ cartilage damage and BML are highly frequent among Olympic athletes especially those competing in Beach volleyball and Volleyball. SHFP edema is more common among female athletes. Further studies are needed to determine whether PFJ cartilage damage has a stronger association to sports disciplines rather than trochlear morphology.

Safety of Intra-articular Hip Corticosteroid Injections: A Matched-Pair Cohort Study.

BACKGROUND: Recent studies have suggested there is an increased risk of avascular necrosis (AVN), subchondral insufficiency fracture (SIF), femoral head collapse, and osteoarthritis (OA) progression in the 12-month period after hip corticosteroid/anesthetic injection (CSI); however, these studies have failed to account for preinjection OA severity or preexisting AVN/SIF. PURPOSE: To compare these complication rates in patients treated with versus without hip CSI, while minimizing the aforementioned forms of selection bias present in previous investigations. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: For all patients who had undergone a single hip CSI and hip magnetic resonance imaging (MRI) within the preceding 12 months at a single institution (CSI cohort), 2 musculoskeletal radiologists retrospectively graded OA severity (modified Kellgren-Lawrence classification) and femoral head collapse on hip radiographs taken within 12 months before, and 1 to 12 months after, CSI. Using identical methodology, radiographs from a control cohort (composed of hips that had never undergone CSI and had undergone hip MRI with hip radiographs taken within 12 months before, and 1-12 months after, MRI) were also graded. The cohorts were matched for age, sex, body mass index, and OA severity. Readers were blinded to cohort and time point. OA progression was defined as an increase in modified Kellgren-Lawrence grade ≥1 between radiographs. RESULTS: Included were 141 matched pairs. After exclusion of 48 matched pairs with at least 1 incidence of preexisting AVN or SIF on index MRI, CSI (n = 93; mean time between CSI and final hip radiograph, 5.43 months) and control (n = 93; mean time between MRI and final hip radiograph, 4.87 months), groups did not significantly differ in rates of OA progression (3.2% vs 3.2%) or new femoral head collapse (3.2% vs 2.2%). CONCLUSION: In contrast to the findings of recent retrospective investigations, we did not find that patients treated with hip CSI had significantly higher rates of short-term OA progression or femoral head articular surface collapse after controlling for baseline OA severity and preexisting AVN or SIF. Future randomized trials investigating safety of hip CSI are needed to determine its exact short-term risk profile.

Intra- and Intersubspecialty Variability in Lumbar Spine MRI Interpretation: A Multireader Study Comparing Musculoskeletal Radiologists and Neuroradiologists.

BACKGROUND AND PURPOSE: The purpose of this study is to assess the differences in degenerative spine MRI reporting between subspecialty-trained attending neuroradiologists and musculoskeletal radiologists (MSK) at a single institution, academic medical center. MATERIALS AND METHODS: Fifty consecutive outpatient noncontrast lumbar spine examinations were selected from the Picture Archiving and Communication System. Three MSK and 3 neuroradiologists (NR) independently reviewed and interpreted the exams at the L4-L5 and L5-S1 levels in the same manner as in clinical practice. The assessment of neural foraminal stenosis (NFS) and spinal canal stenosis (SCS) was converted to a 5-point ordinal scale. The assessment of lateral recess stenosis (LRS) and facet osteoarthritis (FO) was recorded as present/absent. Intersubspecialty and intrasubspecialty analysis was performed using Cohen's kappa coefficient with a binary matrix of all reader pairs. RESULTS: There was moderate intersubspecialty agreement (k = 0.527) for NFS and SCS (k = 0.540). Intersubspecialty agreement was slight for LRS (k = 0.0818) and FO (k = 0.176). The MSK group demonstrated greater intrasubspecialty agreement in assessment of NFS and SCS compared to the NR group, with nonoverlapping confidence intervals. The NR group demonstrated greater nominal intrasubspecialty agreement in the assessment of both LRS and FO, although with nonoverlapping confidence intervals. CONCLUSION: There is moderate intersubspecialty agreement between MSK radiologists and neuroradiologists in reporting the severity of NFS and SCS, although MSK radiologists demonstrated greater intrasubspecialty agreement. There is slight intersubspecialty agreement for LRS and FO. The demonstration of differences in inter-reader agreement is a crucial first step to attempt to ameliorate these variabilities.

ACR Appropriateness Criteria® Chronic Foot Pain.

Chronic foot pain is a frequent clinical complaint, which can significantly impact the quality of live in some individuals. These guidelines define best practices with regards to requisition of imaging studies based on specific clinical scenarios, which have been grouped into different variants. Each variant is accompanied by a brief description of the usefulness, advantages, and limitations of different imaging modalities. The present narrative is the result of an exhaustive assessment of the available literature and a thorough review process by a panel of experts on Musculoskeletal Imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Radiation-Induced Painful Neurogenic Hypertrophy Treated With Botulinum Toxin A.

Painful neurogenic hypertrophy is a rare complication of radiation therapy. We report a 27-year-old woman with a history of adenoid cystic carcinoma of the submandibular gland presented with painful twitching of her left shoulder. Electrodiagnostic studies were consistent with a diagnosis of radiation-induced spinal accessory nerve hyperactivity. The patient failed conventional medical therapy. She was treated with an injection of botulinum toxin A, and within 1 month experienced significant relief of symptoms. We thus conclude that Botulinum toxin is a therapeutic option for the pain associated with radiation-induced peripheral nerve hyperactivity.

ACR Appropriateness Criteria® Shoulder Pain-Atraumatic.

Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

MRI Before Radiography for Patients With New Shoulder Conditions.

PURPOSE: To assess the patterns of Appropriate Criteria application among orthopedic specialists and other fields of medicine for use of MRI and radiography and the subsequent necessity for surgical intervention. METHODS: The hospital electronic medical record was used to identify all shoulder MRI studies at a single large urban teaching hospital between January 2, 2011, and June 30, 2011. For each study, variables collected included ordering department, patient age, patient gender, patient's self-reported race/ethnicity, whether the patient obtained surgery for an issue related to the MRI diagnosis, the type of MRI ordered, the date of pain onset, the date of x-ray (if any), and the date of the MRI. RESULTS: A total of 475 patients who underwent shoulder MRI were included in our study. We found significant associations between a patient having had a prior x-ray and ordering department (P < .0001), male gender (P = .0005), and subjects who had subsequent surgery (P = .0006). Neither age nor race and ethnicity had an influence on x-ray before MRI. Orthopedic specialists ordering MRIs had the highest percentage of patients undergo subsequent surgery (33.3%) compared with the second-most, primary care (18.4%), and all other ordering departments (P = .0009). CONCLUSIONS: Detailed analysis suggests that providers who do not have specific training in shoulder pathology should consider consultation with an orthopedic surgeon before ordering shoulder MRI for patients who may need additional imaging after radiography.

ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density.

Osteoporosis is a considerable public health risk, with 50% of women and 20% of men >50 years of age experiencing fracture, with mortality rates of 20% within the first year. Dual x-ray absorptiometry (DXA) is the primary diagnostic modality by which to screen women >65 years of age and men >70 years of age for osteoporosis. In postmenopausal women <65 years of age with additional risk factors for fracture, DXA is recommended. Some patients with bone mineral density above the threshold for treatment may qualify for treatment on the basis of vertebral body fractures detected through a vertebral fracture assessment scan, a lateral spine equivalent generated from a commercial DXA machine. Quantitative CT is useful in patients with advanced degenerative bony changes in their spines. New technologies such as trabecular bone score represent an emerging role for qualitative assessment of bone in clinical practice. It is critical that both radiologists and referring providers consider osteoporosis in their patients, thereby reducing substantial morbidity, mortality, and cost to the health care system. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis.

Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. This review first discusses the characteristic osseous and soft tissue abnormalities seen with inflammatory arthritis and how they may be imaged. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity as there is significant overlap of imaging findings among the various types of arthritis. This review provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Imaging After Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is the most commonly performed joint replacement procedure in the United States and annual demand for primary TKA is expected to grow by 673% by 2030. The first part provides an overview of imaging modalities (radiographs, CT, MRI, ultrasound, and various nuclear medicine studies) and discusses their usefulness in the imaging evaluation of TKA. The second part focuses on evidence-based imaging and imaging-guided intervention algorithms for the workup of TKA and its complications, including routine follow-up, component wear, periprosthetic infection, aseptic loosening, granulomas/osteolysis, conventional and rotational instability, periprosthetic fracture, patellar complications, and a variety of periprosthetic soft tissue abnormalities. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae.

Stress fractures, including both fatigue and insufficiency types, are frequently encountered in clinical practice as a source of pain in both athletes and patients with predisposing conditions. Radiography is the imaging modality of choice for baseline diagnosis. MRI has greatly improved our ability to diagnose radiographically occult stress fractures. Tc-99m bone scan and CT may also be useful as diagnostic tools. Although fatigue and insufficiency fractures can be self-limited and go onto healing even without diagnosis, there is usually value in initiating prompt therapeutic measures as incomplete stress fractures have the potential of progressing to completion and requiring more invasive treatment or delay in return to activity. This is particularly important in the setting of stress fractures of the femoral neck. Accuracy in the identification of these injuries is also relevant because the differential diagnosis includes entities that would otherwise be treated significantly different (ie, osteoid osteoma, osteomyelitis, and metastasis). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.