Acute ankle and knee injuries

Ankle and knee sprains are common presentations in primary care, and the number of imaging requests for these injuries has been rising.


For consumers, check out
 Ankle sprains: 10 things you should know

Acute ankle and knee injuries

Key points

  • Patient history and physical examination are as accurate as imaging for diagnosing acute ankle and knee injuries.
  • Apply the Ottawa Ankle Rules or Ottawa Knee Rules to rule out fracture.
  • Only consider imaging if the results will change your management of the injury
  • Conservative management is based on RICE and no HARM in the first days after injury.
  • If physical examination is limited because of pain and swelling, provide conservative management and re-evaluate 4 days after injury for ankle sprains (lateral ligament) and 1–2 weeks after injury for ACL tears.
  • Consider referral to an orthopedic specialist if symptoms persist, despite conservative management.

GP survey results: how did this program change practice? 

Woman with hurt ankle

In October 2016 NPS MedicineWise launched the program Ankle and knee injuries: your imaging choices. As part of our regular evaluation, we surveyed GPs on how their knowledge, awareness and practice in diagnosis and management of acute ankle and knee injuries had changed as a result of taking part in the program. 

Read the full evaluation


MedicineWise News: Diagnosing knee pain in middle-aged patients

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Knee pain is common in middle-aged patients, and brings them to your surgery often. But is it an acute injury or older damage? In almost all cases a diagnosis can be made without advanced imaging techniques such as MRI.

Find out more about the latest evidence and recommendations


NPS MedicineWise videos: physical examination of acute ankle and knee injuries

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See how to perform physical examination tests and apply the Ottawa Rules for the diagnosis of these common acute ankle and knee injuries.

  • Meniscal tears
  • Anterior cruciate ligament (ACL) tears
  • Ankle sprains (lateral ligament)
  • Fractures
  • Meniscal tears
  • Anterior cruciate ligament (ACL) tears
  • Ankle sprains (lateral ligament)
  • Fractures

CPD options for knee and ankle imaging

Consolidate your knowledge about knee and ankle injuries and imaging, brush up on current guidelines and practices and earn CPD points through our learning activities.

For GPs:


In my practice: Dr Andrew Rees on diagnosing ankle and knee injuries

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Since the early 2000s the number of ankle ultrasounds and knee MRI referrals has been rising in primary care. GPs can turn the tide by improving their knowledge and building confidence in their diagnostic and management skills.

Find out how one GP has tackled the challenge.


Clinical snapshot: Help remembering the Ottawa Ankle Rules

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The Ottawa Ankle Rules (OAR) are a highly sensitive, validated tool for deciding whether to order an X-ray for an acute ankle injury.

The 44-55-66-PM mnemonic might  help you remember them.

A single-blind RCT of 206 participants (96 medical students and 94 hospital residents) gave one group the mnemonic and a control group the standard version of the OAR.

At 3 weeks both groups had improved their memory of the OAR, after 5–9 months the mnemonic group had better recall.

The Ottawa Ankle Rules (OAR): 44-55-66-PM

Patients need an X-ray only if:

4 Unable to do 4 steps immediately AND

4 Unable to do 4 steps in the emergency department


5 Has pain at the base of the 5th metatarsal

5 Has pain at the 5caphoid (navicular)


6 Tenderness in 6 cm posterior edge of lateral malleolus

6 Tenderness in 6 cm posterior edge of medial malleolus

Clinical resources and tools


Choosing Wisely

These colleges and associations recommend that health professionals use the Ottawa Ankle Rules:

For your patients

Discuss acute ankle and knee injuries with your patients using our mediated action plan. The plan has been designed and developed by NPS MedicineWise to support your consultation.

Essential reading

Knee: general

Meniscal tears

Anterior crucial ligament (ACL) tears


Ankle: general

Ankle sprains (lateral ligament)