Twisted ankle – how bad is it? Xray or not?

by | Jun 27, 2017

It’s the highlight of your running week: a Saturday morning trail run. But then it gets interrupted by a stumble and a turned ankle. Of course, you’ve sprained your ankle plenty of times before (you even have some crutches!). “Just walk it off, it will be fine”, you think to yourself. But the pain doesn’t want to let up, forcing you to limp back to your vehicle and get home to rest and ice it.

The next morning, it’s still sore, but maybe in a slightly different way, and you can see some bruising. Should you seek out a doctor? Of course, it’s Sunday morning, so your choices are either the ER or an Urgent Care Center – either of which will mean major inconvenience and cost – plus, they’ll probably just tell you it’s a sprain and you just need to rest it, right? But still….it really hurts, and it’s worrying you…

If this has happened to you, you definitely aren’t alone! In fact, foot injuries are faced so often in busy ER departments, that researchers out of Canada produced a tool to help people in exactly this situation: the Ottowa rules1. The Ottowa rules are well researched and are used to help us know whether an ankle sprain/pain is likely to be a fracture that needs an X-ray, or not.  

Ottowa Rules for ankle and foot xray suspicion fracture

Stiell IG, Mcknight RD, Greenberg GH, et al. Implementation of the Ottawa ankle rules. JAMA. 1994;271(11):827-32.



Ottowa Ankle Rules

The rules have been found to be almost 100% sensitive. This means that those who are not given an x-ray based on the rules are very unlikely to have a fracture – i.e. this is a good tool! The result of using this tool has been a reduction in x-ray use by 30% in all settings and 49% in sports settings2 which is great as we don’t want to be exposed to too many x-rays over our lifetime! Plus, this can help you avoid unnecessary trips to the ER, wasted healthcare dollars, and reduce any worry you are feeling over the injury.

Of course, if pain or ability to walk are unchanged after 5-7 days3, you will want to check in with your PT or GP for a quick check-out to make sure that you don’t have a more serious injury. Also, note these rules have only been validated for adults aged 18 or older.

Do you experience frequent sprained ankles? Even a single sprained ankle, if not rehabbed well, can lead to recurrence later on, and possibly to an eventual fracture. So, even if your sprain turns out to not be a serious injury, I would recommend seeking out Physical Therapy. This doesn’t necessarily mean you need to come in for lots of visits – just two or three visits may be all you need to be on the right track for healing and preventing future injury.


  1. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992 Apr;21(4):384–390
  2. Beckenkamp PR, Lin CC, Macaskill P, Michaleff ZA, Maher CG, Moseley AM. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis. Br J Sports Med. 2016;
  3. Stiell IG, Mcknight RD, Greenberg GH, et al. Implementation of the Ottawa ankle rules. JAMA. 1994;271(11):827-32.


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