Ankle and foot injuries
Use the Ottawa rules to decide on an X-ray, and don't miss the 5th metatarsal base, the Achilles tendon or the high fibula.
A 25-year-old rolled his ankle inwards playing football. He limped off but couldn't take four steps in the department. There's swelling over the outside of the ankle and tenderness at the tip of the lateral malleolus. He also has tenderness at the base of the fifth metatarsal.
A 42-year-old man felt "someone kick me at the back of my heel" while jumping in a badminton game. He can walk, with a limp.
Who needs which X-ray, and what is the second man's injury?
- Neurovascular checkPulses, capillary refill, sensation. Deformity with skin at risk: reduce urgently.
- Ottawa ankle and foot rulesX-ray only if positive. Press the right spots.
- Simmonds' testCalf squeeze for Achilles rupture, even if they can walk.
- Feel the whole fibulaProximal tenderness with a medial ankle injury is a Maisonneuve fracture.
- Squeeze testPain at the ankle when squeezing mid-calf suggests a syndesmosis injury.
- SprainProtect, rest, ice, compression, elevation, then walk as able.
- FracturesBoot or below-knee cast, or orthopaedics if unstable.
- Follow-upFracture clinic, or return if not better in 2–3 weeks.
- Deformity or skin tenting (fracture-dislocation)
- Open fracture
- Cold, pale or numb foot
- Achilles rupture
- Weber C, or Weber B with medial tenderness
- Lisfranc injury
- Calcaneal fracture after a fall from height (check the spine)
- Achilles rupture because they can still walk
- Maisonneuve fracture (high fibula)
- 5th metatarsal base fracture when only the ankle is X-rayed
- Lisfranc injury
- Talar dome injury
- Diabetic neuropathic (Charcot) foot
- Compartment syndrome after crush
| Ottawa ankle X-ray | Bone tenderness at the back edge or tip of either malleolus (bottom 6 cm), or can't walk 4 steps immediately and in the department |
| Ottawa foot X-ray | Bone tenderness at the base of the 5th metatarsal or the navicular, or can't walk 4 steps |
| Weber A | Below the joint, usually stable |
| Weber B | At the joint level, stability depends on the medial side |
| Weber C | Above the joint, unstable, orthopaedics |
| Achilles rupture | Equinus cast or boot, same-day or next-day orthopaedics |
| Paracetamol | 1 g 4 times daily |
| Ibuprofen | 400 mg 3 times daily with food for up to 5 days |
Check every dose against a current drug reference and your hospital protocol.
On this page
History
- Mechanism: inversion (rolling outwards: lateral ligaments, fibula, 5th metatarsal), eversion (medial side, deltoid ligament, Maisonneuve), direct blow, fall from height (calcaneus, spine), twisting with the foot fixed (midfoot, Lisfranc).
- Could they walk 4 steps straight after, and now?
- A "kick" or "shot" at the back of the heel: Achilles rupture.
- Previous sprains, diabetes (neuropathy), steroids or fluoroquinolones (Achilles).
Examination
- LookSwelling, bruising, deformity, skin at risk, sole bruising (Lisfranc).
- Feel the Ottawa pointsBack edge and tip of each malleolus (bottom 6 cm), base of 5th metatarsal, navicular.
- Feel moreWhole fibula up to the knee, Achilles tendon (gap), midfoot, calcaneus.
- Special testsSimmonds' (calf squeeze), squeeze test (syndesmosis), anterior drawer later.
- Walk and neurovascular4 steps, pulses, capillary refill, sensation.
Tenderness at the front of the lateral malleolus (over the anterior talofibular ligament) is a sprain sign. It's the back edge or tip of the bone that counts in the Ottawa rules.
Ottawa ankle and foot rules
- No X-ray
- sprain treatment
Ankle X-ray
Foot X-ray
Which injury?
| Injury | Clues |
|---|---|
| Lateral ligament sprain | Inversion, tender in front of and below the lateral malleolus, can walk |
| Lateral malleolus fracture | Bony tenderness at the back edge or tip |
| Bimalleolar or trimalleolar fracture | Both sides tender, swelling, often unstable |
| Maisonneuve fracture | Medial ankle injury with proximal fibula tenderness |
| 5th metatarsal base fracture | Inversion, tender lateral midfoot |
| Achilles rupture | "Kick" at the heel, palpable gap, positive Simmonds' test |
| Lisfranc injury | Midfoot pain, bruising on the sole, can't stand on tiptoe |
| Calcaneal fracture | Fall from height, heel pain and swelling; check the lumbar spine |
| Talar dome injury | Ongoing pain after a "sprain" |
Weber classification
| Type | Fibula fracture level | Usual management |
|---|---|---|
| A | Below the ankle joint (syndesmosis) | Stable; boot, walk as able |
| B | At the level of the joint | Stable if no medial injury; unstable with medial tenderness or talar shift |
| C | Above the joint | Unstable; orthopaedics, often surgery |
Achilles tendon rupture
- Typically men aged 30–50 in stop-start sports, or older people on steroids or after fluoroquinolones.
- They can often still walk and plantarflex weakly (long toe flexors), so it's easily called a sprain.
- Simmonds' (Thompson) test: patient kneels on a chair or lies prone with feet over the edge. Squeeze the calf: the foot should point down. No movement = rupture.
- Treatment: equinus (toes pointed) cast or boot, crutches, orthopaedics within a day. Many are treated without surgery using functional rehabilitation.
Treatment
- Sprain: protect, rest, ice 15–20 minutes every 2–3 hours for 48–72 hours, compression if comfortable, elevate. Walk as pain allows. Most improve in 2–6 weeks; ankle exercises help prevent recurrence.
- Stable fractures: walking boot or below-knee cast, fracture clinic.
- Unstable fractures and dislocations: reduce urgently if deformity or skin at risk, back slab, orthopaedics.
- 5th metatarsal base avulsion: boot or supportive shoe, weight-bear as able. A fracture slightly further along the shaft (Jones fracture) heals poorly: fracture clinic.
- Lower leg cast: consider VTE prophylaxis per local risk assessment.
Common mistakes
- Calling an Achilles rupture a sprain because the patient can walk.
- X-raying only the ankle when the 5th metatarsal is tender.
- Not feeling the whole fibula.
- Missing a Lisfranc injury (bruising on the sole).
- Missing a calcaneal fracture's partner: the lumbar spine fracture.
- Forgetting VTE risk in a leg cast.
Come back if
- Calf pain or swelling, or breathlessness (DVT or PE).
- Foot cold, pale, numb or very swollen.
- Still unable to walk after a few days, or no better in 2–3 weeks.
Frequently asked questions
When does an ankle injury need an X-ray?
Using the Ottawa rules: bone tenderness at the back edge or tip of either malleolus, or inability to walk 4 steps immediately and in the department. For the foot: tenderness at the base of the 5th metatarsal or the navicular.
How do you test for Achilles tendon rupture?
Simmonds' (calf squeeze) test: with the patient kneeling or prone, squeezing the calf should point the foot down. No movement suggests rupture.
How long does an ankle sprain take to heal?
Most improve within 2–6 weeks. Early walking and exercises help; some take several months to recover fully.
What is a Maisonneuve fracture?
A fracture of the upper fibula with an injury on the inner side of the ankle and damage to the ligaments between the tibia and fibula. It is unstable and needs orthopaedic review.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A man twisted his ankle and cannot walk 4 steps. There is tenderness at the tip of the lateral malleolus. What is needed?
Answer: Ankle X-ray. Ottawa ankle rules: bone tenderness at the malleolar tip or inability to bear weight need an X-ray.
- No imaging: Ottawa rules are positive.
- Ultrasound: Not first.
- CT: Not first.
- MRI: Not first.
2. After a jump, a man felt a kick at the back of his heel. Calf squeeze doesn't move his foot. What is the diagnosis?
Answer: Achilles tendon rupture. A positive Simmonds' test indicates Achilles rupture: equinus boot and orthopaedic referral.
- DVT: No.
- Plantar fasciitis: No.
- Ankle sprain: Calf squeeze would be normal.
- Calcaneal fracture: Different.
3. An ankle injury shows a fracture of the medial malleolus and pain near the knee. What must be checked?
Answer: The proximal fibula. Maisonneuve fracture: medial ankle injury with a proximal fibular fracture and syndesmosis disruption.
- The patella: Not linked.
- The calcaneus: Less likely.
- The tibial plateau: Less linked.
- The hip: Not linked.
4. An infant has a port-wine stain over the forehead and upper eyelid (ophthalmic division of the trigeminal nerve) and develops focal seizures. What else must be screened for?
Answer: Glaucoma. Sturge–Weber syndrome (sporadic GNAQ mutation): facial capillary malformation (port-wine stain) in V1 distribution, ipsilateral leptomeningeal angioma → seizures, hemiparesis, learning difficulties; tram-track calcification on imaging; glaucoma (ipsilateral) — regular eye pressure checks. Treat seizures, laser for stain.
- Optic glioma: Optic glioma is linked with NF1.
- Retinoblastoma: Retinoblastoma is not associated.
- Cataract: Cataract is not the key association.
5. A 25-year-old twisted her ankle. She can bear weight for 4 steps, with tenderness only over the anterior talofibular ligament, not the malleolar posterior edges or tips. Is an X-ray needed?
Answer: No X-ray needed. Ottawa ankle rules: X-ray if pain in the malleolar zone AND bone tenderness at the posterior edge or tip of either malleolus, OR inability to bear weight for 4 steps immediately and in ED. Foot X-ray if tenderness at the base of 5th metatarsal or navicular. This patient has a lateral ligament sprain — treat with rest, ice, compression, elevation and early mobilisation.
- Yes — any ankle pain needs X-ray: The Ottawa rules are negative, so no X-ray is needed.
- Yes — CT ankle: CT is not indicated.
- Yes — MRI: MRI is not indicated acutely.
6. A middle-aged man felt a sudden 'kick' in the back of his calf while playing squash and now cannot stand on tiptoe on that side. Thompson's test is positive. What is injured?
Answer: Achilles tendon rupture. Achilles rupture: sudden pain (often feels like being kicked), palpable gap, inability to stand on tiptoe, and positive Simmonds–Thompson test (squeezing the calf does not plantarflex the foot). Plantaris rupture causes calf pain but the patient can still stand on tiptoe because the Achilles is intact. Risk factors: middle age, fluoroquinolones, steroid injections.
- Plantaris tendon rupture: Can still stand on tiptoe.
- Tibialis posterior rupture: Flat foot, medial pain.
- Common fibular nerve injury: Foot drop, sensory loss.
- Medial meniscus tear: Knee locking.
7. After a fracture of the fibula, a man cannot evert his foot and has numbness over most of the dorsum of the foot, but the first web space and dorsiflexion are normal. Which nerve is injured?
Answer: Superficial peroneal. The common peroneal nerve divides at the fibular neck into superficial and deep branches. The superficial peroneal nerve supplies the lateral compartment (peroneus longus and brevis—eversion) and then pierces the deep fascia to supply skin of the lower lateral leg and most of the dorsum of the foot. The deep peroneal nerve supplies the anterior compartment (dorsiflexion, toe extension) and only the skin of the first web space. The sural nerve supplies the lateral foot and is used for nerve grafts; the saphenous nerve supplies the medial leg and foot.
- Deep peroneal: Dorsiflexion and first web space.
- Tibial nerve: Plantarflexion, sole.
- Sural nerve: Lateral border of the foot.
- Saphenous nerve: Medial leg and foot.
References and dose sources
- NICE CKS — Sprains and strains
- Ottawa ankle rules (Stiell et al.)
- NICE NG38 — Fractures (non-complex)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Ibuprofen dosing: Drugs.com: Ibuprofen dosage (see also our ibuprofen dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.