Ankle Pain: When Should You Go Get an X-Ray?
This is a very common question that we receive; when is it a good idea to have an x-ray? This can be after a traumatic injury or just someone who is fearful of their joint making odd noises (clicking, popping, etc)
This is super helpful information for active adults, youth athletes, and their parents or coaches, so that they can decide if getting an x-ray is beneficial to them or not, because lets face it, imaging is not cheap, and who wants to waste hours in the ER to be told nothing substantial is wrong?
It should be noted that there is not always a black & white answer for if getting an X-ray is absolutely necessary, but in many cases we can use a set of “rules” that have been developed and studied to help us make this decision. For the ankle in particular, these rule are considered “Ottawa Ankle Rules”. This set of rules was created by Dr. Ian Stiell out of the university Ottawa and are the gold standard in todays medicine for helping clinicians decide if imaging is needed or not. These rules are to be used following traumatic events to the ankle. For more information on non-traumatic events scroll to the bottom of the post!
The Ottawa Ankle Rules:
This is a view of the INSIDE of the foot
An ankle X-Ray is ONLY required if there is any pain in the MALLEOLAR zone and.
Bone tenderness at the posterior edge or tip of the lateral (outside) ankle bone or malleolus (A, see picture below)
OR
Bone tenderness at the posterior edge or tip of the medial (inside) ankle bone or malleolus (B)
OR
An inability to bear weight both immediately and in the emergency department for four steps
A foot X-Ray series is only required if there is any pain the MIDFOOT zone and...
This is a view of the OUTSIDE of the foot.
Bone tenderness at the base of the fifth metatarsal (C)
OR
Bone tenderness at the navicular (D)
OR
And inability to bear weight both immediately and in the emergency department for four steps.
A person’s clinical judgement should always prevail over these rules if the patient...
is under the influence of drugs or alcohol.
has other painful injuries to other body parts
has reduced ability to feel their legs/feet
has too much swelling which prevents quality palpation of the malleolar bone tenderness
Some extra helpful tips to help improve you’re accuracy:
Make sure to palpate the entire end (6cm) of the fibula and tibia
Do not neglect the importance of medial malleolar tenderness AKA tenderness on the INSIDE of the ankle bone.
“Bearing weight” counts even if the patient limps
Be more cautious in patients under age 18 due to lacking bone development.
To summarize, this is a total of five tender bony landmarks OR inability to put weight on their leg for four or more steps. A patient can certainly have more than one of these, but if they have just ONE then getting imaging is indicated.
What if I didn’t have a traumatic event?
In regards to getting x-rays in other situations that are non-traumatic in nature and not associated with pain, I would refrain from doing so. There are many coincidental finding that can be seen on imaging the can create negative beliefs around your situation and actually create anxiety for you that is unnecessary! Lord knows most of us have enough to deal with already. Moral of the story is if you’re not having pain, don’t worry about things such as clicking, popping, cracking etc. in your joints! IT’S 100% NORMAL!
In conclusion, If you’re an athlete, coach, or parent who is on the fence about whether or not your should get an X-ray, these can be helpful guidelines to follow. If you are EVER unsure then you should absolutely consult an expert for advice! Because Virginia has what’s known as DIRECT ACCESS, we can be that expert for you so that we can save you time and money.