How to Write a Radiology Order for Foot Radiographs
Order weight-bearing radiographs of the bilateral feet, specifically requesting AP, lateral, and oblique views, with the indication "evaluate plantar fasciitis and rule out calcaneal stress fracture." 1
Essential Components of the Order
Your radiology order should include these specific elements:
1. Imaging Modality and Technique
- Study type: Radiography (X-ray) of bilateral feet
- Weight-bearing status: Weight-bearing views are essential for evaluating plantar fasciitis 1
- Standard views: Request AP (anteroposterior), lateral, and oblique projections
2. Clinical Indication
Write clearly: "Evaluate plantar fasciitis and rule out calcaneal stress fracture"
This indication is critical because:
- Radiography is the appropriate initial imaging study for chronic foot pain and suspected plantar fasciitis 1
- Weight-bearing radiographs have 85% sensitivity and 95% specificity for plantar fasciitis when showing thickened plantar fascia and fat pad abnormalities 1, 2
- Radiographs detect calcaneal stress fractures with 12-56% sensitivity initially, but remain the first-line study 1
3. Laterality
Specify "bilateral" if comparing symptomatic to asymptomatic side, or "left/right" if unilateral symptoms
Sample Order Format
"Radiographs bilateral feet, weight-bearing, 3 views (AP, lateral, oblique). Indication: Chronic heel pain, evaluate for plantar fasciitis and rule out calcaneal stress fracture."
Key Clinical Reasoning
Why Weight-Bearing Matters
Weight-bearing radiographs are specifically supported by evidence for plantar fasciitis evaluation 1. The ACR Appropriateness Criteria explicitly state that "evidence supports the use of weight-bearing radiographs" for painful heel evaluation 1.
What Radiologists Will Assess
- Plantar fascia thickness and fat pad abnormalities (the combination has 85% sensitivity/95% specificity for plantar fasciitis) 1, 2
- Calcaneal spurs (present in both symptomatic and asymptomatic patients, so less diagnostically useful) 2
- Stress fracture lines in the calcaneus (though sensitivity is limited early on) 1
- Bone marrow edema patterns (subtle on plain films)
Important Caveats
When Initial Radiographs Are Negative
If radiographs are negative or equivocal but clinical suspicion remains high:
- MRI is the next appropriate study for both plantar fasciitis (most sensitive imaging) and calcaneal stress fractures 1, 3, 4, 5
- MRI allows accurate characterization of plantar fascia tears and bone marrow edema from stress fractures 1
- Ultrasound is an alternative with 80% sensitivity/88% specificity for plantar fasciitis 1
Common Pitfall
Do not order MRI or CT as the initial study for chronic foot pain—this contradicts ACR guidelines which state there is "no relevant literature to support" MRI or CT as first-line imaging 1. Start with plain radiographs, then escalate if needed.
Stress Fracture Considerations
Calcaneal stress fractures frequently appear normal on initial radiographs 3, 4, 5. If clinical suspicion is high (point tenderness over calcaneus, recent increase in activity, pain with weight-bearing), explicitly mention this in your indication so the radiologist knows to look carefully for subtle findings and may recommend follow-up imaging if initial films are negative.