ACHA Clinical Benchmarking Program

Acute Care Module 

Acute Care Measure: Application of “Ottawa Ankle and Foot Rules” for Acute Ankle Injury

The information on this page is intended to help you complete the Acute Care Module of the Clinical Benchmarking Program. A worksheet is offered for each of the three measures in the Acute Care Module to help you organize your submission before entering it directly into the Clinical Benchmarking Program Data Input Tool. Once you have completed all three worksheets for this module, please use the link provided in your email invitation to submit the information compiled in the worksheet to ACHA. If you need help accessing the unique link for your institution, please contact ACHA Research Director Victor Leino.

Download Background, Instructions, and Worksheet [pdf]       Download Background, Instructions, and Worksheet [doc]


The original 1993 JAMA article by Stiell et al. outlined what came to be known as the "Ottawa Ankle Rules," a clinical decision tool useful in identifying patients with ankle injuries who could safely be managed without an x-ray. The Ottawa Ankle Rules set the criteria to establish a sensitivity of 100%, meaning that if the clinical criteria are met, the managing provider can rule out a fracture without having to get an x-ray. In subsequent prospective validation of the Ottawa Ankle Rules in various settings (emergency departments, community-based clinics, primary care), sensitivity ranges from 96-99%; application of these clinical rules reduces x-rays by ~1/3, thus preventing unnecessary testing, radiation, and costs.

The specificity of the Ottawa Ankle Rules does not help "rule in" an ankle or foot fracture. Thus, if a patient does not pass the full set of clinical criteria, the treating provider must do further clinical evaluation in order to assess for a fracture and whether an x-ray is required for management. A patient who does not "pass" the Ottawa Rules should have documentation of either an x-ray ruling out the fracture or documentation of the clinician's clinical judgment that the person is at low suspicion for fracture and ankle support and planned follow-up may be a reasonable approach.

Bottom-line application of the Ottawa Ankle and Foot Rules:

  • All patients should have documentation of the use of the elements of the Ottawa Ankle and Foot Rules
  • If a patient "passes" all of the clinical criteria, then no x-ray should be ordered
  • If a patient "does not pass," management is at the provider's discretion and should be well-documented in the chart.

The clinical decision rules are outlined below:

  1. Ability to weight-bear at the time of injury. This means walking at least four steps, without assistance (two steps on the injured foot/ankle), even if limping.
  2. Ability to walk at the time of evaluation. This means walking at least four steps, without assistance (two on the injured foot/ankle), even if limping.
  3. Absence of tenderness along the distal 6cm of the tibia or fibula (medial and lateral malleoli) (for ankle x-ray).
  4. Absence of tenderness of the proximal 5th metatarsal and navicular bone (for foot x-ray).

Because ankle injuries are one of the most common orthopedic injuries and the validity of these clinical decision rules is well- established, the ACHA Benchmarking Committee selected adherence to the Ottawa Ankle and Foot Rules in assessing patients with ankle injuries as an evidence-based acute care benchmark.


Each health center should identify 25 unique patients who were seen clinically for an acute ankle injury over the past 12 months. Suggested ICD-10-CM (diagnosis) codes include:

  • Sprain of ankle:
    S93.401-S93.499, but only A codes (A refers to initial encounter; D subsequent encounter; S sequella)


  • Injury of muscle and tendon at ankle and foot level:
    S96.001-S96.999, also only A codes

Charts should be selected rather randomly from those meeting this search, without any prescreening of management or limitation to particular practitioners. To be eligible, the patient must have had a traumatic ankle injury and been cognitively alert, without any neuropathy or spinal cord lesions that would affect their sensory status.

For each eligible chart, answer the following questions:

  1. Could the patient bear weight at the time of the injury (four steps, unassisted, even if limping) AND at the time of the evaluation in the health center?
    Yes     No     Not documented

  2. Based on the injury area (ankle/foot), was there any tenderness of
    1. the lateral malleolus (distal 6 cm of fibula) OR
    2. the medial malleolus (distal 6 cm of the tibia) OR
    3. the 5th metatarsal head OR
    4. the navicular bone area?
  3. Was an x-ray ordered?
    Yes     No

  4. If no x-ray was ordered, was there documentation of the clinician's judgment on low-risk of fracture with a management plan to follow up with the patient?
    Yes     No


JAMA. 1993 Mar 3;269(9):1127-32. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. Stiell IG1, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP, Maloney J.

Clinical Benchmarking Program Sections

Screening and Prevention Module

Acute Care Module