Treat an Injured Ankle
The potential for injury while climbing outside is frighteningly infinite, and boulderers sometimes feel the pain more than anyone, with their repetitive high-impact landings on rocky and unfriendly terrain. The most common non-finger-related injury among boulderers is a sprained or broken ankle, and while it’s not always preventable—no matter how many crashpads you stack—it is easily managed in the field. The following is a simple technique for both sprained and fractured ankles that involves assessing the injury and then splinting it for stabilization and preventing more harm. By using available resources, knowledge, and creativity, anyone can assist an injured friend and get him to care.
Three Parts of Assessment
A. After making sure there are no more immediate or life-threatening injuries (i.e., no head trauma and he is breathing, warm, well-hydrated, and not bleeding to death), evaluate the ankle. Remove climbing shoes; they are not comfortable to begin with, but with a sprained or fractured ankle, they will only become worse. And unlike hiking or mountaineering boots, they have no ability to support or splint an injured ankle. Open any laces or Velcro straps as wide as possible and slowly wiggle the shoe off. It might be very painful and difficult, but the sooner the shoe is off, the fewer problems it will cause down the road. Signs of a serious injury (fracture or sprain) include: obvious deformity, tenderness/pain, inability to bear weight, rapid swelling or bruising, crepitus (a crunching or popping sound when moving the ankle), and loss of normal movement (or movement that is not normal).
B. Determine if the climber has circulation, sensation, and movement (CSM) in his foot. Can you feel pulses in the climber’s foot? Pulses in the dorsalis pedis artery and the posterior tibial artery are difficult to locate sometimes even for an experienced professional. The dorsalis pedis artery is located on the top and outside of the most prominent ridge of the foot (tibial side of the dorsum of the foot). The posterior tibial artery is located behind and below the bone that sticks out on the inside of the foot (medial malleolus). A good technique that is helpful in finding these pulses is to press hard into the skin along these areas and slowly release pressure. Can the climber feel your touch and distinguish between a sharp or dull touch— like getting poked with a pine needle versus patted with a sock? Can the climber wiggle his toes? If the answer is NO to any of these questions, the injury is serious and needs to be treated as shown on the next page.
C. Figure out if it’s a sprain or a fracture by following the “Ottawa Ankle Rules,” which are used by emergency rooms around the world. If the climber answers YES to both of the following questions, then it is most likely not a fracture. While the field treatment for a sprain and a fracture is the same (see next page), a fracture requires quick evacuation and evaluation by a medical professional. With a sprain, it isn’t as much of a show stopper; with a little RI CE (step #2), the pain and tenderness are more manageable.
Question 1: Can the climber stand and put weight on the ankle?
Question 2: Is the climber pain-free when a partner touches the ankle at the points on the diagram below? These arrows point to common areas for fracture (fig. 1).
If the climber has a loss of circulation, sensation, or movement (CSM) in the foot below the injured ankle, you must fix this or immediately evacuate before serious harm like nerve damage, hemorrhage, or death of tissue due to lack of circulation occurs.
Attempt to identify why he does not have CSM, loosen clothing, and, if possible, attempt to align the foot into a normal position. The most likely reason for a loss of CSM is the impingement of nerves or blood vessels by a broken bone or extreme swelling. Realigning a broken ankle is extremely painful and should be done with great care. If you have medical training or feel confident in skills learned during a Wilderness First Responder (WFR) course, it may be beneficial to apply light traction when attempting to align the ankle and thus restoring CSM. If you are not confident or do not have these skills, do not attempt this technique as it is possible to cause greater damage.
If there is still no pulse, sensation, or movement in the foot, it is necessary to evacuate immediately.
Consider administering ibuprofen as soon as possible to help with pain and inflammation.
If the climber has good pulses, feels sharp and dull sensations, and can wiggle the toes but cannot walk on the injured ankle, think about the following acronym for treatment: RICE
R: Rest— take stress off the injured ankle
I: Ice—snow or a cold stream are great field alternatives that help reduce swelling and inflammation
C: Compression— to reduce swelling
E: Elevation—place ankle above the heart to reduce swelling
In order to assist your injured partner, you may need to build a field splint. Below are some techniques that use little equipment and can help get your buddy to the trailhead.
The following two types of splints require minimal gear to complete. Depending upon the situation and the ankle injury, either of these techniques is useful. Assess the materials available, the severity of injury, and your location to determine which splint to use. Remember always to check for CSM before—and after—placing a splint, and every 30 minutes afterward. Pad the injured ankle well to prevent any further damage. When applying the splint, ask your injured partner how it feels: Is it tight enough? Is it too tight? Does it need to be padded more?
The Tape Splint (fig. 2): A tape splint works best after swelling has decreased. Twoinch athletic tape or climber’s tape work best if you don’t have an ACE bandage or a proper first aid kit. Make sure the foot/ ankle/lower leg is as clean as possible. Attempt to gently align the foot and leg in a 90-degree angle.
A) Start taping to the inside of foot (on top, behind big toe) and wrap under the ball of the foot, around the outside of the foot, and then to the inside of ankle across the top of the foot.
B) Continue around behind the ankle, angling upward and anchoring the tape strip below the calf on the outside. Repeat two to three more times.
C) Using longer strips of tape, attach one end to the interior of the leg (mid-calf ) and run directly under heel and anchor tape to exterior of the leg (mid-calf ). Repeat two to three times.
The U-Splint: This splint uses blankets, jackets, or whatever clothing is available.
1) Find suitable material ( jacket, T-shirt, etc.).
2) Roll material tightly into a tube-like shape.
3) Place injured ankle/foot in a position as close to 90 degrees as possible and wrap rolled material across the center sole of the foot and up both sides of the leg.
4) Using tape, bind the rolled material to the inside and outside of the injured foot and ankle by wrapping tape a few times around the ball of the foot, base of the ankle, and a bit higher up on the leg. The more tape, the more stable it will be.
Assist your partner in hobbling out very slowly. Make sure he takes plenty of breaks, and continually assess his ankle and look for change in his physical status: Is he eating and drinking OK? Is the pain increasing? Is he warm enough?
Available at many outdoor retailers and online (sammedical.com) for about $15, the SAM Splint is a very useful item. The splint is made of aluminum covered with foam, which can be used similarly to the U-splint to fashion in a stirrup that goes under the center of the sole and up on either side of the leg. Then use tape to wrap around and keep the splint in place. The versatile 36-inch model weighs about five ounces and is durable and reusable. If you venture out bouldering often, especially in the backcountry or to a place with uneven landings and/or highballs, consider carrying one of these along.