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

Ankle Sprains and Other Injuries

Just because an ankle isn't broken doesn't mean that no injury has occurred. An ankle sprain means that the ligaments that keep the ankle stable have been stretched or torn. Sometimes a torn ankle ligament is just as important as a broken bone, especially if it is the deltoid ligament on the medical or inner aspect of the ankle. That ligament is all that keeps the ankle from dislocating and may be injured in association with a fractured lateral malleolus (with this injury, there is always significant swelling and pain that would fit the criteria to require an X-ray). Some patients do not fit into the Ottawa ankle rules such as children under 6, pregnant women, or someone unable to respond to appropriate questions.

Initial treatment for a sprained ankle starts with RICE (rest, ice, elevation and compression), and anti-inflammatories such as ibuprofen or naproxen. Ace bandages help with compression and aircasts or active ankle brace, worn inside the shoe in addition to the ace wrap may help with ankle support. Crutches may be used for walking support especially if there is difficulty walking without pain or a limp.

Depending upon the degree of injury, physical therapy may be helpful in getting the ankle back to normal. This is the other important difference between the pro-athlete and non pro-athletes. Physical therapy is an afterthought for many patients (and some doctors) because many patients will not, or cannot go to a physical therapist for various reasons. The patients may struggle to find the time and the funds to see a therapist on a routine basis. The compromise is an initial visit to a physical therapist where home exercises are taught to the person, and patient follow-up occurs sporadically. The elite athlete has but one job, and that is to heal the injury to return to practice and competition. They can devote whole days at a time to therapy without worrying about the real world. Getting better is their job.

Perhaps one of the most important discussions a doctor can have with the patient involves the use of testing, be it blood tests or X-rays. The result of the test should be used to help make the diagnosis or follow the effects of treatment. It is also reasonable to order a test to reassure the patient and sometimes the doctor. Except in emergency situations, it is reasonable to have the patient understand the purpose of each test and how it might affect treatment. If the diagnosis can be made clinically, perhaps the patient should trust the doctor's judgment. At the end of the day, that's all that the doctor has to offer.


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Medically reviewed by Aimee V. HachigianGould, MD; American Board of Orthopaedic Surgery


Dowling S, Spooner C, Liang Y. et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and midfoot in children: A meta-analysis. Acad Emerg Med, 16(4):277-287, 2009.

Keogh S, Shafi A. Wijetunge D. Comparison of Ottawa ankle rules and current local guidelines for use of radiography in acute ankle injuries, J R Coll Surg Edinb., 43:341—343, 1998.

Stiell I, Greenberg G, McKnight R. et al. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med., 21(4):384-90, 1992.