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Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis
  1. Paula R Beckenkamp1,2,3,
  2. Chung-Wei Christine Lin1,
  3. Petra Macaskill4,
  4. Zoe A Michaleff1,
  5. Chris G Maher1,
  6. Anne M Moseley1
  1. 1Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
  2. 2School of Science and Health, Western Sydney University, Australia
  3. 3Faculty of Health Sciences, The University of Sydney, New South Wales, Australia
  4. 4School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Paula R Beckenkamp, The George Institute for Global Health, PO Box 5389, Sydney, NSW 2001, Australia; pbeckenkamp{at}


Objective To review the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules and explore if clinical features and/or methodological quality of the study influence diagnostic accuracy estimates.

Design Systematic review with meta-analysis.

Data sources MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library.

Eligibility criteria for selecting studies Primary diagnostic studies reporting the accuracy of the Rules in people with ankle and/or midfoot injury were retrieved. Diagnostic accuracy estimates, overall and for subgroups (patient’s age, profession of the assessor and setting of application), were made. Sensitivity analyses included studies with a low risk of bias and studies where all patients received radiographs.

Results 66 studies were included. Ankle and Midfoot Rules presented similar accuracies, which were homogeneous and high for sensitivity and negative likelihood ratios and poor and heterogeneous for specificity and positive likelihood ratios (mean, 95% CI pooled sensitivity of Ankle Rules: 99.4%, 97.9% to 99.8%; specificity: 35.3%, 28.8% to 42.3%). Sensitivity of the Ankle Rules was higher in adults than in children, but the profession of the assessor did not appear to influence accuracy. Specificity was higher for Midfoot than for Ankle Rules. There were not enough studies to allow comparison according to setting of application. Studies with a low risk of bias and where all patients received radiographs provided lower accuracy estimates. Specificity heterogeneity was not explained by assessor training, use of imaging in all patients and low risk of bias.

Conclusions Study features and the methodological quality influence estimates of the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules.

  • Ankle
  • Fracture
  • Injury
  • Sprain

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  • Contributors PRB, C-WCL, ZAM, CGM and AMM conceived and designed the study. PM, PRB, C-WCL, CGM and AMM analysed and interpreted the data. PRB, C-WCL, PM, ZAM, CGM and AMM contributed by drafting the article. PM provided statistical expertise. PRB, C-WCL, ZAM, CGM, AMM collected and assembled the data. PRB is guarantor. All authors participated in the revision and final approval of the manuscript.

  • Funding PRB was funded by the International Postgraduate Research Scholarship (IPRS) and Australian Postgraduate Award (APA). C-WCL and CGM have fellowships that are funded by the National Health and Medical Research Council, Australia.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.