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SportsOttawa Ankle Rules: does the ankle need an X-ray?

After an acute ankle injury, the Ottawa Ankle Rules decide whether the ankle or the midfoot needs radiographs. They were made to cut unnecessary X-rays and almost never miss a fracture. The NATA rates them a valid clinical tool, with its highest evidence grade.

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Scenarios

  • Pain in the malleolar zone: the ankle rules.
  • Pain in the midfoot zone: the foot rules.

The steps

  1. Ask where the pain is: in the malleolar zone (ankle) or in the midfoot zone.
  2. Palpate the distal 6 cm of the posterior edge of the lateral malleolus and of the medial malleolus.
  3. Palpate the tip of the lateral malleolus and the tip of the medial malleolus.
  4. With pain in the midfoot, palpate the navicular bone and the base of the fifth metatarsal.
  5. Ask whether the athlete could bear weight and walk 4 steps right after the injury, and check 4 steps at the examination.
  6. Pain in the malleolar zone plus any of these findings: the ankle needs radiographs.
  7. Pain in the midfoot zone plus tenderness of the navicular or the base of the fifth metatarsal, or no 4 steps: the foot needs radiographs.
  8. With no finding, the rules do not call for radiographs.

Safety rules that stop the station

  • One finding is enough to send the ankle or the foot for radiographs.
  • Bone tenderness over the fibular attachment of the anterior talofibular ligament is not a sign of fracture.

To pass

  • Both malleoli, the navicular and the base of the fifth metatarsal palpated where the pain is.
  • The 4 steps checked, right after the injury and at the examination.
  • Correct decision: radiographs or no radiographs.

Official source

Athletic trainers · NATA position statement

National Athletic Trainers' Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes (J Athl Train, 2013)

The National Athletic Trainers' Association position statement on ankle sprains (Journal of Athletic Training, 2013), free on PubMed Central: recommendation 7 and its literature review.

Making Synapses is not affiliated with, sponsored by or endorsed by the NATA, the BOC, CAATE, the Ottawa Hospital Research Institute or any university. NATA, BOC and CAATE are trademarks of their respective owners and are named only to describe the content.

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