Whether an ankle or foot X-ray is needed after acute injury
For patients ≥ 18 seen within ~10 days of injury. Apply with caution if intoxicated, uncooperative, with a distracting injury, or with reduced sensation.
Ankle X-ray — malleolar zone pain PLUS one of:
Pain in the malleolar zone
Bony tenderness at the posterior edge or tip of the lateral malleolus
Bony tenderness at the posterior edge or tip of the medial malleolus
Foot X-ray — midfoot zone pain PLUS one of:
Pain in the midfoot zone
Bony tenderness at the base of the 5th metatarsal
Bony tenderness at the navicular
Either zone:
Unable to bear weight (4 steps) both immediately and in the department
Evidence
Original publication
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. Derived the Ottawa Ankle and Foot Rules (malleolar/midfoot pain plus bony tenderness at defined sites or inability to bear weight); 100% sensitive for clinically significant fractures.
Annals of Emergency Medicine, 1992
Open source
Validation
Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa ankle rules. Prospective multicentre validation and implementation reduced ankle and foot radiography by ~25–30% without missing significant fractures, shortening ED stays.
JAMA, 1994
Open source
Guideline
Widely adopted in emergency-medicine practice for patients ≥ 18 within ~10 days of injury; apply with caution and clinical judgement in intoxication, distracting injuries, sensory deficits, or when the exam is unreliable.
Last reviewed: 2026-09
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MedScore is an educational and clinical decision-support tool. It does not provide a diagnosis, a treatment, or a drug-dosing recommendation, and it does not replace clinical judgement or local guidelines. Confirm every result against the original source before acting on it. The treating clinician remains responsible for all decisions.