See the video version here.
Take 5 – 5 Critical Takeaways to Improve your Practice
- The Ottawa Ankle Rules (OAR) are highly sensitive and can help providers determine if radiographs are necessary.
- Low specificity can lead to false positive tests.
- The OAR consist of: pain or tenderness in the posterior distal tibia or tip of medial malleolus, pain or tenderness in the posterior distal fibula or tip of lateral malleolus, and unable to bear weight after injury or four steps in the ED.
- Don’t forget about the foot rules: tenderness to palpation over the navicular bone or tenderness to palpation over the base of the 5th metatarsal
- We have 20+ years of researching validating the OAR. So why do we still not implement it into clinical practice?
A patient comes into the ED after stepping “funny” off of a ladder. They are having a hard time walking and want to make sure their ankle is okay so they can return to work. What do you need to rule out? How do you know if you need imaging? And how long will all of this take? Based on the injury, how will this affect your plan of care and management of this patient?
The study “Diagnostic Accuracy of the Ottawa Ankle Rule (OAR) to Exclude Fractures in Acute Ankle Injuries in Adults: a systematic review and meta-analysis” studied the diagnostic accuracy of the OAR in excluding ankle fractures and if we can reduce use of radiography with patients with acute ankle injury (1). While other countries, like Canada and Australia, have healthcare systems founded in cost reduction, the US healthcare system benefits from high costs and use of healthcare resources.
However, our EDs are flooded with problems including high wait times, high volume, and increasing health care costs for patients. Knowing when to use or omit imaging is extremely important in PT scope of practice, as well as being experts in using the tools that we have to make these decisions. Here are the five biggest takeaways from this article and a good reminder for how to use the Ottawa Ankle Rules.
- The Ottawa Ankle Rules (OAR) are highly sensitive and can help providers determine if radiographs are necessary.
High sensitivity means that we can be confident that someone does not have a fracture if none of the OAR are true. This meta-analysis found that the sensitivity is 0.91 for the OAR, meaning a provider can be confident there is no fracture if none of the OAR are true. The study encourages always pairing the OAR with clinical judgement, given the low specificity of the OAR (see #2 below).
- Low specificity can lead to false positive tests.
We have to be aware that the OAR are susceptible to false positives due to its low specificity of 0.25. When we use the OAR in clinical decision making, we have to accept that we may be wrong in thinking someone has a fracture when they do not and use our clinical judgment when determining if a patient needs imaging.
- So what are the OAR?
The OAR sounds great! But what are the rules?
– pain or tenderness in the posterior distal tibia or tip of medial malleolus OR
-pain or tenderness in the posterior distal fibula or tip of lateral malleolus OR
-unable to bear weight after injury or take four steps in the ED
If any of these are true, ankle imaging is warranted for concern for ankle fracture. If all of these are false, then we are 91% confident the patient does not have an ankle fracture.
- What about the foot?
As I was reading the article, I kept wondering about the other midfoot rules that I learned when ruling out fractures in the ankle and foot complex. While the OAR are specific to the ankle, don’t forget about the foot! This article did not include these, but it is important to consider after a traumatic injury.
-tenderness to palpation over the navicular bone OR
-tenderness to palpation over the base of the 5th metatarsal
If either of these are true, seek out foot imaging (2).
- We have 20+ years of research showing diagnostic accuracy of the OAR. So why do we still not implement it into clinical practice?
Easy access to radiography, fear of litigation, and limited sharing of how to use the OAR all contribute to why not all ED and primary care settings have not adapted the OAR into a standard of clinical practice (1). As EDs start to include many different APPs and services, like PT, the OAR should be used as a cost-effective tool by any and all disciplines to determine the need for imaging after an ankle injury.
Summary
I hope this article is a great reminder of the OAR, how to use it, and why we should encourage the use of it in ED and primary care settings. Especially in the ED where any provider can use the OAR, it is possible to improve clinical practice, prevent overuse of resources, improve patient wait times, and decrease medical costs (1). With a systematic review like this, it seems like a no-brainer for us to adopt the OAR as a standard of practice and use it as another tool in PT scope of practice to expand our role in the ED.
- Gomes YE, Chau M, Banwell HA, Causby RS. Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2022 Sep 23;23(1):885. doi: 10.1186/s12891-022-05831-7. PMID: 36151550; PMCID: PMC9502997.
- Jenkin M, Sitler MR, Kelly JD. Clinical usefulness of the Ottawa Ankle Rules for detecting fractures of the ankle and midfoot. J Athl Train. 2010 Sep-Oct;45(5):480-2. doi: 10.4085/1062-6050-45.5.480. PMID: 20831394; PMCID: PMC2938320.