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Do I need to X-ray my ankle?

How do you know that it’s only an ankle sprain, and not anything worse like a fracture?

Ankle sprains are one of the most common athletic injuries. Not only just in athletics but also in activities of daily living. Many are just minor ankle sprains and don’t require any x-rays or surgical treatment. They often may look much worse than they are, but it is always smart to be thorough and receive a proper diagnosis from a trained healthcare professional.

However, in more serious injuries, there can also be fractures of the bones of the ankle and foot as well. Many times, these injuries are a specific type of fracture called an avulsion fracture, in which the force on the ligament is so strong that it literally breaks off a portion of the bone with it.

It’s important to screen for these types of injuries because early weight-bearing is usually encouraged for minor ankle sprains; however, if there is a fracture, there needs to be a slight period of offloading or even immobilization – depending on the stability of the fracture. Furthermore, more serious fractures like Jones fractures (fracture of the base of the 5th metatarsal) need a longer period of immobilization or even surgery. This area receives less blood flow than other areas in the foot, and thus requires more rest/healing time and a more conservative rehab program from the beginning.

The most important screening is called Ottawa Ankle Rules. The specificity (the ability of the test to determine if someone has a fracture) of the Ottawa ankle rules is low. It is simply a screening test to rule out if someone has an ankle fracture.

This is a summary of the screening test:

  • Can you take 4 steps (it’s okay if need to limp)? NO? get an X-Ray

  • Do you have tenderness/pain around your medial or lateral malleoli (the little bone bumps on either side of your ankle)? Specifically, the backside of the bones? YES? Get an x-ray

  • Do you have tenderness/pain around the base of the 5th metatarsal (bump on the lateral/outside portion of your foot; halfway between your heel and your little toe)? YES? Get an x-ray

  • Do you have tenderness/pain around the navicular bone (bump on the medial/inside portion of your foot?) YES? get an x-ray.

If you didn’t make out so lucky and ended up sustaining a fracture to your ankle, the prognosis is still good for these injuries. Depending on the extent of the fracture, surgery may or may not be indicated. You simply will be in a cast or a boot to protect the fracture, allowing the bone to heal, followed by specific rehabilitation to regain your foot and ankle function. On the other hand, if you sustained a more serious injury that led to a larger, potentially displaced fracture, surgery may be indicated.


Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003 Feb 22;326(7386):417. doi: 10.1136/bmj.326.7386.417. PMID: 12595378; PMCID: PMC149439.

Avulsion Fracture Causes and Treatments

Updated on October 27, 2022

Medically reviewed by Yaw Boachie-Adjei, MD

Types of Fractures in Broken Ankles

Updated on March 15, 2023

Medically reviewed by Stuart Hershman, MD

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