‘Hiking for health: a guide for hill walkers & hikers on how to prepare & avoid injury.’
Dr Frank O’Leary

Good evening everybody, and thank you for joining this talk on hiking for health, a guide for hill walkers and hikers on how to prepare and avoid injury. My name is Frank O’Leary I’m a consultant in sports and exercise medicine here at the UPMC Sports Surgery Clinic in Dublin.

So, what I’m going to be talking  about this evening is, certain health benefits of hill walking and hiking, how you might prepare for an event, some of the common musculoskeletal injuries that might be involved as a result of excessive hiking or excessive hill walking, some of the injury prevention strategies before a big hike or walk that you might be predicting, how to manage certain extremes of temperatures and then a few slides on skin and wound managements that are common issues around hiking and hill walking.

What I won’t be covering is altitude sickness, and complications from high altitude, and I won’t be covering high adjuncts like footwear and certain hiking sticks.

If we just go back to the physical activity guidelines and what the chief medical officer advises, what adults should be doing from an exercise both aerobic and anaerobic perspective. So, adults age 18 to 64 years should be doing about 150 minutes of moderate intensity aerobic physical activity or 75 minutes of vigorous intensity aerobic physical activity per week. Now you might say well what’s moderate? and what’s vigorous? and often I talk to patients about a thing called a talk test, so if you can talk while you’re doing the exercise then probably it’s moderate,  if you can sing while doing the exercise it’s probably less than moderate and mild and if you have to take a breath between each word as you’re doing the exercise then it’s probably vigorous. A lot of people do fulfil this but what they forget about is the strength-based stuff, so you should be doing about twice a week strength-based work, this can be in the gym, this can be yoga, this can be carrying heavy bags, but it should be part of your week. Then if you’re over 65 years you should also be doing some balance work, as well as strength-based work. Again, this can be different aspects of activities like dancing or bowls or tai chi so and so on and so forth. Unfortunately, in Ireland only about 31% of adults fulfil all of these criteria for physical activity and 12% of adults don’t do any physical activity at all per week.

In terms of hiking and hill walking the cardiovascular benefits are evidently there. It helps reduce blood pressure, it also helps improve mood and anxiety levels, and does help reduce the risk of osteoporosis and help manage osteoporosis through its loadbearing capacity. What makes hill walking and hiking unique, is the change in terrain, the uneven terrain and then the unstable terrain, so you may not be surefooted when you’re going up certain mountains. The environmental exposures be it hot or cold also make it unique to hiking and hill walking as well as access to certain services like the emergency services.

In terms of medical operation if you’re thinking about a long hike you might want to discuss if you’re going in a group about certain medical conditions that you might have. For example, type 1 diabetes, to alert people that maybe you are a type 1 diabetic and that it will be unusual if you display certain symptoms, it might be a sign of that your blood sugars are either too low or too high. Similarly, with heart issues you might want to alert people where your emergency medications might be, whether it’s Insulin, be it Anapen if you have severe anaphylaxis or be it glucose for type 1 diabetes. Medical clearance is one of those ones that always comes up sometimes amongst doctors or whether patients should come and be medically cleared for a hike or a hill walk. Often you don’t need it however, if there’s been a change in your condition or a change in your medications relatively recent you might want to consider it. Then ultimately the big medical prep is the training both aerobic and anaerobic.

Just some of the practical aspects of hiking and hill walking, it’s like any event you need to prepare in advance, you should think about your route and know about it as best possible, speak to people about the route, what are the dangerous paths, what are the risky areas, know the emergency contact details, bring a phone with you, check if there’s coverage in the area, inform people of your travel and estimated time of return. Prepare for certain weather extremes be it be hot, cold, foggy etc. Think about what you would do if someone got ill or got injured at certain points of the of the route, bring some first aid kit with you like bandages, plasters and antiseptic solution and bring certain things with you that in case you do get stuck like food, water, torches, blankets etc.

So, I’m just going to talk a bit about temperature extremes uh hot and cold, so heat illness is exertional heat illness is when the core body temperature rises as a result of exercise. This is as a result of increased muscle activity and metabolism, so the balance is lost between heat loss and what heat generated the heat is lost through sweating in hot and human conditions the sweating becomes less effective and therefore you have reduced sweat evaporation and the body can overheat. Now at the end scale of this a medical emergency is heat stroke which is life threatening, and this is when your core body temperature is above 41° Centigrade. Some early signs of heat illness might include fatigue, weakness, dizziness, diarrhoea, vomiting, confusion or change in behaviour be it aggression, irritability or hysteria. Now these are very non-specific signs and if you think back in the last slide about type 1 diabetes, if your blood sugar is very low you might have some similar symptoms so it is very non-specific but if someone is displaying some of these and it’s a very hot day you might want to think about heat illness. It’s important to state what heat illness is not and it’s not dehydration, it’s not due to lack of fitness or due to a low glucose.

The main management for heat illness is to cool the body, and this in whatever means possible be it get you know cold water immersion, ice, fans, if you have ice you put it in areas like the axilla, the groin, the head, the neck, these are areas where there’s excellent vasculature. In terms of preventing heat illness getting acclimatized to the hot and humid conditions is essential and people should avoid exercising if they’re unwell, especially things like viral infections as this can increase the risk of heat illness.

We think about the cold accidental hypothermia refers to the involuntary dropping for body temperature below 35 degrees centigrade, and this can be caused by exposure to cold air or cold water and can be as a result of your own body not being able to thermoregulate. Sometimes this can be a result of certain traumas like burns, or alcohol, or drug use.

Some early signs of being excessively cold would include shivering cold hands or feet, palpitations, rapid breathing and mild in coordination. The main management again is passive rewarming so just warming up the body, removing any wet clothes, cover the body with blankets, and trying to remove them from that environment. If you can’t remove them from that environment then consider removing the wet clothing or if you have nothing to replace it with, keep the wet clothing on, cover them with blankets and then use a plastic bag over that to kind of keep the heat in. Active rewarming involves using hot packs and you need to be careful if someone is severely hypothermic as too active rewarming of the of the body can result in a worse outcome.

In terms of musculoskeletal preparation, the main areas to focus on in regards to hill walking and hiking will be the calf muscles, ankle stabilization, quadricep strengthening, and hip stabilizers, if we focus on the hip you can see some of the exercises here that you can do and you don’t need a gym for this. The first one on the left is the goblet squat and literally you’re going from sitting to standing, so sitting in the upright 90-degree position and then standing, you can add a weight and carry a weight for this. Doesn’t have to be a dumbbell you could use a heavy book and simply go from sitting to standing, this activates the buttock and the abdominal muscles, hip abduction, means bringing your leg out to the side and this activates the lateral hip muscles which are important for leg stabilization. Hip extension again can be used to activate the big gluteal muscles and the hamstrings at the back and this can be done with a stretchy band which is available in a lot of shops and retail outlets. Then the bridge is useful for activating hamstrings and glutes also.

In terms of quadriceps again you can do this at home, the picture on the left can be a little bit challenging because you’re doing it single leg and if you’re at risk of falls I’d advise avoid doing the picture on the left that exercise, maybe you could do the one on the far right which again is a sit to stand or a sliding squat against the wall. Then once you get comfortable with that move to the single leg rdl exercise which involves activating the quadriceps muscle.

The unique thing about hill walking and climbing is the uneven terrain, so you may have underlying issues like a dodgy ankle or an unstable ankle or a bit of arthritis in the big toe and it might be fine on the flat, but once you get into the uneven, unstable terrain it can flare up. So things like osteoarthritis of the big toe, ankle instability, hammer toes, Achilles tendon issues, planter fascia issues or even knee osteoarthritis these may all be stable and relatively mild on the flat terrain but when you go into the uneven and unstable terrain it can really flare up, so you need extra strength in the particular areas I mentioned in the previous slide to if you want to go ahead and go and hill walk and a hike.

Some of the common areas that are injured would include the ankles, the knees, the calves, the feet, sometimes you can get head injuries and muscle cramping and fatigue. If we think about what happens when you go up and downhill the forces change going through the joints. If we think about going downhill we place a huge amount of stress on our knees and our quadriceps this is because on the way down the knees and quadriceps need to take a huge amount more force to try and slow us down and break the body, so there’s about three to four times the force going through your knee downhill versus through your knee going on the flat. If we think about going uphill there’s less work on the knee but there’s more work on the hip and the ankle and it requires more energy to get ourselves uphill. So, the main movers here are your calf muscles and your hip muscles which would include the glutes and the Hamstrings.

I want to talk a bit about foot injuries mainly stress fractures and Plantar Fasciitis. A stress fracture is a fracture, it’s a partial or complete fracture that results from repeated application of a stress that is lower than that stress required in order to fracture the bone in a single loading. So what that means is rather than get one single blow and fracture your foot for example it’s the repetitiveness and repetitive strain that ultimately leads to a fracture in the foot.

The risk factors for stress fracture would include loading up too much so doing too much too quick, if you’re weak in the muscles around that bone, if you have thin bones, or osteopenia or osteoporosis, if you’re low on vitamin D, or certain Sports and exercise like endurance sports which would include long distance walking and hill climbing.

The main management for stress fracture is offloading. The main symptoms are pain sometimes you can have swellings sometimes not but the pain then, once you offload it take your weight off the pain tends to settle if you go back to that previous activity the pain flares up again. Typically, if there’s a stress fracture of one of the foot bones we’ put you in a boot to offload the stress going through that bone. We would address the risk factors and then we’d ask you to build on your strength.

Planter Fasciitis is a very common condition that we see a lot here in the sport Surgery Clinic so ultimately it presents with heel pain or pain around the arch of the foot. Pain is worse when you get up out of bed and you start to walk so if you rest for a long period of time and you go to start walking you’d feel the pain significantly, generally it eases as you keep walking but then it can it can flare up again as you return to rest, it’s difficult to lift your heel off the floor in Planter Fasciitis.

The main management is again stretching, calf exercises, for example the heel raise as you can see in the picture here on the left is a double heel raise and which is easier than on the right is single heel raise. You can wear something like a night splint which keeps the ankle bent and keeps that stretch on the Planter Fascia and then we have other adjuncts here in the Sports Surgery Clinic like shock wave therapy and occasionally we need to inject the area to help move it along in its management.

In terms of ankle injuries, the most common injury is an inversion injury when you roll your ankle and this affects the ligaments, the outer ligaments of the ankle and then Achilles tendon flares or even tears can happen. If we look at the ankle there are major stabilizers of the ankle and there are three main ones on the outside, and these are the ligaments, the main function of the ligament is to stop movement, stop the bones moving between the joints, to give some stability to the joint and then provide feedback to let you know where your foot is planting. Occasionally if you roll your ankle you can fracture it as well the most common injury is the ligament injury but occasionally you can fracture. So, if you do roll your ankle and you’re finding it difficult to put your foot down and it’s getting worse and there is a lot of swelling you might need to seek medical attention.

The lateral ligaments if they’re injured, the main the main treatment is to get the ankle moving better so getting the range back, getting the swelling down through compression and then building up the strength in the ankle muscles around that joint, and some of them you can see here in Dorsiflexion and Plantar flexion, so moving the ankle up and down against resistance to help build that strength.

We look at the Achilles tendon which on the MRI scan here is the black line at the back of the ankle coming down. The Achilles tendon is the strongest tendon in the body it attaches the calf muscles down to the heel, there’s a huge force that goes through the Achilles tendon and it’s a common sight of injury. You can see here on the MRI scan where the Achilles tendon comes down in a line but then it becomes thickened and this is the mid portion of the Achilles tendon and it’s a common area to be injured. The main treatment for it is strengthening a loading program, through calf raises and calf drops and build on that strength as you get more proficient. There are again some other adjuncts that we can use here and that we’ve used in the Sport Surgery Clinic which will include shock wave therapy and injection.

If you completely tear your Achilles it generally feels like a sudden pop or a sudden tear some people describe it like someone being shot in the back of your heel, there’s significant weakness in your ankle, there’s pain in the back of the heel and there’s a notable gap and you lose the contours of your Achilles tendon. You can see in the picture below where on the right you’ve got a nice heel and an Achilles tendon coming up where on the left is just swelling and there’s no definition. You’ll have difficulty bending your foot and pushing your foot away.

In general, for Achilles tendon pain, the pain is worse in the morning it can warm up with movement and then gets worse after movement. There can be swelling in different areas uh depending on where the tendon is injured. The two most common areas where the tendon is injured is the mid portion in the middle of the attendant, and at the insertion as the attendant inserts into the heel. The pain can be the day after or the evening after exercise, so often during exercise you can warm up the tendon and pain eases off but then towards the evening it starts flaring up again.

For mid portion Achilles tendon problems generally, this is what a loading program might look like, with heel raises, heel drops, with the knee straight and the knee bent and these can be done not just for treating Achilles tendon but if you want to build up the strength before you do a long hike in your calf muscles these would be some of the exercises that you would do.

Calf injuries are very common, there’s two main calf muscles the Gastrocnemius and the Soleus. Gastrocnemius is the real powerhouse, is the producer of power in short sharp bursts, where your Soleus is an endurance muscle. Gastrocnemius tears you’ll generally know all about it will feel like a pop, it’ll feel like you’re being shot in the back of the leg if there’s significant tear. Soleus tears are much more subtle and often just feel like a strain and you mightn’t notice it as much.

In terms of cramp with exercise or that sense of half cramp often it’s due to deconditioning and fatigue so often it’s due to the muscle not being able to produce the force or the level of activity that you’re demanding of it. Things you may need to consider that you might need to seek medical attention for would be is it a blood supply issue so is there enough blood supply getting down there or is it referred pain from the lower back, so if you are doing conditioning and you can’t progress through calf pain you might need to seek some medical attention.

I’m just going to talk now about some skin issues that are common when you hill walk and hike and these would be blisters, wounds, bites and sunburn. In terms of blisters prevention is better than cure so if there’s certain areas of your foot that you think are going to be at risk of blisters then you’re better off just covering them with things like hypafix like you see in the picture here. So, risk factors for blisters would be new shoes, poorly fitting shoes, heat or any foot abnormalities, like bunion or hammer toe that you might have or running on a regular surface. If you have new footwear then try to protect those particular areas that you think are vulnerable with some tape like you can see here. If you do get a blister try not to burst it if it’s relatively small in size and often you can use plasters like hydrocolloid plasters to give it that cushion which can come in various sizes. If there’s a large heel blister you might need extra padding at night to get you a night’s sleep and if the blister is burst try and remove the dead skin around it, clean the area and apply a dressing.

In terms of wounds if you’re out in the wilderness and you do get a wound try and clean your hands maybe with bring some alcohol gel, if you can bring gloves if not it’s not a big issue, clean the wound with clean water, remove any debris, apply antiseptic and just cover it with some bandages or plasters like you can see here with the picture.

Sunburn is an issue even in Ireland and clothing is the best form of sun protection. You should wear some protection even if it’s cloudy because about 70% of the rays still get through the cloud and you should look at the sun cream bottle that you have and make sure there’s UVA and UVB protection. Vulnerable areas would include the scalp, the nose, the ears, and the lips, and risky environments would be if you’re out in water or prolonged exposure or between the hours of 11:00 a.m. and 3 p.m.

If we look at insect bites try to avoid areas of stagnant water where insects love, avoid skin exposure at certain times like dusk or at night and try to keep yourself covered with long sleeve bottoms, wear in insect propellants if you can.