The Ottawa Ankle Rules
Reading time: 5 minutes
The ankle is THE most common site of athletic injury. Most of the time, clinical prediction rules and diagnostic clusters illuminate the most probable diagnosis. However, when orthopedic tests are inconclusive, the history is not clear, the mechanism of injury doesn't add up, or there are red flags— we must consider imaging to gather additional information. Separating an ankle sprain from a fracture requires a detailed history, physical exam, and sometimes x-ray evaluation.
So, how can you quickly decide whether to image an ankle for a suspected fracture?
Watch this quick video.
When Should I X-Ray An Ankle?
The literature is clear concerning imaging for ankle trauma. The Ottawa Ankle Rules are a helpful screening tool to assess the ankle for fracture while avoiding unnecessary imaging. (1) Here’s a quick refresher on the current imaging indications for this complex and injury-prone region.
X-ray if ankle/foot pain AND any one of the following findings:
1. Bone tenderness at the posterior aspects of the medial malleolus
2. Bone tenderness at the lateral malleolus
3. Bone tenderness at the base of the fifth metatarsal
4. Bone tenderness at the navicular
5. The patient could not bear weight on the joint immediately following the injury.
DID YOU KNOW the Ottawa ankle rules have a sensitivity of almost 100% and have been used to reduce the number of unnecessary radiographs by 30-40%? Using these criteria will bring you and your patients’ piece of mind. Patients who present with no positive findings during the screening have less than 1% likely to have a fracture. (2)
Don't Avoid Using X-Rays
Don't dig your head in the sand and shun imaging in every case.
It is important to remember not to radiograph every patient who walks into your clinic. However, many patients that should be imaged are not. Performing appropriate x-rays protects you and your patients. The decision to image is not universally applied to all patients, as each patient is a case study of one. Fortunately, most patients visit you for problems that are not attributable to radiographic findings. The use of clinical prediction rules and diagnostic clusters generally yields correct diagnoses - many times, with the same specificity and sensitivity of imaging.
"Imaging was NOT performed where appropriately indicated in 65.6% of patients who presented with red flags, and 60.8% with clinical suspicion of severe pathology." (4)
Most peer-reviewed recommendations cite 4-6 weeks of conservative care before imaging in the absence of red flags or other concerning findings. But, if your clinical suspicion is high, never shy away from looking deeper sooner with imaging or additional diagnostic tests.
Speaking of guidelines... ChiroUp subscribers can download this imaging infographic from the Forms Library for a breakdown of your X-Ray or MRI findings. You'll be able to quickly educate your patients on the specific findings for their condition.
Did you know that ChiroUp subscribers have access to specific imaging recommendations per condition -- and you can too! ChiroUp exists to streamline both provider & patient education in one easy-to-use system. The time to get started is NOW!
Here is how to access imaging guidelines per conditions:
Keep In Mind: Ankle Sprains Common
1. The ankle is responsible for up to 1/3 of all sports-related injuries.
2. Lateral ankle sprains comprise approximately ¾ of those injuries.
3. Approximately 20% of physically active patients will sustain an ankle sprain at some point in their life.
4. Lateral ankle injuries are among the most commonly reported musculoskeletal injury in spite of the fact that half of those injured do not seek medical attention for their injury. (3)
ChiroUp is the leading online platform for evidence-based chiropractors.
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Gomes YE, Chau M, Banwell HA, Causby RS. Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2022 Dec;23(1):1-1.
Kerkhoffs, G.M., van den Bekerom, M., Elders, L.A., van Beek, P.A., Hullegie, W.A., Bloemers, G.M., de Heus, E.M., Loogman, M.C., Rosenbrand, K.C., Kuipers, T. and Hoogstraten, J.W.A.P., 2012. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British journal of sports medicine, 46(12), pp.854-860.
Bertelsman, T and Steele, B. Lateral Ankle Sprain. www.ChiroUp.com. Accessed 11/8/2022.
