Do I Need an X-ray After an Ankle Sprain?

Ankle sprains are a common occurrence and something that we see frequently at Kaizen. These injuries can range from a minor, first-time roll of the ankle to chronic, recurring ankle sprains that just keep happening – sometimes leaving you hobbling around with an ankle that is swollen and black-and-blue.

Oftentimes these injuries are minor and don’t require any X-rays or surgical intervention, and can be treated with some physical therapy aimed at gaining strength/stability and proprioception (perception or awareness of the position and movement of the body).

In some injuries, however, you can also have a fracture in the bones of the ankle or even in the foot. When this happens, we often see avulsion fractures where the force on the ankle from the sprain is so much that it breaks off a portion of the bone with it.

We also sometimes see what is called a Jones fracture. This is a fracture in the base of the 5th metatarsal, a bone in your foot. The type and severity of these injuries determines how they are treated. A minor ankle sprain calls for early weight-bearing through that foot.

However, if there is a fracture, there needs to be a period of offloading and possibly immobilization depending on the severity and how stable the fracture is. If the injury is very unstable, it may call for surgery, which means even more rest and healing time prior to a more conservative rehab program initially.

How do I know if I need an X-ray?

Because of this uncertainty, people often ask if they should get an X-ray or whether or not they need an X-ray before they come to see us. The answer, of course, isn’t always clear-cut and can vary depending on the context of the injury.

Fortunately there is a screening tool, called the Ottawa Ankle Rules, that we can use to help us make this decision.

5 components to test:

• Bony tenderness along the back edge of the fibula, or the tip of the outer ankle bone.
• Bony tenderness along the back edge of the tibia, or the tip of the inner ankle bone.
• Bony tenderness at the base of the fifth metatarsal, the bony bump on the outside of the foot.
• Bony tenderness at the navicular bone, on the inside of the foot.
• Inability to bear weight for four steps, both right after the injury and again at your evaluation.

An ankle X-ray is generally called for when there’s pain around the ankle bones themselves, plus tenderness in one of those specific spots or trouble walking four steps. A foot X-ray follows the same logic for pain in the middle of the foot. The tool is very good at ruling a fracture out: someone who can walk four steps and doesn’t have tenderness in those specific spots almost certainly doesn’t have a fracture. It’s not as precise at ruling one in, a positive finding means an X-ray is worth getting, not that a fracture is confirmed.

Ankle X-ray screening questions

• Can you take four steps right now, limping is fine? If no, get an X-ray.
• Any tenderness around the bony bumps on the back of your ankle? If yes, get an X-ray.
• Any tenderness at the bony bump on the outside of your foot? If yes, get an X-ray.
• Any tenderness at the bony bump on the inside of your foot? If yes, get an X-ray.

Medical disclaimer

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