Ottawa ankle rules

Last revised by Dr Tom Foster on 03 Nov 2018

The Ottawa ankle rules are a clinical decision-making strategy for determining which patients require radiographic imaging for ankle and midfoot injuries. Proper application has high (97.5%) sensitivity and reduces the need for radiographs by ~35% 1,2,4

There are two components, assessing for ankle and midfoot fractures. A patient with traumatic ankle pain qualifies for ankle radiographs if they have any of the following 1,3:

  • point tenderness at posterior edge (of distal 6 cm) or tip lateral malleolus
  • point tenderness at posterior edge (of distal 6 cm) or tip medial malleolus
  • inability to weight bear (four steps) immediately after the injury and in emergency department

A patient with traumatic midfoot pain qualifies for foot radiographs if they have any of the following 1,3:

  • point tenderness at the base of the fifth metatarsal
  • point tenderness at the navicular
  • inability to weight bear (four steps) immediately after the injury and in emergency department

The Ottawa ankle rules have been validated in children, although children need to be normally ambulating to apply the rule, and due to a lack of data the rules should applied with caution in children <6 years old 4,5

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