American Medical Society for Sports Medicine

View all recommendations from this society

Released March 29, 2022

Do not order ankle or midfoot X-rays for patients older than 6 years old without positive criteria per the Ottawa ankle rules.

Both children and adults commonly present to healthcare settings in the outpatient clinics, urgent care clinics and hospital emergency rooms with ankle and foot injuries. Multiple randomized control studies and meta-analyses have shown the high sensitivity of the Ottawa Ankle Rules (OAR) to rule out fractures when criteria are not met, and thus avoid the need for imaging in the acute setting. Unnecessary imaging increases healthcare costs, patient wait times, and radiation exposure. It should be noted that there is much less data for application of the OAR for pediatric patients under the age of 6, due to less ankle and midfoot injuries in this patient population as well as difficulty of children in this age group to walk independently.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American Medical Society for Sports Medicine (AMSSM) has identified this list of clinical recommendations for the Choosing Wisely® campaign. The goal was to identify common topics in the practice of sports medicine that, supported by a review of the literature, would lead to significant health benefits and a reduction of common procedures that can be unnecessary or cause harm. For each item, evidence was reviewed from peer-reviewed literature and several sports medicine consensus statements. The list was initially generated and drafted by AMSSM’s Quality Measures Subcommittee. It was then edited and approved by AMSSM’s Practice and Policy Committee and the Board of Directors.

The American Medical Society for Sports Medicine’s disclosure and conflict of interest policy can be found at www.amssm.org.

Sources

Beckenkamp PR, Lin CC, Macaskill P, Michaleff ZA, Maher CG, Moseley AM. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis. Br J Sports Med. 2017 Mar;51(6):504-510. doi: 10.1136/bjsports-2016-096858. Epub 2016 Nov 24. PMID: 27884861.

Can U, Ruckert R, Held U, Buchmann P, Platz A, Bachmann LM. Safety and efficiency of the Ottawa Ankle Rule in a Swiss population with ankle sprains. Swiss Med Wkly. 2008 May 3;138(19-20):292-6. PMID: 18491243.

Dowling S, Spooner CH, Liang Y, Dryden DM, Friesen C, Klassen TP, Wright RB. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 2009 Apr;16(4):277-87. doi: 10.1111/j.1553-2712.2008.00333.x. Epub 2009 Feb 2. PMID: 19187397.

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):384-90. doi: 10.1016/s0196-0644(05)82656-3. PMID: 1554175.

Plint AC, Bulloch B, Osmond MH, Stiell I, Dunlap H, Reed M, Tenenbein M, Klassen TP. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999 Oct;6(10):1005-9. doi: 10.1111/j.1553-2712.1999.tb01183.x. PMID: 10530658.