Falls are the leading cause of serious injury and evacuation in mountain hiking. They happen on terrain that has been walked thousands of times before, to people who are experienced, fit and adequately equipped. They happen because mountain terrain is inherently unpredictable — a wet stone, a loose root, a moment of inattention on a descent, a misjudged step in fading light. The fall itself is rarely preventable in the moment. What you do in the two minutes after it is entirely within your control.

Understanding the assessment sequence — and the specific first aid for the two most common fall outcomes (sprains and suspected fractures) — is what determines whether a fall ends a day’s walking or ends much more.

Immediate Assessment: Before You Help Anyone

Scene safety

Before approaching a fallen person, assess whether the site is safe to approach. A fall on a steep slope may have left the person in a position where approaching from above risks displacing them further. An avalanche zone, a stream crossing or a rockfall area may create immediate hazard to rescuers. Assess before you move.

The AVPU scale: Is the person conscious?

The fastest way to assess consciousness level is the AVPU scale — a tool used by emergency responders worldwide that requires no training:

• A — Alert: the person is awake, eyes open, responds normally
• V — Voice: the person responds only when spoken to loudly
• P — Pain: the person responds only to a painful stimulus (sternal rub)
• U — Unresponsive: no response to any stimulus

Any result below A (Alert) is a medical emergency. Call for rescue immediately and manage the airway — tilt the head back gently and lift the chin to open the airway, then place in the recovery position if the person is breathing and there is no suspected spinal injury.

The Ankle Sprain: Most Common, Most Mismanaged

Ankle sprains account for the majority of fall-related trail injuries. They occur when the foot rolls inward (inversion sprain — 85% of ankle sprains) or outward (eversion sprain), stretching or tearing the lateral or medial ankle ligaments. They are graded I (stretch, minor), II (partial tear, moderate) to III (complete tear, significant).

The POLICE protocol (replacing RICE)

Current sports medicine guidelines have replaced the classic RICE (Rest, Ice, Compression, Elevation) with POLICE, which better reflects evidence on recovery:

• P — Protection: protect the ankle from further injury; support with taping or bandage; use trekking poles to offload the ankle while walking
• OL — Optimal Loading: contrary to older advice, gentle movement and partial weight-bearing (if tolerable) promotes faster ligament healing than complete immobilisation
• I — Ice: cold (stream water, snow pack in a bag) reduces initial swelling and pain; 15–20 minutes maximum every 2 hours; never apply ice directly to skin
• C — Compression: a figure-8 ankle bandage or elastic compression bandage applies firm but not constricting pressure to limit swelling
• E — Elevation: raise the foot above heart level during rest stops to assist venous return and reduce swelling

Can you continue hiking with a sprained ankle?

This is the decision that matters most on the trail. The guide is weight-bearing ability, not pain level — pain alone is not a reliable indicator of injury severity. If the person can bear full weight within 5 minutes of the fall and walk 4 steps on the injured ankle without severe pain, a grade I sprain is likely and continued hiking with taping and poles is reasonable. If they cannot bear weight, a grade II–III sprain or fracture is possible and descent via the easiest available route is the decision. Never encourage someone to walk on an injury they cannot bear weight on — ankle fractures and severe sprains that are walked on cause secondary injury that extends recovery from weeks to months.

Ankle Taping: The Field Technique

A figure-8 ankle taping with elastic adhesive bandage provides significant stability support and allows continued walking in grade I–II sprains. The technique:

• Position the ankle at 90° (foot at right angle to leg) — the neutral position; never tape in plantar flexion (toes pointing down)
• Anchor strip: one circle of tape around the lower shin above the ankle; this is the fixed point for all subsequent strips
• Stirrup strips: two to three vertical strips running from anchor, under the heel, back up to anchor on the other side; these prevent inversion
• Figure-8: one strip beginning at anchor, crossing the front of the ankle diagonally, circling under the foot and crossing back over the ankle in the other direction — this locks the ankle in neutral
• Closing circles: two to three circles closing the taping structure starting from the foot upward to the anchor
• Check circulation after: the foot should be warm, capillary refill under the nail should be under 2 seconds; if the foot goes cold or numb, the taping is too tight and must be immediately removed

Knee Injuries: When the Descent Fails

Knee injuries from trail falls typically involve either the patella (kneecap), the medial collateral ligament (inner knee, from a direct blow or twisting fall) or — most seriously — the anterior cruciate ligament (ACL, from a sudden stopping or twisting mechanism). The ACL in particular often produces a pop, immediate swelling and near-complete loss of stability.

Field management of knee injuries

• Assess stability: can the person straighten the knee fully? A locked knee (unable to extend) indicates possible meniscal involvement; a completely unstable knee on attempted weight-bearing is likely an ACL rupture
• Compression bandage: a tubular compression bandage or elastic bandage applied firmly around the knee reduces swelling; do not apply over an obviously displaced patella (dislocation)
• Trekking pole use: two poles allow a person with a knee injury to significantly offload the joint — set poles 10cm longer than usual and use both simultaneously on the affected side
• Improvised splinting: in cases of suspected fracture or ACL rupture, improvise a straight leg splint from trekking pole sections or sleeping mat sections to prevent knee movement during evacuation

Wrist and Hand Injuries from Falls

The instinctive response to a fall is to put a hand out. The wrist absorbs the impact. Colles’ fractures (distal radius fractures) are the most common upper limb fracture in hikers and produce characteristic dinner-fork deformity of the wrist. A suspected wrist fracture should be splinted in a neutral position (slight extension, fingers relaxed), the arm supported in a sling, and the person evacuated. Most wrist fractures, while painful, do not prevent walking — the person can descend to the trailhead under their own power with the arm splinted and supported.

Head Injuries: The Symptom to Watch For

Any fall involving a head impact requires monitoring for concussion symptoms over the following 24 hours, regardless of whether the person felt immediately affected. Concussion symptoms: headache, nausea, dizziness, confusion, sensitivity to light, slurred speech, loss of balance, memory gaps around the event. A person who loses consciousness even briefly following a head impact must be evacuated for medical assessment — loss of consciousness indicates a significant brain injury event regardless of the duration.