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To access, purchase, authenticate, or subscribe to the full-text of this article, please visit this link: http://dx.doi.org/10.1016/j.jacr.2017.02.035 Byline: Jenny T. Bencardino, MD [jenny.bencardino@nyumc.org] (a,*), Taylor J. Stone, MD (b), Catherine C. Roberts, MD (c), Marc Appel, MD (d), Steven J. Baccei, MD (e), R. Carter Cassidy, MD (f), Eric Y. Chang, MD (g), Michael G. Fox, MD (h), Bennett S. Greenspan, MD, MS (i), Soterios Gyftopoulos, MD (j), Mary G. Hochman, MD (k), Jon A. Jacobson, MD (l), Douglas N. Mintz, MD (m), Gary W. Mlady, MD (n), Joel S. Newman, MD (o), Zehava S. Rosenberg, MD (p), Nehal A. Shah, MD (q), Kirstin M. Small, MD (q), Barbara N. Weissman, MD (r) Expert Panel on Musculoskeletal Imaging: Key Words Appropriateness Criteria; Appropriate Use Criteria; AUC; fatigue; fracture; imaging; insufficiency; MRI; radiography stress Abstract 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. Author Affiliation: (a) Principal Author and Panel Vice-Chair, New York University School of Medicine, New York, New York (b) Research Author, Charlotte Radiology, Charlotte, North Carolina (c) Panel Chair, Mayo Clinic, Phoenix, Arizona (d) James J. Peters VA Medical Center, Bronx, New York; American Academy of Orthopaedic Surgeons (e) UMass Memorial Medical Center, Worcester, Massachusetts (f) UK Healthcare Spine and Total Joint Service, Lexington, Kentucky; American Academy of Orthopaedic Surgeons (g) VA San Diego Healthcare System, San Diego, California (h) University of Virginia Health System, Charlottesville, Virginia (i) Medical College of Georgia at Georgia Regents University, Augusta, Georgia (j) New York University Medical Center, New York, New York (k) Beth Israel Deaconess Medical Center, Boston, Massachusetts (l) University of Michigan Medical Center, Ann Arbor, Michigan (m) Hospital for Special Surgery, New York, New York (n) University of New Mexico, Albuquerque, New Mexico (o) New England Baptist Hospital, Boston, Massachusetts (p) Hospital for Joint Diseases, New York, New York (q) Brigham & Women's Hospital, Boston, Massachusetts (r) Specialty Chair, Brigham & Women's Hospital, Boston, Massachusetts * Corresponding author: Jenny T. Bencardino, MD, Attn: Dept of Radiology, New York University, 301 E 17th Street, New York, NY 10003. (footnote) The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. (footnote) Reprint requests to: publications@acr.org (footnote) Dr. Mintz reports personal fees from Current Rheumatology Reports and the ARRT, and his father owns some stock which he does not control in Virtualscopics, which have no bearing on the current work. Dr. Weissman received royalties from: Elsevier 2009. Imaging of Arthritis and Metabolic Bone Disease. Ed Barbara N. Weissman; UpToDate, Inc, Imaging Techniques for the Evaluation of the Painful Joint. The other authors have no conflicts of interest related to the material discussed in this article. (footnote) Disclaimer: The 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 examinations 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 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.