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Broken Ankle or Ankle Sprain?

When an X-ray Is Needed to Diagnose a Sprained or Broken Ankle

The difference between doctors who look after mere mortals and those who look after elite athletes may have to do with how many tests they can order, regardless of the cost. And when X-ray and MRI reports lead the news, it makes it difficult for family doctors to explain why those tests aren't necessarily appropriate for them (or even the elite athlete).

Ankle sprains are common injuries and historically, patients expected that if they went to the ER or their doctor's office, they would have an X-ray taken to prove there were no broken bones. As it turns out, the vast majority of those ankle X-rays done were normal and, in retrospect, could be seen as expensive, wasteful, and posed another opportunity to expose a person to unneeded radiation. Ian Stiell and his colleagues in Ottawa, Canada completed a study that showed it was not useful to order all those tests, since less than 15% of those ankle X-rays were positive for a fracture. The results of the study also allowed Dr. Stiell to develop the Ottawa ankle rule guidelines. They give the doctor and the patient a starting point for the discussion about care and treatment for ankle injuries.

Following the Ottawa ankle rules, X-rays are only needed when these criteria are present:

  • Tenderness over the tip of the lateral malleolus (the fibula bone on the outside of the ankle) and the last 2.5 inches (or 6 cm) of the bone
  • Tenderness of the tip of the medial malleolus( the tibia bone on the inside of the ankle) and the last 2.5 inches of the bone
  • Tenderness over the navicular, a bone in the instep, or of the fifth metatarsal base, the bony prominence on the outside of the foot
  • Inability to weight bear for 4 steps immediately or in the ER/office
Medically Reviewed by a Doctor on 4/19/2017

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