x-ray after an ankle sprain the prehab guys

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


Learn How To Rehab After An Ankle Sprain!


Ankle Sprains

Ankle sprains are one of the most common athletic injuries. Not only just in athletics but also in activities of daily living. We are all human, things happen! Missing a step, stepping into a pothole, or twisting your ankle – next thing you know your ankle swells up like a balloon! Many are just minor ankle sprains and don’t require any x-rays or surgical treatment. They often may look much worse than they actually are, but it is always smart to be thorough and receive a proper diagnosis from a trained healthcare professional. A comprehensive rehabilitation plan is all that’s needed to gain back proprioception and stability in the ankle.


Have You Injured Your Ankle And Are Eager To Return To Activity?

ankle sprain rehab the prehab guys

This ankle sprain program has been designed for you to take ownership of your body and health. Lateral ankle sprains can be challenging and frustrating due to having the highest injury AND reinjury rate among 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!

There Also Can Be More Serious Injury With Ankle Sprains

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 fracture

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.


tissue healing prehab guys


Do I Need an X-Ray After an Ankle Sprain? Use The Ottowa Ankle Rules

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 X-ray after an ankle sprain!


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 X-ray after an ankle sprain. 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, 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.

Ultimately, this is not medical advice and if you’re concerned you should follow up with your medical profressional.


Prehab Membership The Prehab Guys

The Prehab membership is the anti-barrier solution to keeping your body healthy. Access state-of-the-art physical therapy, fitness programs, and workouts online in the comforts of your own home or gym! Taking control of your health with exercise & education from the palm of your hand has never been easier. Get access to 50+ programs, 100+ unique workouts, and 3000+ exercises to build your own workout routines. Trial it for free, and learn how to get out of pain, avoid injury, and optimize your health with [P]rehab!


A Summary Of The Ankle X-ray Screening Questions

  • Can you take 4 steps (it’s okay if need to limp)? NO? –> GET AN XRAY


  • 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 XRAY


  • 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


  • Do you have tenderness/pain around the navicular bone (bump on the medial/inside portion of your foot?) YES> –> GET AN XRAY


live well with lymphedema prehab guys ankle sprain x-ray

Swelling is inevitable after any type of ankle injury. A potential complication of prolonged swelling in the development of lymphedema. Listen to our [P]Rehab Audio Experience with Taryn Everett, as we dive into the topic of how to live well with lymphedema!


So What Happens If I Have A Fracture?

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. For instance, if you sustained a very small, hairline fracture that is non-displaced, in most instances, you will NOT have to have surgery! 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. We have an entire blog article on the topic of what to do after an ankle fracture that you can read below!


What To Do After An Ankle Fracture do I need an xray the prehab guys


Closing Thoughts

Ankle sprains are very frequent and oftentimes are treated conservatively. The quick swelling and pain as well as difficulty with walking may have you fearing the worst: a fracture. Luckily, the Ottawa Ankle Rules are a highly effective, quick, evidence-based screening tool that can save you the energy, time, and money of avoiding an X-Ray! It is always smart to receive a proper evaluation and diagnosis from a trained healthcare professional who can outline the best road to recovery for you specifically while also ensuring you receive the correct diagnosis!


Make A Full Return To Activity On Your Own Terms

ankle sprain rehab the prehab guys

Ankle sprains can be scary and to add fuel to the uncertainty fire there is a lot of misguided information about treating it. We are here to set the record straight because the best treatment is not complete rest, but rather early safe and protected movement. What is done in the initial phases of injury plays a role in the long-term outcome. The goal is that you regain confidence in your ankle’s ability to support movement and generate higher levels of force needed for walking, climbing stairs, and running.


About The Author

Michael Lau, PT, DPT, CSCS

[P]rehab Co-Founder & Chief Product Officer

Michael was born and raised in Northern California but now currently resides in Sunny SoCal ever since attending the University of California, Los Angeles as an undergraduate majoring in physiology. After his undergraduate studies, he received his Doctorate in Physical Therapy from cross-town rival the University of Southern California. As a licensed physical therapist with a strong background in strength and conditioning, Michael likes to blend the realms of strength training and rehabilitation to provide prehab, or preventative rehabilitation, to his patients. A common human behavior is to address problems after they become an issue and far often too late, which is a reactionary approach. He believes the key to improved health care is education and awareness. This proactive approach-prehab-can reduce the risk of injuries and pain in the first place. He is a huge proponent of movement education and pain science. Clinically, he has a special interest in ACLR rehab and return to sport for the lower extremity athlete.






Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.

About the author : Michael Lau PT, DPT, CSCS


  1. Bluey September 29, 2017 at 5:04 pm

    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 October 7, 2017 at 8:50 am

      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!

  2. Anonymous October 26, 2017 at 3:49 pm

    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 October 27, 2017 at 8:16 am

      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 March 14, 2018 at 7:08 pm

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

  3. Omidreza February 23, 2018 at 4:04 am

    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 February 24, 2018 at 11:30 pm

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

  4. Geoff Gamble March 14, 2018 at 7:06 pm

    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.

  5. Irene abdou May 3, 2018 at 2:29 am

    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 May 14, 2018 at 6:09 pm

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

  6. Kristo Holm July 16, 2018 at 8:10 am

    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 July 20, 2018 at 6:05 pm

      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.

  7. Sally Joe July 31, 2018 at 8:55 am

    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.

  8. Kate Welling February 19, 2019 at 1:59 pm

    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 February 25, 2019 at 11:26 am

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

  9. Peter Rotondo November 8, 2019 at 9:50 am

    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 January 13, 2020 at 7:32 pm

      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!

  10. R3 Stem Cell November 15, 2020 at 11:39 pm

    Thank you for this article and it seems so helpful, and individuals must also look for regenrative medicine since it has delivered tremendous results.

  11. Ronda L Villines May 19, 2021 at 6:09 am

    This article eases my mind – but for more understanding (I am not athletic, I am an art teacher who incurred an ankle injury while playing football with the students). I have full ankle range of motion, I can bear weight, but I limp. It hurts above the outer ankle – which worries me thinking about a possible fracture of the fibula (but, I am following the RICE – rest, ice, compress, and elevate) method of healing it. So, should I not worry about getting (and paying for an x-ray unnecessarily). Thanks – for your time!

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