ACR Appropriateness Criteria® Chronic Ankle Pain: Update 2025

Chronic ankle pain is common and can be caused by a variety of osseous or soft tissue abnormalities, either alone or in combination. Common etiologies of chronic ankle pain include osteoarthritis, impingement, osteochondral lesion, tarsal coalition, instability, or a chronic sequela of ligament or tendon injury. This document summarizes the current evidence for the appropriate use of specific imaging modalities for each of these clinical scenarios. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.