What is the best view for a foot X-ray (X-ray)?

Best Foot X-Ray Views

For routine foot trauma evaluation, obtain a standard three-view radiographic series consisting of anteroposterior (AP), lateral, and medial oblique projections, with weight-bearing views strongly preferred when clinically feasible. 1, 2

Standard Imaging Protocol

Essential Three-View Series

• The AP, lateral, and medial oblique views form the cornerstone of foot radiographic evaluation, achieving 99% sensitivity for detecting foot fractures when clinically indicated. 2
• The oblique view is not redundant—it uniquely reveals abnormalities in 4.8% of cases and increases diagnostic confidence by reducing equivocal findings from 13.9% to 8.4%. 3
• All three views provide complementary information about the osseous anatomy that cannot be adequately assessed with fewer projections. 4

Weight-Bearing vs Non-Weight-Bearing

• Weight-bearing (standing) radiographs are strongly preferred as they detect dynamic abnormalities including joint malalignment, subluxation, and fracture displacement that are invisible on non-weight-bearing images. 4, 1
• Non-weight-bearing radiographs are unreliable for detecting subtle injuries and should only be used when patients cannot bear weight due to pain, limited mobility, or risk of further displacement. 4, 1
• For bilateral comparison, include both feet on the AP view to detect subtle malalignment when compared to the uninjured side. 1, 2

Location-Specific Modifications

Calcaneal (Heel) Fractures

• Add an axial Harris-Beath (axial calcaneal) view to the standard three-view series to increase specificity for calcaneal fractures and sensitivity for distinguishing intra-articular involvement. 2, 5

Lisfranc (Midfoot) Injuries

• Obtain the standard three-view series plus an additional AP view with 20° craniocaudal angulation to improve visualization of the Lisfranc joint complex. 1, 2
• Weight-bearing views are absolutely critical for Lisfranc injuries, as purely ligamentous injuries without diastasis are particularly challenging to diagnose on non-weight-bearing films. 1

Ankle Involvement

• When ankle pathology is suspected alongside foot injury, include AP, mortise, and lateral ankle projections to adequately visualize the ankle joint. 4, 5

Common Pitfalls to Avoid

• Never rely solely on two-view series (AP/lateral only) for initial foot trauma evaluation—the oblique view provides unique diagnostic information that changes management. 3
• Do not accept non-weight-bearing radiographs as adequate when Lisfranc injuries are suspected, as this leads to missed diagnoses of unstable injuries. 1, 2
• Failing to obtain bilateral comparison views can result in missing subtle malalignment that would be obvious when compared to the contralateral foot. 1, 2

When Advanced Imaging Is Needed

• If standard radiographs appear normal but clinical suspicion remains high (warm, swollen foot with pain), proceed to MRI for suspected Charcot neuroarthropathy or occult fractures. 4
• CT is indicated for evaluating complex midfoot fractures, polytrauma patients, or when radiographs show multiple metatarsal and cuneiform fractures suggesting ligamentous Lisfranc injury. 1
• In polytrauma patients, approximately 25% of midfoot fractures identified on CT are overlooked on standard radiographs. 1