Intended for healthcare professionals

Practice Diagnosis in General Practice

The injured ankle and foot

BMJ 2009; 339 doi: (Published 07 August 2009) Cite this as: BMJ 2009;339:b2901
  1. Dan Mayer, professor of emergency medicine
  1. 1Albany Medical College, Albany, NY, USA
  1. mayerd{at}

    In this pair of articles, Gavin Falk and Tom Fahey (doi:10.1136/bmj.b2899) set out what to consider when using a clinical prediction rule, and Dan Mayer (doi:10.1136/bmj.b2901) shows how one such rule, the Ottawa ankle rules, is applied

    While playing basketball, a 26 year old student went up for a shot and came down inverting his ankle. He heard a loud pop and felt severe ankle pain. He was unable to get up for a few minutes, but his friends helped him up and he was able to limp off the court. He saw his primary care physician the next day, limping badly.

    Diagnostic dilemma

    Injuries to the ankle and mid-foot are commonly seen in primary care and hospital emergency departments. Only 15% of these are fractures,1 and the diagnostic dilemma for the clinician is thus to identify patients with such fractures, as these require plaster immobilisation or referral to an orthopaedic specialist. Most other injuries are treated for ligamentous stretch or disruption with dynamic stabilisation, rest, and physical therapy.

    In the past, the decision making process for ankle and mid-foot injuries involved subjective elements of the history and physical examination, followed almost always by an x ray, a process that is potentially harmful and wasteful. Historical clues included asking patients whether they heard a pop at the time of injury and were able to walk after the injury. Examination findings suggesting fracture were the presence of swelling, ecchymoses, stability when the ankle or mid-foot was moved, and ability to dorsiflex or plantar flex against resistance. However, such clinical findings were found to be unreliable, with poor inter-rater reliability.2

    Thus clinicians need a more accurate method to identify high risk …

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