OBJECTIVES: In the US, an estimated 2 million ankle injuries occurred in 2012 costing $4.5 billion, associated with approximately 1.6 million physician office visits and 8000 hospitalizations. We examined the prevalence and burden of ankle injuries in North Carolina emergency departments. METHODS: Using a cross-sectional study of the 2010 NC Emergency Department Database, we identified ankle injury patients (ICD-9-CM: 845.xx). Patients were categorized into two groups: lateral and non-lateral ankle injury (medial, high, and unknown). Frequencies and percentages for patient demographics were compared using bivariate statistics. Multivariable analyses were used to assess the outcomes associated with type of ankle injury while adjusting for confounding, including a generalized linear model for charges and logistic regression for use of X-ray. RESULTS: The study contained a sample of 35,729 patients including 32,651 (91%) lateral and 3,078 (9%) non-lateral ankle injury events. Most (66%) were below the age of 35 and female (57%). The mean total charge for an ankle injury event was $1,057. Patients with non-lateral ankle injuries had higher proportion of X-rays than lateral [1145 (37%), 7323 (22%)] but more events with total charges below $1500 (94% and 87%) respectively. However, lateral ankle injuries were associated with a $52 greater charge than non-lateral. Additionally, non-lateral ankle injuries were 2 times more likely to have an X-ray than lateral (OR= 2.00, 95% CI: 1.86-2.18). Patients with private insurance were 20% less likely to have an X-ray than Medicare patients (OR= 0.80, 95% CI: 0.71-0.90). CONCLUSIONS:  Females below 35 years of age represent higher proportion of ankle injury emergency room visits than males. Older patients are more likely to receive X-rays but are associated with lower charges because of Medicare coverage. Older patients are more likely to have non-lateral ankle injuries. Further research is required to understand cost drivers in both groups.