The Ottawa Ankle Rules
Ankle injuries are common in sporting environments as well as day to day life. Most people will have misplaced their foot or misjudged a change in surface and partially or fully rolled their ankle.
Ankle injuries are common in sports that involve changes in direction as well as contact. After an injury to the ankle, one of the first questions asked by patients is whether they need an x-ray to identify if they have broken a bone. This should be a question your physiotherapist is asking also. Fractures need to be excluded before proceeding with further testing.
The Ottawa ankle rules are a decision aid for excluding fractures of the ankle and mid-foot. They are designed to avoid unnecessary x-rays. Below is a summary:
An ankle x-ray series is only required if there is any pain in the malleolar (highlighted in green below) zone and either...
The outside portion of the ankle joint (fibula). Labelled “A” in Figure 1
The bony portion on the inside of the ankle joint (Tibia). Labelled “B” in Figure 2
An inability to bear weight both immediately and in the emergency department for four steps.
Figure 1: Showing lateral view of ankle including points of bony tenderness
Retrieved from http://www.theottawarules.ca/ankle_rules
A foot x-ray series is only required if there is any pain the midfoot (highlighted in red below) zone and either...
The outside of the foot. Labelled “C” in Figure 1.
The bony portion of the foot below the ankle joints itself. Labelled “D” in Figure 2.
Or inability to bear weight both immediately and in the emergency department for four steps
Figure 2: Showing medial view of ankle including points of bony tenderness
Retrieved from http://www.theottawarules.ca/ankle_rules
If the bony landmarks don’t reproduce tenderness and you can walk for 4 steps, then you do NOT require an x-ray. Now your physiotherapist can proceed with further testing to further assess your injured ankle.
Author: Calvin Amos - Physiotherapist
Reference List
Stiell, I.G., Greenberg, G.H., McKnight, R.D., Nair, R.C., McDowell, I. & Worthington, J.R. (1992). A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 21 (1), 384–90.
Bachmann, L.M., et. al. (2203). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ, 326-417. doi: http://dx.doi.org/10.1136/bmj.326.7386.417
Polzer, H., Kanz, K. G., Prall, W. C., Haasters, F., Ockert, B., Mutschler, W., & Grote, S. (2011). Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthopedic reviews, 4(1), e5.