The Ottawa ankle rules are a validated way to decide who needs an X-ray after an ankle injury. Ankle radiographs are indicated if there is pain in the malleolar zone and any of: bone tenderness along the posterior edge or tip of the lateral malleolus, bone tenderness along the posterior edge or tip of the medial malleolus, or inability to bear weight for four steps both immediately and in the department. A foot series is indicated for midfoot pain with tenderness at the base of the fifth metatarsal or the navicular, or the same inability to bear weight. The rules are highly sensitive for fracture and cut unnecessary imaging.
- Palpate the posterior edge and tip of both malleoli, not just the area of swelling.
- Check the base of the fifth metatarsal and the navicular for foot injuries.
- Test four steps of weight bearing.
- Use clinical judgement in intoxicated patients or those with reduced sensation.
Why it matters
Most ankle sprains do not need an X-ray, and the rules find the fractures that do.
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