Sprain or Broken Ankle? 6 Clues

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6 Clues Your Ankle is Broken, Not Sprained

6 Clues Your Ankle is Broken Not Sprainedby James Hubbard, MD, MPH

Sometimes it’s not that easy to tell a sprain from a broken ankle.

Just this past year, a seventyish-year-old woman came limping into the clinic where I was working to have her ankle checked. Seemed she had twisted it a couple of weeks before and her husband was going to keep nagging her until she came in.

The X-rays revealed a break. A pretty bad one at that. She couldn’t believe it. I don’t know if she was more upset that she was going to need a cast and crutches or she’d have to acknowledge that her husband was right.

Many people come to the clinic convinced they have a break or just as sure it’s just a sprain. Often they end up being wrong. It’s not so easy for doctors to tell either. Fortunately we have the benefit of X-rays. But what if getting an X-ray is impossible? What can tip you off that it’s a sprain or a broken ankle? And why does it matter?

Well, why it matters is easy. If it’s broken, you must be much more careful to stabilize the ankle. Make it so the ankle won’t move. And if it’s any break other than the fibula (the littler of the two leg bones), then you shouldn’t bear a lot of weight on it because, again, the bone fragments could move around, not allowing healing.

The Ottawa Ankle Rules

Years ago, some docs in Canada, trying to cut down on the amount of X-rays done for ankles (Canada must not have as many malpractice suits as we do in the U.S.), came up with a set of guidelines to tell a break from a sprain. It’s called the Ottawa Ankle Rules. The rules aren’t perfect, but many studies since have shown over and over that these guidelines can reliably predict about 95 percent of breaks. They do, however, tend to overdiagnose (predict a fracture that turns out to be a sprain).

The bad news is that studies have also shown that if nonmedical people try to use the guidelines and make predictions they’re not nearly as accurate. So don’t use these to keep from getting your injured ankle checked out when a clinic actually is available. But maybe they can help a little if there ever comes a time when you can’t get expert medical help right away.

Next, the rules.


Photo by eltpics on Flickr.

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  • Kholoud

    I was walking and there was a unstable stone I stood on it my foot twisted and poped really loudly it swollen I can’t move it and the pain isHORRIFICLY PAINFULL we when to the local go they said nothing’s wrong elevate it but I know something is wrong I’m a heavy girl with weak calf musels so when I walk on my toes my legs hurt and it is numb

    • http://thesurvivaldoctor.com/ James Hubbard, MD, MPH

      Did the gp say nothing’s wrong, or nothing is broken? There’s a big difference. Typically the initial treatment for an ankle sprain, even a break, is stay off of it (or use crutches) for pain and RICE. http://www.thesurvivaldoctor.com/2013/02/28/rice-for-injuries/ And, usually, my advice would be to check back in a few days to a week for further tests if needed. Certainly sprains can tear ligaments and some breaks can take about a week to show up on x-ray. However, all this advice is general and the doctor who actually examined you would be able to give you more specifics geared to your particular case.

  • Andrea

    I have had many sprains of both ankles over the past 30 years (I’m 43, play basketball, and pronate due to fallen arches). 7 years ago I badly injured my ankle and although I had never had a broken bone before, it was much worse than any of my previous sprains, so I went to the ER to have it x-rayed. I was told it was just sprained, so I did what I could with the RICE protocol, took Ibuprophen constantly and about 2 1/2 weeks later went to physio only to be told they thought it was broken. Back to the hospital for new x-rays, and sure enough I had a non-displaced fracture.
    Now, I am at the 3 week mark with another bad sprain (opposite foot). X-rays the morning after I rolled it showed no fracture. I still have some brusing on my foot and up my leg, I still have swelling on both sides and the front of my ankle, and it is still tender to touch in many areas. Is it possible I have another fracture missed on an x-ray?

    • http://thesurvivaldoctor.com/ James Hubbard, MD, MPH

      Sure. X-rays sometimes take up to about a week to show some fractures. Even then, some can be missed that a cat scan might reveal.

  • Heidi

    I sprained my ankle 1 week ago. It completely rolled out ward. Hurt more than anything I ever felt and I’ve had three babies. It blew up like a tennis ball. I had X-ray that night and they didn’t see any broken bones. I have appointment with ortho tomorrow. I can point toe but can not twist at all . I am just stating to be able to put some pressure one it. Could it be broken? Bruises and swollen still

    • http://thesurvivaldoctor.com/ James Hubbard, MD, MPH

      Yes, it could be, or a bad sprain, possible tears also. Sometimes, an initial break doesn’t show up well on x-ray right away but will a week or so after the injury.

  • Maddie

    hey, I am a netball player and whilst playing a university match, I landed from a high catch on the side-front of my foot and there was a large pop/crack noise that people all around me heard. the initial pain was unbearable agony but after 5 mins it eased up a bit but still hurt and has remained at that level now for two days. I can bare weight but I can only walk for short distances and there is a continual dull ache. there is swelling around the ankle bone but I wanted to know whether I should visit the doctor because I don’t want any long lasting damage due to future netball, thank you.

    • http://thesurvivaldoctor.com/ James Hubbard, MD, MPH

      Yes, sounds like you should get it checked.

  • Bmurphy-lol-I-love-dogs

    Last night I missed a step walking downstairs and I fell. I hit my ankle but it didn’t hurt that bad. Today I hit my ankle on the wall in my school gym. I can walk on it but it hurts if I twist it, turn it, or walk on it the wrong way. I don’t know what to do, all I know is that it hurts

  • Anne

    In PE I twisted my ankle and it swelled up and it popped what should I do

    • http://thesurvivaldoctor.com/ James Hubbard, MD, MPH

      Have someone check it.

  • Kendra H

    In the summer of 2013 I was jumping on a trampoline and landed on it sideways, I heard a loud pop and my friend heard it too, a couple hours later and I still couldn’t put any pressure on it I went to the ER. They did a xray and said it was just a sprain, I had crutches for a week and after I was walking on it fine. In the spring of 2014, during one of my track and field meets, I was doing triple jump, and it started to hurt after my second jump, I think it was from the impact, and running my other race right after without break. I went to the doctors the next day and they said it was just a sprain without doing an xray, it was swelling up, and still now the swelling from it hasn’t gone. A month or two ago I rolled it while walking and noticing a step in the ground. I was walking on it fine, but after a while of just running on it, it hurt. I wore a tenser badge for about a month til I finally got to the doctors, they didn’t do an xray again, and didn’t really tell me much other than to get an ankle brace, and insoles for my shoes. I have done both of those things, but it still hurts. Now in my gym classes after 20 minutes of activity my foot completely cramps up and makes it impossible to do much on it, and also I can’t walk much without the brace because when I put too much pressure on it for a while it starts to hurt. I don’t know whether I should get a xray, or go to the doctors once again, but I don’t see any improvement of it getting better, and it only seems to hurt even more everyday.

    • http://thesurvivaldoctor.com/ James Hubbard, MD, MPH

      If you have a regular family doctor, you should see her/him. If not, I’d suggest checking with a orthopedist who 1. sees your age, 2. Has an interest in ankle problems.

  • Annie

    Hi i just got my cast off on Thursday December 4th and they told me my ankle was healed but i just needed a brace. I was walking on it practicing my walking and everyday i got better but today december 8th i was going up a block with my cousin and i fell on the foot which hurt so much and i was on the ground for a little. It didn’t feel like when i broke it but close. I tried standing on it at first but it hurt a lot so right now i’m just on the couch resting. Can anyone help ? Did i break my ankle again or was it just a minor problem?

    • http://thesurvivaldoctor.com/ James Hubbard, MD, MPH

      You should have it rechecked.

  • K

    About 2 weeks ago a girl and I collided at soccer practice and I think she landed on my right ankle, I’m not sure, all I knew was it hurt so bad! I got a compression sock, iced it and put heat on it and I also took ibprofen then played in a soccer game the next day.. 2 days later, the swelling went down a lot and it barely hurt but I had this nasty bruise at the bottom of the right side of my foot.. The bruise went away and my ankle was still a little stiff but I just ignored it and today I was at soccer practice and a girl kicked my tibia? Anyways it hurt so bad and I just dropped and its starting to swell and I think it’s starting to bruise again.. I don’t want to go see the doctor if it’s nothing big, but I have a soccer game tomorrow against our rivals, so do you think it will be okay to play on? I can put weight on it and move it but I just have to warm it up first… What do you think I could’ve done to it?

    • http://thesurvivaldoctor.com/ James Hubbard, MD, MPH

      You should have someone check it out. There’s no way I could tell you without an exam and possibly an X-ray.

  • CuriousKid

    Last night I fell down the stairs and rolled my ankle weird. I heard a slight pop sound and I couldn’t walk on it since without limping a bit. It’s swollen and slightly bruised and it hurts when I put pressure on it. What should I do? By the way if it still hurts tomorrow, I’m seeing a doctor with my dad. I’ve been on crutches today and I walked on it using the crutches but it still hurt. I now have a wrap on it and I’m keeping it on a footstool. Is it sprained?I can’t tell.