ACR Appropriateness Criteria® Suspected Osteomyelitis of the Foot in Patients With Diabetes Mellitus: 2025 Update

Foot infection is a common cause of diabetes-related morbidity, with 20% of patients with diabetic foot ulcers going on to develop osteomyelitis. Radiography of the foot is recommended for the initial imaging evaluation for suspected osteomyelitis of the foot in adult patients with diabetes mellitus. When initial radiographs are negative or indeterminate or when radiographs are positive for osteomyelitis and treatment planning is necessary, the recommended next imaging study is most commonly MRI of the foot. The presence of metal instrumentation in the foot can alter recommendations in select cases. This document discussing evaluation of diabetes-related osteomyelitis of the foot summarizes the literature and makes recommendations for imaging based on the available evidence. 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.