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To Send for X-rays or Not? A Telemedicine Approach to Ankle Injuries

Created: February 21, 2017
Updated: July 26, 2022
Dark bruise near ankle at the heel of foot
This blog content is provided for informational purposes only, and is not intended as a substitute for professional medical advice, diagnosis, or treatment.

Do all ankle injuries need an x-ray?  Multiple medical studies that have been confirmed time and time again, the answer is clearly no.  You probably would not guess this by visiting or working in Emergency Departments or Urgent Care Centers across this country full of health care providers afraid of missing ANY diagnosis. Maybe it is just that those providers are just too busy to think through and apply the researched and published guidelines on who does or does not need an x-ray.  Health care providers could be saving the patient precious time and money while avoiding unnecessary testing and radiation.  Studies have shown that correct application of these rules can reduce the number or unnecessary x-rays by 30-40% and is sensitive enough of a test to pick up nearly 100% of fractures.

For patients that injure an ankle, telemedicine is a modality of seeing the patient where utilizing these guidelines could save the patient an unnecessary and painful trip.  The guidelines that I speak of are the Ottowa ankle rules.  These set of rules that guide the clinician to who does or does not need an x-ray has been validated on thousands of patients aged 2 and older.  Granted, there have not been specific studies as pertains to its application in the telemedicine evaluation but by confidently engaging the patient in the exam, all of the features of the rules can be approached through a video examination.

Let's start by going over the rules:


1.  There is tenderness to palpation at the posterior edge or tip of the distal 6cm of the lateral malleolus


2.  There is tenderness to palpation at the posterior edge or tip of the distal 6cm of the medial malleolus


3.  The patient was unable to bear weight both immediately after injury and at the time of presentation

Image of ottowa ankle rules used in online urgent care evaluation of ankle injuries

Now the next question is how to apply this to the patient being seen over a video connection.  As is usual in telemedicine, the key is in fully engaging the patient in an honest history and an expertly guided self-examination.


  • Assess level of reliability.  Avoid depending on these rules if patient is clearly distracted, intoxicated, has any altered mentation, or is too young, frail, or debilitated for any other reason to actively and reliably participate.
  • Ask about other injuries and complaints
  • Ask about ability to bear any weight immediately after the injury
  • Also consider referring to in-person evaluation for a patient with multiple painful injuries as a distracting injury can diminish reliability of the exam.
  • Mechanism, prior injuries and surgery


  • Assess for other injuries
  • Have patient remove socks and shoes from both injured and non-injured feet
  • Compare ankles and not skin color, abrasions, lacerations.
  • Guide patient in palpating the posterior and tip of distal 6 cm of medial and lateral malleolus.  Assess for tenderness.
  • Consider assessing capillary refill by having patient push on tips of toes with foot nearer the camera.
  • Guide patient in a weight bearing test in front of camera.

After performing the above history and physical, an experienced health care provider should be able to reliably ascertain whether or not a patient needs to go an get an x-ray series performed or can rest, ice, elevate, and immobilize at home.  With careful application, you are unlikely to miss a significant injury and some patients are less likely to waste extra time and money getting unnecessary tests performed.


  1. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992 Apr;21(4):384–390.
  2. Stiell I, Wells G, Laupacis A, Brison R, Verbeek R, Vandemheen K, Naylor CD. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ. 1995 Sep 2;311(7005):594–597.
  3. Libetta C, Burke D, Brennan P, Yassa J. Validation of the Ottawa ankle rules in children. Journal of Accident & Emergency Medicine. 1999;16(5):342-344.
  4. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ : British Medical Journal. 2003;326(7386):417.
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