Physical Exam

Ottawa Ankle Rule

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Video coming September 2026

How to Perform

After an acute ankle injury, obtain ankle X-rays only if there is pain in the malleolar zone plus any one of: bony tenderness along the distal 6 cm of the posterior edge or tip of the lateral malleolus; bony tenderness along the distal 6 cm of the posterior edge or tip of the medial malleolus; or inability to bear weight (take four steps) both immediately and in the exam room. A parallel foot rule applies to midfoot injuries, keyed to the base of the fifth metatarsal and the navicular.

How to Interpret

Acute Ankle or Midfoot Fracture

Ottawa ankle rule positive

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 (open access). 32 studies met inclusion criteria; 27 studies reporting on 15,581 patients used for meta-analysis. Pre-PRISMA-2009 SR with random-effects model for LR- pooling and bootstrap method for sensitivity pooling. Specificity NOT pooled due to between-study heterogeneity.
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.