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

You just had a BAD ankle sprain. It’s black and blue. It hurts like hell. How do you know that its ONLY an ankle sprain, and not anything worse like a FRACTURE?! Well lucky for you, there’s a quick an easy test you can do NOW to screen if you need an x-ray after an ankle sprain.

Ankle sprains are one of the most common athletic injuries. Many are just minor ankle sprains, and don’t require any x-rays or surgical treatment. A comprehensive rehabilitation plan is all that’s needed to gain back proprioception and stability in the ankle (READ: Ankle Sprain Rehabilitation). 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 (remember, ligaments attach bones to other bones).

x-ray after ankle sprain jones fractureIt’s important to screen for these types of injuries because early weightbearing 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.

Ankle X-ray Screening Questions

  1. Can you take 4 steps (its okay if need to limp)? NO? –> GET AN XRAY
  2. Do you have tenderness/pain around your medial or lateral malleoli (the little bone bumps on either side of your ankle)? Specifically the back side of the bones? YES? –> GET AN XRAY
  3. 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 XRAY
  4. Do you have tenderness/pain around the navicular bone (bump on the medial/inside portion of your foot?) YES> –> GET AN XRAY


This battery of screening tests, called the Ottawa Ankle Rules, has an extremely high negative predictive value. What this means, is that if you CAN take 4 steps AND you DO NOT have tenderness in those specific areas, it almost certainly means YOU DO NOT HAVE AN ANKLE FRACTURE and thus you do not need to get an xray!!

Now, if you CAN NOT take 4 steps or DO have tenderness in those areas, THAT DOES NOT NECESSARILY MEAN YOU HAVE A FRACTURE – it just means you should go to the ED and get an xray. The specificity (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, not to RULE IN if you do indeed have an ankle fracture. It has a sensitivity of almost 100% I know this was a bit complicated…brings me back to statistics 101 in college…so let us know if you have any questions!!


Ankle Sprain [P]Rehab Program

Lateral ankle sprains can be challenging and frustrating due to having the highest injury AND reinjury rate amongst any lower-body injury. The high reinjury rates are likely because most ankle sprains aren’t properly managed in the first place. It’s time to change the narrative with [P]Rehab – we’ve designed a solution for you to get back to normal life while protecting your ankles into the future! Learn more HERE!


  • Bluey
    Posted at 17:04h, 29 September Reply

    You may want to clarify that the Ottowa ankle rules state that tenderness to the malleoli is only significant if it is on the distal posterior 6cm.
    As tenderness found anteriorly can lead to a false positive. Simple (Grade 1 -2) ATFL tears can very commonly present with bony tenderness anteriorly with no actual bony involvement.

    • Michael Lau
      Posted at 08:50h, 07 October Reply

      Correct. Will make the change. We write our posts with the average joe in mind, so we try to simplify things and make them understandable for readers of all backgrounds. Thanks for the feedback Bluey!

  • Anonymous
    Posted at 15:49h, 26 October Reply

    I don’t know all of the terminology but Bluey is right. Tenderness doesn’t tell me anything. I’ve sprained both of my ankles so many times that I’ve lost count. I’ve had almost every incident x-rayed, usually after a few days once the blood starts pooling below my ankle(freaking me out), all of which had tenderness (that comes with the territory…. so yeah) and none of them showed a break or a fracture, period. Tenderness and pain come with injuries so maybe a type of measurement like a type of pain? Or degree or something?

    • Michael Lau
      Posted at 08:16h, 27 October Reply

      This is just what the research has shown to be 100% sensitive for ankle or foot fractures. I’m sure they looked at type of pain but when they ran the stats, it didn’t find into the clinical prediction rule.

    • Geoff Gamble
      Posted at 19:08h, 14 March Reply

      This is why the Buffalo revision happened. It helps eliminate palpation of painful ligaments

  • Omidreza
    Posted at 04:04h, 23 February Reply

    Big question in my experience is what to do as a physioyltherapist when the patient has pain in chronic case (for example after 1 year of sprain)

    • Michael Lau
      Posted at 23:30h, 24 February Reply

      Don’t quote me, but I am almost certain these rules only apply to an acute injury.

  • Geoff Gamble
    Posted at 19:06h, 14 March Reply

    I believe these rules were modified to be more specific… Palpation of the crest of the 6cm of the distal tib and fib. This is often termed the Buffalo revised Ottawa ankle rules or the buffalo rule.

  • Irene abdou
    Posted at 02:29h, 03 May Reply

    On #2, it hurts when I press the outer side of the bone bump on the outside of my foot close to the heel, but it does not hurt on the backside of that bone bump. So did I pass or fail test #2?

    • Michael Lau
      Posted at 18:09h, 14 May Reply

      Technically it has to be the back or bottom of the bone that is tender, so you passed the test!!

  • Kristo Holm
    Posted at 08:10h, 16 July Reply

    Quick question, what is the point of getting an xray, unless there’s sever pain and restriction to mobility so a cast is needed? If I am able to walk with a slight limp, and ankle mobility is decent surely I’m fine. I just need to rest and get the inflammation down of ligaments and soft tissue. The possibility that there is a hairline fracture? Surely this will just heal as I am resting anyway due to soft tissue damage.

    Curious because I sprained my ankle and heard a crack. Been able to weight bear whole time but walking hurts (not overwhelming, just uncomfortable) and taking it at an easier pace. Saw a GP two days after and he told me to get an xray because pressing on the lateral malleolus is sore. But only when pressing on it, not when walking.When walking the pain is on the inner side of achilleus but not the achilleus itself.

    I just feel like of all the past sprains and strains, you go get an xray, waste your own time, waste the NHS resources and get told there’s no fracture and there’s nothing more to be done.

    • Michael Lau
      Posted at 18:05h, 20 July Reply

      That is why the ottawa ankle rules were created. If you are able to bear weight, then you would be negative and there would be 100% accuracy that you do NOT have an ankle fracture. Hope that helps.

  • Sally Joe
    Posted at 08:55h, 31 July Reply

    I rolled my ankle about a week ago. Immediately after I had extreme pain over the navicular bone and had a hard time walking. I thought it might just be a strain of the posterior tibialis tendon. However, a week later it is bruised and purely tender over the navicular bone. I figured if it was a strain of the tendon, more of the tendon would be tender. I can walk now, however it is very sore to walk. Taping for support makes it feel a little better. How do you determine if it is the navicular bone or the tendon that is hurt? I do not want to go get an x-ray for a strain or tendonitis.

    • Michael Lau
      Posted at 08:33h, 08 August Reply

      best to go see an orthopedic specialist in person if you are concerened

  • Kate Welling
    Posted at 13:59h, 19 February Reply

    I’m happy that I read this article because my son is worried that he broke his ankle. You mentioned that if you can’t take more than 4 steps, then you need to get an x-ray. He limps when he takes steps, so I am going to look for a doctor to bring him to. I thought he sprained it when he was jumping on the trampoline early this morning, but I was wrong! I hope that the podiatrist can help us.

    • Michael Lau
      Posted at 11:26h, 25 February Reply

      I hope you got some answers from your podiatrist!!! Always best to be safe if you are unsure!

  • Peter Rotondo
    Posted at 09:50h, 08 November Reply

    I tripped the other day and my ankle hurts, but not when I touch it according to the above. Everyone tells me that I need an xray. I just don’t understand where the clicking noise/feeling is coming from if there’s no fracture.

    • Michael Lau
      Posted at 19:32h, 13 January Reply

      Hi Peter,

      Hopefully your ankle is feeling better by now! The popping in the ankle is commonly just from a tendon rubbing over a bone or from the joint capsule itself. Both nothing to be worried of!

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