Ankle injuries: Do I need an x-ray?

Ankle injuries, particularly ankle sprains are among the most common injuries seen by sports physiotherapists. Especially on the Northern Beaches where people are out and about playing sports, running and generally doing things that put them at more risk of doing themselves a mischief.

So, you’ve just rolled your ankle down at the beach playing volleyball and it hurts like heck! What do you do?

Hundreds of thousands of people attend emergency rooms around the world with ankle injuries, usually sustained recreationally or in a simple fall. Most of the time, these people end up having a simple soft tissue injury or a small fracture of no clinical significance. With most people just going straight for the emergency room, they’re exposing themselves not just to the germs of the emergency ward, but also to x-ray radiation for possibly no benefit.

Ankle injuries make up around 5% of all patients who visit emergency rooms. Fewer than 15% of them will have a clinically significant fracture.[1] Some will have more serious fractures, requiring immobilisation or internal fixation, but there are more ways than one to determine whether you have a more serious injury of the ankle.

Are x-rays needed? Turn to the Ottawa rules

Ankle sprains cause pain, oedema, ecchymosis, and often make it impossible to bear weight without pain. Even though uncomplicated sprains usually heal with physio treatment, other ankle injuries may require a more surgical approach.

Differentiating between a simple and complicated injury is not always easy, particularly for relatively inexperienced physiotherapists. This is why a series of tests and rules have been developed to serve as guidelines for sports physios to diagnose ankle injuries and to determine the indications for radiography.[2]

The Ottawa foot and ankle rules are an evidence-based guide that helps determine the use of initial x-rays after acute ankle injury. The rules state:

An ankle X-Ray series is required if there is any pain in the malleolar zone and:

  • Bone tenderness at the posterior edge or tip of the lateral malleolus


  • Bone tenderness at the posterior edge or tip of the medial malleolus


  • An inability to bear weight both immediately and in the emergency department for four steps

A foot X-Ray series is required if there is any pain the midfoot zone and:

  • Bone tenderness at the base of the fifth metatarsal


  • Bone tenderness at the navicular


  • An inability to bear weight both immediately and in the emergency department for four steps

In a recent review of 27 studies evaluating the implementation of the Ottawa ankle rules, a hit rate of almost 100% was found for the rules, with a possibility of reducing the number of unneeded x-rays by between 30–40%.[3] With a reliability of nearly 100%, the rules have also shown to diagnose and exclude ankle and foot fractures in children and young adults.[4]

Of course, the value of a normal x ray in providing reassurance and diagnosis of more serious injuries is still relevant. However, the Ottawa ankle rules provide a high level of diagnostic confidence in the absence of x-rays when considering treatment options and recommendations for return to activity.

If you have hurt your ankle, don’t waste any time in getting to your local sports or musculoskeletal physio ASAP. They will be able to take you through an in-depth physical assessment and likely determine the severity of your injury without clogging up emergency rooms and exposing yourself to radiation in the process.


[1] Heyworth, J. (2003). Ottawa ankle rules for the injured ankle. British Journal of Sports Medicine, 37(>3), 194–194.

[2] Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries: refinement and prospective validation. JAMA 1993;269:1127–32.

[3] Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 2003:326:417–9.

[4] Plint AC, Bulloch B, Osmond MH, et al. Validation of the Ottawa ankle rules in children with ankle injuries. Acad Emerg Med 1999;6:1005–9.

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