Straight, No Chaser: How I Know If Your Ankle is Broken Without X-Rays – The Ottawa Ankle Rules

There are medical secrets, and there are tips.  Then there are initiatives that help the public better understand what’s going on, like the big initiatives on heart attacks and strokes.  I wonder why there’s never been a push to teach the public how to better deal with strains and sprains.  The cumulative radiation exposure and the expense of coming to the emergency room are sufficiently high enough that we should want patients not to expect as many unwarranted x-rays as you end up receiving.  Truthfully, the overwhelming majority of ankle sprains (consistently estimated at 85%) don’t have associated fractures.  The initial research done in developing what are known as the Ottawa Ankle Rules demonstrated a complete absence of ankle fractures in the absence of certain exam findings.
An ankle X-ray is only required if any of the following are present (Doctor version).

  • Inability to bear weight for four steps (both immediately and in the emergency room);
  • Bony tenderness along the posterior edge of the distal 6 cm (almost 3 inches) of either the lateral or medial malleolus;
  • Point tenderness over the proximal base of the 5th metatarsal; or
  • Point tenderness over the navicular bone.

Now that was the medical terminology (I bet you thought I’d lost it for a second!).  Here’s the same information translated for you.

  • Inability to bear weight for four steps (both immediately and in the emergency room);
  • Bony tenderness along the back of those big bones sticking out of either side of your ankle (A and B in the diagram above);
  • Point tenderness right about the middle of your foot down from your pinky toe (C in the diagram); or
  • Point tenderness over top of the middle of your foot (D in the diagram).

These rules aren’t applied to those under 18, intoxicated or otherwise distracted, say from another injury.
What does this mean?

  • More than a third of ankle x-rays can be eliminated by applying these rules, saving you money and radiation exposure.
  • If you find your physician asking you if you’d like to not have an x-ray done, you know this is what s/he’s thinking.  Several major studies showed application of these rules had a 100% sensitivity.  In other words, you don’t need the x-ray.
  • All of you playing with your ankles have made me smile.

What this doesn’t mean for you…

  • You can play doctor at home.

Finally, don’t forget about RICE, remember?  That’s how you treat your ankle sprain.
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0 thoughts on “Straight, No Chaser: How I Know If Your Ankle is Broken Without X-Rays – The Ottawa Ankle Rules

  1. Thank you very much for this information Dr. Sterling. I’ve not yet learned German, or Finnish, or whatever language the first section was written in, and even though I know encryption and cryptology, I still could not decipher it, so thanks for the English translation.
    Can you tell me why are the rules not applied to those under 18 in English please?

    1. Hi, Stephanie. That language was actually Doctor-speak, and it was pretty basic stuff as these things go! Actually, research has shown the Rules have about a 98.5% sensitivity in kids above age 6, however many physicians aren’t going to send an anxious parent home without an x-ray. Missing one in 100 is still a big deal, given the volume of ankle sprains occurring. Missed fractures are the number one cause of lawsuits in the U.S. Besides that, there are different considerations in X-ray interpretations for kids who are still growing that may warrant the extra caution. Growth plate injuries are a big deal; missing a fracture in this area could cause one leg to be shorter than the other, for example. Thanks for the question.

  2. Last summer my son sprained his ankle while away at a summer program at Carnegie Mellon. The doctor from the school called me and told me that he had hurt his ankle, and that she could not tell if it was broken or not so she was sending him to the emergency to have an x-ray done. So according to this blog entry, she did know that it was not broken…….she just didn’t want to take the chance because he was 16 years old or so that I wouldn’t worry and drive to Pittsburgh to get my child??!!!

    1. Hi, Stephanie. I can’t speak to your individual case without having examined your son. That said, it would not be expected that a physician that’s not either an orthopedist or emergency physician would necessarily be seeing a sufficient volume of cases to be completely confident in applying the Ottawa Ankle Rules, although many primary care physicians do so with frequency. At the end of the day, if in a physician’s best judgment, obtaining x-rays is the appropriate thing to do, that’s what should be done, as occurred with you son. I suspect you’d be much more upset if the story was that the physician didn’t order x-rays and a fracture was discovered later! Thanks for the comment.