Ottawa ankle rules: Sign may not be objective

EDITOR—In their paper on the accuracy of the Ottawa ankle rules Bachmann et al consider the wide variation in specificity, citing subtlety of palpation technique as a possible contributing factor.1

They are correct. If you palpate an ankle, or anything else for that matter, and ask the patient, “Is that sore?” you will invariably get a much higher positive response rate than if you palpate silently and simply observe for a non-verbal response.

The moment you rely on a patient to “give you” your clinical sign you are no longer dealing with an objective sign, such as an enlarged liver or a heart murmur. Instead you are dealing with an extension of symptoms, with all the subjectivity that this entails. It is no wonder then that studies that rely on the estimation of bony tenderness are frequently associated with wide variations in specificity.