Rapid Review: Ottawa Ankle Rules

Reviewed February 2024

Ottawa Foot and Ankle Rules

• X-rays required if
  • Patient cannot bear weight for four steps
  • Distal 6 cm of tibia or fibula is tender
  • Medial or lateral malleolus is tender
  • Fifth metatarsal is tender
  • Navicular bone is tender

Sample question:

A 25-year-old man presents to the ED for evaluation of right ankle pain. He fell and twisted his right ankle while playing basketball 8 hours ago. Immediately after his injury, he experienced difficulty bearing weight on the ankle. He has since experienced increasing pain over his lateral malleolus. He has no significant medical history or prior ankle injuries. Vital signs are normal. On physical exam, there is swelling over the lateral ankle without focal tenderness to palpation of the right distal tibia, lateral or medial malleoli, foot, or Achilles tendon. He is able to take two steps on his right ankle but cannot walk further. Which of the following is the most appropriate next step in evaluation?