Ottawa Ankle Rules sprain strain fracture foot management treatment conservative care symptoms x-ray scans prognosis chiro chiropractor chiropractic sportschiro physio physiotherapist physiotherapy sportsphysio osteo osteopathy osteopath sportsosteo Balmain balmainchiro balmainphysio balmainosteo sydneyspineandsportscentre s3c inner west sydney

Ottawa Ankle Rules in Acute Ankle Injuries

The Ottawa ankle rules are a set of guidelines that provide clinicians a clinical decision-making strategy for determining which patients require radiographic imaging (i.e., X-rays) for ankle injuries when a fracture is suspected. Correct application of the Ottawa ankle rules is associated with 95% sensitivity and reduces the need for unnecessary radiographs by approximately 35%.

History of the Ottawa ankle rules

The Ottawa ankle rules were first published in 1992 by a team of doctors in the emergency department of the Ottawa Civic Hospital in Ottawa, Canada. Before the introduction of the Ottawa ankle rules, most patients with ankle injuries would have been routinely imaged. However, the majority of patients with symptomatic ankle injuries do not have bony fractures. As a result, many unnecessary radiographs were taken, which was costly, time consuming and presented a health risk to patients due to radiation exposure.

Ankle sprains overview

Ankle sprains are one of the most common sporting injuries in athletic populations. Sports requiring jumping, turning and twisting movements such as basketball, volleyball, netball and football; and explosive changes of direction such as soccer, tennis and hockey are particularly vulnerable to ankle sprains. In the USA, approximately 25,000 ankle sprains occur per day, which equates to 1 sprain per 10,000 daily. Read more about ankle sprains on our blog site.

Method of Ottawa ankle rules

Ankle radiograph is only required if there is any pain in the malleolar area, and any one of the following:

  • bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, or
  • bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, or
  • an inability to bear weight both immediately and in the emergency department for four steps.

Mid-foot radiograph is only required if there is any pain in the mid-foot area, and any one of the following:

  • Bone tenderness at the base of the fifth metatarsal (for foot injuries), or
  • Bone tenderness at the navicular bone (for foot injuries), or
  • An inability to bear weight both immediately and in the emergency department for four steps.

Certain groups are excluded from these rules, in particular pregnant females, and those with an inability to follow the procedures (e.g., due to head injury or intoxication). Several studies strongly support the use of the Ottawa Ankle Rules in children over 6 years of age ( with 98.5% sensitivity); however, their usefulness in younger children has not yet been thoroughly examined.

Clinical relevance

More frequently sport clinicians are becoming the first contact for patients and and important consideration is the ability to rule out fractures. Acute foot and ankle injuries can make it challenging to rule out bony fractures; therefore, the Ottawa Ankle Rules are an informative and helpful tool for clinicians to clinically reason if radiological imaging is indicated. At Sydney Spine & Sports Centre (S3C), our Balmain chiropractors are trained in Ottawa Ankle Rules and provide the best, evidence-based conservative management for ankle and foot injuries.

More information

Please visit our website and blog page for more information on ankle and foot conditions:


Chris Knee

Chris is an experienced and qualified chiropractor, sports chiropractor, McKenzie Credentialed practitioner, nutritionist and Certified Strength and Conditioning Specialist (CSCS) and is finishing of his Doctor of Physiotherapy at Macquarie University.