Physical examination maneuver
Physical Exam
Ottawa Ankle Rule
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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
Showing all 7 findings
Ankle Fracture
Inability to bear weight 4 steps in the emergency room
Rule in
Minimally helpful
Rule out
Very helpful
Evidence:Moderate
Bone tenderness at the posterior edge or tip of the lateral malleolus
Rule in
Helpful
Rule out
Helpful
Evidence:Moderate
Bone tenderness at the posterior edge or tip of the medial malleolus
Rule in
Helpful
Rule out
Minimally helpful
Evidence:Moderate
Ankle or Midfoot Fracture
Ottawa ankle rule positive in a patient with an acute ankle or midfoot injury
Rule in
Minimally helpful
Rule out
Very helpful
Evidence:Strong
Midfoot Fracture
Bone tenderness at the base of the fifth metatarsal
Rule in
Very helpful
Rule out
Helpful
Evidence:Moderate
Inability to bear weight immediately after injury
Rule in
Minimally helpful
Rule out
Minimally helpful
Evidence:Moderate
Bone tenderness over the navicular
Rule in
InconclusiveWide CI
Rule out
Not helpful
Evidence:Moderate
Related Bedside Tests
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Ottawa Foot Rule
Rule in:VHMidfoot Fracture
Rule out:VHMidfoot Fracture
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Ankle Dorsiflexion-external Rotation Test
aka Kleiger test
Rule in:ICAnkle Syndesmosis Injury
Rule out:ICAnkle Syndesmosis Injury
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Thompson Test
aka Simmonds test; Simmonds-Thompson test; calf squeeze test
Rule in:VHAchilles Tendon Rupture
Rule out:VHAchilles Tendon Rupture
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Lower Extremity Inspection and Palpation
Rule in:VHDiabetic Foot Osteomyelitis, VHKnee Osteoarthritis, HAchilles Tendon Rupture +7 more
Rule out:SHAchilles Tendon Rupture, SHDiabetic Foot Osteomyelitis, SHKnee Osteoarthritis +7 more
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Achilles Deep Tendon Reflex
aka Ankle jerk
Rule in:VHPeripheral Neuropathy, SHHypothyroidism, NHLumbosacral Radiculopathy +5 more
Rule out:VHPeripheral Neuropathy, MHHypothyroidism, NHLumbosacral Radiculopathy +5 more
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Babinski Reflex
aka Plantar reflex
Rule in:VHUpper Motor Neuron Lesion, VHVascular Parkinsonism, HMultiple System Atrophy +4 more
Rule out:SHUpper Motor Neuron Lesion, MHMultiple System Atrophy, NHVascular Parkinsonism +4 more