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Ankle Injuries: When Do You Need An X-ray

Whether you play football, basketball, volleyball, or soccer, ankle injuries are common in sports. Our first priority as sports medicine physicians is avoiding further injury.

This often means not being able to return to the game immediately. One question that comes up often, usually after the injured athlete has gotten home and the initial efforts – Rest, Ice, Compression and Elevation, have not completely eliminated the pain and swelling, is whether an X-ray is necessary. The two benefits of an X-ray are to evaluate for a broken bone and to elevate the alignment of the ankle joint. Sprains can cause just as much pain and swelling as a broken bone so it is not easy to tell the difference by just looking at the ankle. There are a few simple rules that have been identified to help determine when an X-ray is helpful. There are known as the Ottawa rules, developed in Canada by emergency room physicians to help them reduce the number of X-rays performed when evaluating this very common injury.

  1. Bone tenderness over the back half of the fibula. The fibula is the bone on the outer part of the ankle. If you look at the other ankle, that hopefully is not swollen, you can use that to help you identify where these parts are. The bony bump on the outer ankle is the bottom of the fibula. It is usually a little wider than your thumb. Start several inches above the ankle and press firmly on the bone. By moving slightly forward and backward you should be able to identify where the bone is and where the muscle is. While pressing on the bone, work your way down to the ankle joint, pushing on the front and then the back of the bone.
  2. Bone tenderness over the back half of the medial malleolus. The bony bump on the inner part of the ankle is the medial malleolus. Tenderness on the front half of either of these bumps could be a simple sprain but tenderness over the back half is more suspicious for a fracture.
  3. Inability to bear weight on the injured leg both immediately and during the evaluation. If the player limps that is still considered able to bear weight.

If the injured player is able to bear weight, even if it is painful, and if the tenderness is not in the areas listed above, there is a low likelihood of a fracture. In that case, continued elevation, intermittent icing, and anti-inflammatory medication can be helpful to reduce the pain and swelling. If the pain continues more than a couple of days, it is worthwhile to get it evaluated by an orthopedic surgeon or sports specialist. It is generally not advised to return to play (practice or game) if you are still having pain until a specialist has evaluated the ankle and determined it is safe.

Whether you are an aspiring athlete or a weekend warrior, our goal is to keep you healthy and active without over-treating simple problems that just need a little TLC to improve. If you have a problem that is simply not going away, don’t ignore the pain. Get the treatment you need to fully recover so you can live and play at 100%.