A pooled analysis was conducted of the seven studies on the clinical diagnostic effectiveness of the Ottawa ankle rules when used with adult patients in the emergency department (ED). The seven studies, conducted in university and community hospital EDs, had examined the sensitivity, specificity, and positive and negative predictive values of the Ottawa ankle rules. ED physicians applied the Ottawa ankle rules with adult patients who had blunt ankle injuries. The gold standard was radiography. The combined sensitivity for the seven studies was 97% or higher for ankle/foot, original/refined Ottawa ankle rules and negative predictive value was greater than 99%. These results support the effectiveness of the Ottawa ankle rules for ruling out a fractured ankle or foot. Specificity was lower, ranging from 31% to 63%; positive predictive value was <20%. Thus, the Ottawa ankle rules should not be used for ruling in a fractured ankle or foot. This pooled analysis shows the Ottawa ankle rules to be effective as clinical practice guidelines for acute ankle and foot injuries in the adult ED patient. Patients with negative results when the rules are used are highly unlikely to have a fractured ankle or foot, but the diagnosis for positive patients is much less certain, suggesting the need for radiography.