Ankle Injuries

27th March 2019

Ankle Injuries are perhaps the most common injuries one may encounter in a remote or wilderness setting. (1, 2, 3).

The challenges in the remote setting are the diagnosis and decision making; has the casualty sustained a fracture or soft tissue damage? Will an ankle injury require evacuation, immobilisation or simple strapping?


As with all musculoskeletal injury we may identify common signs and symptoms:

  • Pain

  • Swelling

  • Heat

  • A change of skin colour

  • Deformity

  • Reduced (or exaggerated) range of movement

  • Guarding

  • Loss of function

With the exception of gross deformity (bone visable through or under skin) or gross exaggeration of movement, the remainder are non-specific, they do not differentiate between fractures or soft tissue injuries such as sprains or strains.

Ottawa Ankle Rules

The Ottawa Ankle Rules were developed to rule out the need for x-ray in a clinical setting and the results are incredibly accurate (4, 5, 6).

The most common fractures found in ankle injuries are:

  • Tip of the lateral malleolus or posterior edge of the distal fibula

  • Tip of the medial malleolus or posteria edge of the distal tibia

  • Bone tenderness at the base of the fifth metatarsal

  • Bone tenderness at the navicular

The most common ligament injuries occur at:

  • Anterior talofublar (ATF) ligament

  • Posterior talofibular (PTF) ligament

  • Calcaneofibular (CF) ligament

Ottawa Ankle Rules

The requirement for an X-Ray is either

  • The casualty cannot bear weight for four steps


  • Pain in the malleolar or midfoot zone


  • Bone tenderness at the posterior edge or tip of the lateral or medial malleolus


  • Bone tenderness at the base of the fifth metatarsal or at the navicular

If either of these signs are present in a wilderness setting, this would warrant an x-ray in a clinical setting and therefore we can assume a high suspicion of fracture would warrant immobilisation and possible evacuation.

In the absence of such finding we may assume soft tissue injury which may simply require rest and support.


1. Our generic treatment plan for musculoskeletal injuries is here.
If you are still using RICE you need to read this.

2. Additional information of pain management can be found here.

3a. For injuries which require immobilisation Sam Splints can be used with great effect here.

3b. For injuries excluded by the Ottawa Ankle rules and where the casualty can weight-bear consider strapping:

1. Place a strip of tape around the forefoot and around the mid-calf. Do not go around the mid-calf completely.

2. Place a stirrup under the heel, connected to the mid-calf tape.

3. Place a web of three strips over the lateral malleolus to support the ATF, PTF and CF ligaments.

4. Secure the web with additional strapping around the mid-calf (not completely around) and the forefoot.

5. Apply a ‘heel lock’ around the heel.


  1. The Remote, Austere, Wilderness and Third World Medicine Discussion Board Moderators  (2017)  “Survival and Austere Medicine: An introduction”.  3rd edition.

  2. Gentile DA, Morris JA,  Schimelpfenig T, Bass SM, Auerbach PS.  (1992)  “Wilderness Injuries and Illnesses”.  Annals of Emergency Medicine.  21(7):853-61 


  4. Stiell IG, Greenberg GH, McKnight RD, et al.  (1992)  “A study to develop clinical decision rules for the use of radiography in acute ankle injuries”.  Annals of Emergency Medicine.  21 (4), 384–390.

  5. Stiell IG, McKnight RD, Greenberg GH, et al.  (1994)  “Implementation of the Ottawa ankle rules”. Journal of the American Medical Association.  271 (11), 827–832.

  6. Stiell I, Wells G, Laupacis A, et al.  (1995)  "Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group". British Medical Journal. 311 (7005): 594–7.