Physical Exam

Ottawa Ankle Rule

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Video coming September 2026

How to Perform

In a patient with an acute ankle injury and pain in the malleolar zone, assess the three Ottawa Ankle Rule criteria: bony tenderness along the distal 6 cm of the posterior edge or at the tip of the lateral malleolus; bony tenderness along the distal 6 cm of the posterior edge or at the tip of the medial malleolus; and inability to take four weight-bearing steps both immediately after the injury and at the time of evaluation. The rule is positive if any one of these criteria is present.

How to Interpret

Ankle or Midfoot Fracture

Ottawa ankle rule positive in a patient with an acute ankle or midfoot injury

Rule in

—

Rule out

Very helpful

Evidence:Strong

References

Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003 Feb 22;326(7386):417. doi:10.1136/bmj.326.7386.417. PMID: 12595378. PMC149439.
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(9):1127-1132. PMID: 8433468.
Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21(4):384-390.

Research last updated September 10, 2026.