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A common question following a foot and ankle injury is whether or not to get an x-ray to rule in or rule out a fracture. Sometimes it can be obvious whether or not we need to get immediate medical attention and sometimes it can be difficult to tell if it is just a sprain.   But, the last thing we want to do is spend days or even weeks waking around a body part that we thought was just a sprain and turns out to be a fracture.  Foot and ankle fractures are typically managed acutely through immobilization to help take pressure off of the fracture site and allow for appropriate healing.  Fractures take several weeks, up to a couple months to heal, so we want to make sure we start that process as quickly as possible to be able to return to our normal activity level as quickly as possible.  Luckily, there is a series of tests called the Ottawa Ankle Rules, which help make this decision a little more clear.  

The Ottawa Ankle Rules are used as a screening tool, not a diagnostic tool.  This means they are not designed to tell you whether or not you have a fracture, but instead assess the risk factors that would make your more likely to have a fracture. This means, if you are able to perform the Ottawa Ankle Rules guideline without any issues, it is unlikely that you have a fracture.  If you test positive for one the test in the procedure, it does not mean that you have a fracture, but the risk of a fracture is heightened and it would be in your best interest to get radiographic imaging.

The testing guidelines are as follows:

  1. Do you have tenderness at the posterior edge or the tip of the medial malleolous?  (Does it hurt if you push on the back portion of the inside part of your ankle)

  2. Do you have tenderness at the posterior edge of the tip of the lateral malleolous? (Does it hurt if you push on the back portion of the lateral aspect of your ankle)

  3. Do you have tenderness at the base of the 5th metatarsal? (Does it hurt if your press on the outside of your foot midway between your heel and pinky toe on the small bone that protrudes outward)

  4. Do you have tenderness at the navicular (Does it hurt if you press up and into the arch underneath the medial part of your ankle)

  5. Are you able to take 4 steps on the injured leg immediately after injury? 

The rules above are guidelines and should be used as a tool to help determine the severity of injury.  If you have any of the warning signs above you should contact a medical professional, give them a detailed report on your situation and they will best guide you on whether or not radiographic imaging is necessary.  Hopefully, you never need to make the decision of whether or not to go to the ER, but if presented with the scenario, you now have an objective way to make an educated decision.