Too often in field sports, we see two players collide, go down and one clutches their ankle. The sport therapist is immediately faced with the challenge of determining the type and the extent of the injury and explaining to the athlete if they think it’s safe to return to play, wait it out on the sidelines or go to hospital. This is wrenching for everyone involved as these decisions can have far reaching implications. Further, upon sending an athlete to the ER, they will almost inevitably be subjected to an x-ray to eliminate fracture- a costly procedure.


Stiell et al 1992 introduced the Ottawa ankle rules. After completing a 5 month study of over 750 patients in 2 ERs, they determined these rules had 100% sensitivity and 40% specificity. They asked that this become part of the standard procedure in screening ankles. Bachmann’s et al 2003 10 year review of the Ottawa ankle rules of over 15,000 patients determined that it has a >99% sensitivity and a specificity of 30-40%. This strongly supports Stiell’s original assertion that this procedure should be used throughout the sports world.


Keeping in mind that prior to the integration of the Ottawa ankle rules, only 15% of those x-rayed had ankle fractures, and that post adoption of this procedure, over 80% of those x-rayed had fractures- a far more acceptable rate. The procedure also has a low false negative rate- with only 2% passing as not needing x-ray to later be found to have a fracture.


Here are the Ottawa ankle rules:

A patient should have an X-ray IF:

1-      They are over 55  years old

2-      They can not weight bear for 4 steps at the time of the accident and upon presentation in the ER

3-      They experienced bone tenderness at the posterior edge (6cm) or the inferior tip of the lateral malleolus

4-      They had bone tenderness at the posterior edge or inferior tip of the medial malleolus.

The Ottawa ankle rules should NOT be used IF:

1-      The patient reports more than 10 days of pain

2-      The patient is pregnant

3-      The presence of isolated skin injuries

4-      The patient is under 18


New studies are investigating the use of a modified protocol for children 6-18 years old but nothing has yet been established as conclusive. Given that study after study shows such a high sensitivity, low false positives and negatives and acceptable specificity- it should be integrated into all ankle screens.