Rolled Your Ankle? When Do You Need an X-Ray or Scan?

Rolling your ankle is one of the most common injuries we see in physiotherapy. It can happen playing sport, running, stepping off a curb or simply landing awkwardly.

Sometimes you know immediately that you have done something significant. Other times, you may be able to walk away from the injury but develop increasing pain, swelling and bruising over the following hours.

A common question we hear at Body Fit Physiotherapy is:

“I've rolled my ankle. Do I need an X-ray or scan?”

The answer is: not necessarily.

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Many ankle sprains can be assessed and managed without imaging. However, there are certain findings that may increase the need for an X-ray or further investigation.

Understanding the difference is important because the goal isn't simply to organise a scan—it is to work out what you have injured and what you need to do next.

What Happens When You Roll Your Ankle?

Most commonly, a rolled ankle occurs when the foot turns inwards underneath you. This can place considerable stress through the ligaments on the outside of the ankle.

The lateral ankle ligament complex includes:

• Anterior talofibular ligament (ATFL)

• Calcaneofibular ligament (CFL)

• Posterior talofibular ligament (PTFL)

The ATFL is particularly commonly injured during a typical lateral ankle sprain.

However, not every rolled ankle is simply a ligament sprain.

Depending on how the injury occurred, other structures can potentially be involved, including bone, tendons, cartilage and the syndesmosis—the structures involved in what is commonly referred to as a high ankle sprain.

This is why the mechanism of injury and a thorough clinical assessment are important.

Do All Ankle Sprains Need an X-Ray?

No.

If every person who rolled their ankle received an X-ray, a large number of people would undergo imaging despite not having a fracture.

One commonly used clinical decision-making tool is the Ottawa Ankle Rules.

These rules were developed to help healthcare professionals determine when an X-ray may be appropriate following an acute ankle injury.

An X-ray may be indicated when there is significant tenderness over particular bony areas around the ankle or foot, or when the person is unable to adequately bear weight following the injury.

Importantly, these are clinical decision rules rather than something that should be considered in isolation. Your age, injury mechanism, symptoms and physical examination all contribute to deciding whether further investigation is appropriate.

What Are Some Signs That I Should Have My Ankle Assessed?

Following an ankle injury, consider seeking an assessment if you have:

• Significant pain when trying to walk

• Difficulty putting weight through the injured leg

• Significant or rapidly developing swelling

• Extensive bruising

• Significant tenderness directly over a bone

• Pain that isn't beginning to improve

• A feeling that the ankle is unstable or giving way

• Pain higher above the ankle

• Ongoing symptoms preventing you from returning to normal activity or sport

Severe deformity, an open injury, significant loss of sensation or circulation, or an inability to bear weight following significant trauma warrants more urgent medical assessment.

What Is the Difference Between an X-Ray, Ultrasound and MRI?

One source of confusion following an ankle injury is what people mean when they say they need a “scan.”

Different types of imaging provide different information.

X-Ray

An X-ray is primarily used when we are concerned about a possible fracture or other bony injury.

For many acute ankle injuries where fracture is the primary concern, this may be the first investigation considered.

Ultrasound

Ultrasound can be useful for assessing certain soft tissue structures, particularly tendons and some ligament injuries.

However, an ultrasound is not automatically required simply because you have sprained your ankle.

MRI

MRI provides detailed imaging of many structures around the ankle, including ligaments, tendons, cartilage and bone.

It may become more useful when the diagnosis remains unclear, a more significant injury is suspected, symptoms are persisting unexpectedly, or the findings are likely to influence treatment decisions.

Again, the important point is that more imaging isn't necessarily better.

The investigation should have a reason behind it.

Can a Physiotherapist Tell If I've Sprained My Ankle Without a Scan?

In many cases, yes.

A physiotherapy assessment can provide a considerable amount of information about the likely structures involved and the severity of the injury.

At Body Fit Physiotherapy, an ankle assessment may include looking at:

How the injury occurred

The direction your ankle moved, whether someone landed on you, whether you heard or felt anything at the time and whether you could continue your activity can all provide useful information.

Where your pain is located

Pain directly over a ligament may point us in a different direction to significant tenderness over a bone.

Your ability to walk and bear weight

How comfortably you can load the ankle provides important information about both the injury and your current function.

Swelling and bruising

The location and extent of swelling can help guide the assessment.

Ligament testing

Specific clinical tests can help assess the structures around the ankle once appropriate.

Range of movement

We assess how much movement you have lost and which movements reproduce your symptoms.

From here, we can determine whether conservative management appears appropriate or whether we believe further investigation is warranted.

I've Rolled My Ankle but Can Still Walk. Does That Mean It's Fine?

Not necessarily.

Being able to walk is generally reassuring, but it doesn't tell us everything about the injury.

Some people with significant ankle sprains can still walk, particularly once the initial pain settles.

Likewise, being unable to walk immediately after an injury does not automatically mean you have fractured something.

This is why we look at the whole clinical picture rather than one symptom alone.

If My X-Ray Is Normal, Does That Mean Nothing Is Wrong?

No.

An X-ray is excellent for looking at bone, but a normal X-ray doesn't mean that you haven't sustained an ankle injury.

You may still have injured ligaments or other soft tissues around the ankle.

This is particularly important because rehabilitation following an ankle sprain is about much more than waiting for the pain and swelling to disappear.

What Should I Do After an Ankle Sprain?

Once we are comfortable that the injury can be managed conservatively, rehabilitation should progressively restore the ankle's capacity.

Depending on the injury, this may include:

• Regaining comfortable ankle movement

• Gradually restoring normal walking

• Progressive calf and lower-limb strengthening

• Balance and proprioception exercises

• Ankle stability exercises

• Progressive hopping and landing exercises

• Running progression

• Sport-specific change-of-direction exercises

The exact program should reflect both the severity of your injury and what you need your ankle to do.

Someone wanting to comfortably walk around the neighbourhood has very different physical requirements from someone returning to football, netball, basketball or running.

Why Is Rehabilitation Important After Rolling Your Ankle?

One of the mistakes we commonly see is someone resting their ankle until it feels better and then immediately returning to their previous activity.

Pain settling doesn't necessarily mean your ankle has regained its previous strength, balance or capacity.

Ankle sprains can be associated with ongoing instability and recurrent sprains in some people. Appropriate rehabilitation therefore aims not only to settle the current injury but also to restore the physical qualities required for your activities.

For someone returning to sport, we may need to progressively assess and retrain:

• Calf strength

• Single-leg balance

• Landing control

• Hopping capacity

• Acceleration and deceleration

• Change of direction

• Confidence in the ankle

Returning to sport should therefore be based on more than simply how many weeks have passed since the injury.

Rolled Your Ankle? Start With the Right Assessment

If you've rolled your ankle and are wondering whether you need an X-ray or scan, the first step is often a good clinical assessment.

Not every ankle injury needs imaging.

Equally, we don't want to dismiss an injury that requires further investigation.

At Body Fit Physiotherapy in North Adelaide, we can assess your ankle, determine whether further imaging may be appropriate and develop a rehabilitation plan based on what you need to return to.

Whether your goal is getting back to comfortable walking, running, the gym or competitive sport, the aim is to restore the strength, stability and confidence you need—not simply wait for the swelling to disappear.

If you've recently rolled your ankle and aren't sure what to do next, our physiotherapists are happy to help.

References

Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. JAMA. 1993;269(9):1127–1132.

Martin RL, Davenport TE, Fraser JJ, et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(4)–CPG80.

Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British Journal of Sports Medicine. 2018;52(15):956.

Smith MD, Vicenzino B, Bahr R, et al. Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework—an international multidisciplinary consensus. British Journal of Sports Medicine. 2021;55:1270–1276.