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When is an X-Ray Necessary after an Ankle Sprain?

You just rolled your ankle during practice and it swells immediately, leaving you in pain and wondering, “Do I have a fracture or is this just a sprain?”

Ankle sprains are one of the most common injuries in athletes.  Most times, ankle sprains do not require an x-ray or surgery.  However, sometimes an ankle sprain can be accompanied by a fracture in the foot or ankle which could require a different treatment protocol from a sprain.

Types of Fractures
An avulsion fracture is when the force on the ligament is so strong that the ligament tears away part of the bone that it is attached to.  More serious fractures, like a Jones fracture, (fracture of the base of the 5th metatarsal) can occur on occasion, and this type of fracture needs to be addressed with immobilization and sometimes surgery due to the lack of blood flow for healing in the area.

So how do you know if you should get an x-ray or not? 

Here are some basic rules (Ottawa Ankle and Foot Rules) that can help guide your decision on if you should get an x-ray.

  1. 1.  Can you bear weight through the leg taking 4 steps (even with a limp) immediately after the injury and for a couple of hours after?  If you cannot, get an x-ray!
  2. 2.  Do you have severe tenderness around your medial or lateral malleolus (the bones on either side of your ankles)?  If it is severe, get an x-ray!
  3. 3.  Do you have severe tenderness on the outside portion of your foot, half way between your little toe and your heel (around the base of your 5th metatarsal)?  If yes, get an x-ray to rule out a Jones fracture!
  4. 4.  Do you have tenderness around the navicular region, the bone that sits on the inside of your foot, in your arch region?  If yes, get an x-ray.


Arrow 1:  Lateral Malleolus

Arrow 2:  Base of the 5th Metatarsal

Arrow 3:  Medial malleolus

Arrow 4:  Navicular bone


It must be noted that many times, even with just an ankle sprain, you could answer yes to all of the above questions.  But, if that is the case, it is probably a good idea to get an x-ray of your foot or ankle, just to rule out a fracture and clarify how to treat it properly. Omaha Physical Therapy Institute provides FREE injury screens for athletes, including ankle and foot injury/sprain assessments, to assist with guiding your treatment plan and determine if an x-ray is needed or not.  We specialize in ankle and foot rehab!  Call today to schedule your free injury screen!  402.934.8688


1. Barelds I, Krinjnen WP, van de Leur JP, can der Schans CP, Goddard RJ.  Diagnostic Accuracy of Clinical Decision Rules to Exclude Fractures in Acute Ankle Injuries:  Systematic Review and Meta-analysis.  J Emerg Med. 2017 Sep;53(3):353-368.

2. 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 2003; 326:417.