Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot
The Ottawa Ankle Rules (OAR), developed in 1992, are a set of clinical guidelines designed to help healthcare providers determine when an X-ray is needed to rule out fractures in the ankle and mid-foot. These rules were developed to minimize unnecessary X-rays while maintaining a high sensitivity for detecting fractures. The goal is to identify those who need imaging and avoid exposing patients to unnecessary radiation.
Background and Purpose
Despite the high frequency of ankle sprains in sports, only a small percentage of these injuries (less than 15%) result in fractures. This low incidence led to the development of the Ottawa ankle rules, which assess specific signs, including the ability to walk and the presence of tenderness in key areas of the foot and ankle. These rules were designed to quickly rule out fractures, allowing for more efficient triage in emergency departments.
How the Ottawa Ankle Rules Work
To assess the ankle, the rules check if the patient can walk four steps without difficulty and examine for tenderness over specific spots: the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. For the mid-foot, the rules assess walking ability and tenderness over the navicular bone or base of the fifth metatarsal. These tests focus on sensitivity, aiming to ensure that as few fractures as possible are missed.
Effectiveness of the Ottawa Ankle Rules
The Ottawa ankle rules are very sensitive, meaning they can reliably catch most fractures (with a nearly 100% sensitivity in many studies). However, their specificity varies significantly, ranging from 10% to 79%. This variability is influenced by factors like the experience of healthcare providers and patient variability in expressing pain. Despite the lower specificity, the rules’ high sensitivity helps reduce the number of unnecessary X-rays. Studies show that fewer than 2% of patients who test negative for fractures actually have one, indicating the rules’ reliability.
Impact on Clinical Practice
A study of 2,342 patients in emergency departments found that implementing the Ottawa ankle rules reduced ankle radiography by 28% and foot radiography by 14% at intervention hospitals. In addition to reducing X-ray use, there were reductions in patient waiting times and medical costs, with no significant difference in patient satisfaction or subsequent radiographs. The rules showed high sensitivity for detecting fractures, with a sensitivity of 1.0 (100%) for malleolar fractures and 1.0 for midfoot fractures.
Research Spotlight
A 2025 study from the Bulletin of Emergency and Trauma compared the well-known Ottawa Ankle Rules (OAR) with a newer method called the Shetty Test (ST) for identifying ankle and foot fractures. Among 112 adult patients with ankle injuries, the OAR showed higher sensitivity (94.7%) but lower specificity (15%) compared to the ST (68.4% and 76.3%, respectively).
When both tests were used together, sensitivity and the ability to rule out fractures (negative predictive value) reached 100%.
The authors concluded that while the Shetty Test did not outperform the Ottawa Ankle Rules, it is a simple and reproducible addition—especially helpful for non-orthopedic providers—and combining both tests may improve fracture screening accuracy. (“Study comparing the Ottawa Ankle Rules and Shetty Test for ankle fractures – see PubMed.”)
Summary and Key Takeaways
The Ottawa ankle rules are a valuable tool for ruling out fractures in the ankle and mid-foot. Their high sensitivity significantly reduces unnecessary X-rays, which helps reduce patient costs and waiting times. The variability in specificity highlights the importance of provider experience, but overall, the rules have a substantial impact on clinical practice by decreasing unnecessary imaging and improving patient flow in emergency departments.
References / Citations (Optional)
Stiell I G, McKnight R D, Greenberg G H, McDowell I, Nair R C, Wells G A, Johns C, Worthington J R. “Implementation of the Ottawa Ankle Rules.” Orthobullets.
Do you have more questions?
Are the Ottawa Ankle Rules applicable to all patients presenting with ankle or mid-foot injuries?
The Ottawa Ankle Rules are primarily intended for adults with acute ankle injuries and may not be applicable to pediatric patients, those with chronic injuries, or those with significant swelling or deformity.
Can the Ottawa Ankle Rules be used in emergency departments and primary care settings?
Yes, the Ottawa Ankle Rules are designed to be easily applied in various healthcare settings, including emergency departments, urgent care centers, and primary care clinics.
How do healthcare providers use the Ottawa Ankle Rules in clinical practice?
Healthcare providers use the Ottawa Ankle Rules as a tool to guide decision-making regarding the need for X-ray imaging in patients with ankle or mid-foot injuries, based on specific clinical criteria.
What are the clinical criteria assessed when applying the Ottawa Ankle Rules?
The clinical criteria assessed when applying the Ottawa Ankle Rules include the presence of bone tenderness along specific anatomical landmarks and the ability to bear weight on the affected limb.
How do the Ottawa Ankle Rules help healthcare providers determine the need for X-ray imaging?
The Ottawa Ankle Rules help healthcare providers identify patients who are at low risk of ankle or mid-foot fractures based on clinical examination findings, thereby reducing unnecessary X-ray imaging and healthcare costs.
Can the Ottawa Ankle Rules accurately detect all ankle or mid-foot fractures?
While the Ottawa Ankle Rules have high sensitivity for detecting clinically significant fractures, they may not capture all fractures, particularly those involving small bones or subtle injuries that may require further evaluation.
Are there any limitations or challenges associated with using the Ottawa Ankle Rules in clinical practice?
Yes, limitations of the Ottawa Ankle Rules include variability in clinician interpretation, potential for missed fractures, and inability to account for factors such as patient age, mechanism of injury, and presence of other injuries.
How do the Ottawa Ankle Rules impact patient care and outcomes?
The Ottawa Ankle Rules help streamline patient care by reducing unnecessary X-ray imaging, minimizing patient exposure to radiation, and facilitating timely diagnosis and treatment of ankle injuries.
Can the Ottawa Ankle Rules be used in conjunction with other clinical decision tools or imaging modalities?
Yes, the Ottawa Ankle Rules can be used in conjunction with other clinical decision tools, such as the Pittsburgh Decision Rules, and imaging modalities, such as ultrasound or MRI, to enhance diagnostic accuracy and guide treatment decisions.
Are there any specific populations for which the Ottawa Ankle Rules may not be appropriate?
Yes, the Ottawa Ankle Rules may not be appropriate for certain populations, such as pediatric patients, individuals with altered mental status, or those with pre-existing conditions affecting mobility or sensation.
How do healthcare providers ensure proper training and adherence to the Ottawa Ankle Rules?
Healthcare providers receive training on the application of the Ottawa Ankle Rules through educational programs, clinical guidelines, and ongoing professional development to ensure accurate and consistent implementation.
Can patient factors such as pain tolerance or fear of radiation exposure influence the decision to use the Ottawa Ankle Rules?
Patient factors such as pain tolerance, fear of radiation exposure, and preferences for diagnostic testing may influence healthcare providers’ decisions regarding the use of the Ottawa Ankle Rules and X-ray imaging.
How do the Ottawa Ankle Rules contribute to evidence-based practice in orthopedics and emergency medicine?
The Ottawa Ankle Rules represent an evidence-based approach to diagnostic testing in orthopedics and emergency medicine, helping to standardize clinical practice, reduce unnecessary healthcare utilization, and improve patient outcomes.
Can variations in healthcare provider training and experience impact the accuracy of applying the Ottawa Ankle Rules?
Yes, variations in healthcare provider training, experience, and clinical judgment may impact the accuracy of applying the Ottawa Ankle Rules, highlighting the importance of standardized protocols and ongoing education.
How do the Ottawa Ankle Rules compare to other clinical decision tools or imaging guidelines for ankle injuries?
The Ottawa Ankle Rules have been widely studied and validated for their accuracy in excluding clinically significant fractures, but comparisons with other clinical decision tools and imaging guidelines may vary depending on specific patient populations and healthcare settings.
Can patient compliance with weight-bearing instructions affect the reliability of the Ottawa Ankle Rules?
Yes, patient compliance with weight-bearing instructions during clinical examination is essential for accurately applying the Ottawa Ankle Rules and assessing the stability of the ankle joint.
Are there any modifications or adaptations of the Ottawa Ankle Rules for special populations or clinical scenarios?
Modifications or adaptations of the Ottawa Ankle Rules may be necessary for special populations such as pregnant women, individuals with obesity, or those with pre-existing musculoskeletal conditions, to account for unique anatomical considerations and clinical presentations.
How do healthcare providers communicate the results of Ottawa Ankle Rules assessments to patients?
Healthcare providers communicate the results of Ottawa Ankle Rules assessments to patients by explaining the rationale for diagnostic testing decisions, discussing potential risks and benefits of imaging, and involving patients in shared decision-making regarding their care plan.
Can the Ottawa Ankle Rules be integrated into electronic medical record systems to facilitate decision support and documentation?
Yes, the Ottawa Ankle Rules can be integrated into electronic medical record systems to provide decision support tools for healthcare providers, standardize documentation of clinical assessments, and enhance quality of care delivery.
Dr. Mo Athar
