Introduction
Ankle injuries are common amongst hillwalkers and, depending on their severity, these can end a day out in the hill and result in a mountain rescue callout. Studies reviewing attendance records from eight emergency departments in the UK estimate an incidence rate of 52.7 ankle sprains per 10,000 people, however the true incidence is probably higher as many people will see their GP instead or self-manage their symptoms at home.
As always prevention is the best strategy. Pre-trip it is sensible to advise clients on choosing suitable footwear with appropriate ankle support. Similarly, when meeting at the start of the trek it is important to check that the group’s footwear is suitable for the terrain and forecasted weather conditions. Dynamically assessing the proposed route and looking at path choice, the conditions underfoot and whether the client skill-mix is adequate is vital, and making early interventions to address these potential risk factors can be the difference between an injury and a successful trip.
Simple tips such as advising clients about foot placement, using hiking poles to enhance stability, and running a quick set of warm-up exercises, can all help reduce the likelihood of injury.
Types of Ankle Injury
Unfortunately, despite these measures, inevitably some people will sustain ankle injuries. The majority of these involve the soft tissues around the ankle, however, sometimes there may be an associated fracture or dislocation.
Ankle Swelling (photo credit John Carr)
Key terms:
Sprain: a stretch or tear of a ligament. Ligaments are strong bands of tissue that connect one bone to another.Strain: a stretch or tear of muscle fibres or tendons. Tendons are cords of tissue that attach muscles to bone.Fracture: a partial or complete break in a bone.Dislocation: the displacement of one or more bones at a joint.
How do I assess a painful ankle?
Asking the participant about the circumstances surrounding their injury is a good starting point, and establishing whether they inverted or everted the ankle, whether they slipped, tripped or fell over will give you a better idea of what happened. It is also important to check for any associated injuries and ask about past medical history, allergies, and current medications at this point.
Assuming that we are dealing with an isolated ankle injury, it is important to check whether the participant can put weight on the affected limb.
The inability to weight-bear immediately after an injury may indicate either a fracture or a sprain, and on the hill, differentiating between these will not usually impact on your initial management, however it may mean that you need to assist the person off the hill yourself, or call for help from mountain rescue.
Clients with ankle injuries will usually complain of pain regardless of the underlying cause and therefore this is not a particularly good discriminating factor. It is important to try and address pain early with simple analgesia such as paracetamol, ideally from the participant's own personal first-aid kit.
If possible, it is helpful to remove the participant’s boot and sock so you can have a look at the ankle and foot. Obviously if there is a gross deformity and the foot is pointing in the wrong direction, this is most likely to be broken or dislocated, and it may be too painful to remove the boot. In more subtle cases, you may be able to see some bruising or overlying redness of the skin, and the ankle will usually look swollen. Feeling around the ankle can help determine where is most painful. It is also beneficial to assess the range of movement in the ankle joint.
Various rules are used by healthcare professionals to determine whether an ankle is more likely to be sprained or broken and therefore whether an X-ray is required. The specifics of these rules are beyond the scope of this article, however if you are interested in finding out more you might want to consider getting a copy of the Oxford Handbook of Expedition and Wilderness Medicine or attending an outdoor first aid course.
Rarely when someone injures their ankle there can be associated damage to the nerves and blood vessels that supply the foot. It is therefore important to check that the foot is warm, is a normal colour and has normal sensation when compared to the adjacent side. If there is a significant difference, this could suggest damage to these nerves and blood vessels and this requires urgent medical attention.
What should I do?
As with all injuries that occur in a wilderness setting it is important to do the basics well. As mentioned, appropriate early analgesia is valuable, and reassuring the casualty will also make a significant difference.
It is also vital to consider the environmental conditions and ensure that the casualty and wider group are not getting too cold as you may be stopped for a prolonged amount of time.
If you have attended a course or have the appropriate prior knowledge and training, you may wish to tape or strap the ankle to provide support.
How do I get the casualty off the hill?
Following a period of rest and some decent analgesia, the participant may feel able to continue, or at least walk off the hill relatively independently using a trekking pole or with help from some of the other participants.
Several techniques can be used here, including simply supporting the casualty as they walk, a two person seat carry, or even a simple ‘piggy-back.’ Whether you are going to try one of these or call mountain rescue for more formal assistance will largely depend upon the distance you have to travel, the fitness of the rest of the group and the severity of the injury.
1. Supporting the casualty to walk out
2. Two person chair technique to carry casualty
3. Two person chair carry hand position
Overall, regardless of how the casualty gets off the hill, if they are in significant pain or unable to weight bear, they will need to be seen at the local A&E or minor injury unit for review.
Take home messages:
1. Don’t worry too much about whether it is a sprain vs break as the initial management is the same.
2. Manage pain early on and provide ample reassurance.
3. Think about potential evacuation strategies if the participant cannot weight-bear.
4. Don’t let the casualty or group get cold
5. Signpost to A&E if persistent pain and the casualty is unable to weight-bear
Disclaimer
This article does not constitute medical advice and should not be treated as such. You must not rely on the information published here as an alternative to medical advice from your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice or discontinue medical treatment because of information published in this article. If in doubt, please advise all participants to see their doctor for a comprehensive assessment and management plan.