SportsMedicine of Atlanta

CARING FOR ATHLETES

ALPINE SKIING:  COMMON INJURIES IN THE MOST DANGEROUS SPORT

Did you know that recreational Alpine skiers have a greater chance of being 9injured than participants in any other sport, with the possible exception of football?  Over 10 million people currently ski in the U.S., resulting in an estimated 250,000 to 600,000 injuries each year, most of which could have prevented with proper equipment, common sense and preparticipation Sports Medicine intervention.

The most frequently occurring skiing injury, accounting for up to 50% of all ski injuries, is damage to the knee’s anterior cruciate ligament (ACL, the interior knee ligament which holds the knee joint together).  According to John A. Feagin, MD, an orthopedic surgeon at St. John’s Hospital in Jackson Hole, Wyoming, the incidence of ACL injuries is epidemic.  Recent improvements in binding design and function have been able to better protect the ankle and lower leg, therefore decreasing the frequency of injuries to these areas.  However, binding design improvements have been unable to better protect the knee.

Most commonly, knee injuries occur as the skier catches the inside edge of the ski during the fall, causing sudden external rotation below the knee.  In the process, the ACL deep within the knee snaps before the skis binding release can be triggered.

What can a skier do to avoid this type of injury?  Strengthening exercises for the quadriceps and hamstrings (front and back thigh muscles) aid in protecting the knee from such injuries.  Also maintaining a 45-degree to 90-degree knee flexion while skiing can lessen the stress on knee ligaments.  However, even the strongest thighs and knee ligaments are no match for the stiffness of most equipment and the traumatic torque created by a fall on a steep slope.  Until safer binding technology has been developed and implemented, there are certain steps skiers can take to assist in protect themselves.  Robert J. Johnson, MD, an orthopedic surgeon at the University of Vermont College of Medicine in Burlington, recommends skiers perform the three simple ski binding’s tests illustrated in figures 1, 2, and 3.  Each test should be performed using slow and deliberate movements while avoiding violent thrusts.  Keep in mind that these tests are not proven to fully insure the safe functional status of your bindings.  In addition, at the start of each season you should take your skis to a reliable ski shop for objective machine testing and adjusting.  This should be done several times throughout the season if you ski frequently.

Another common injury is skier’s thumb.  Skier’s thumb often goes unreported (75% of the cases) and may actually be the most common skiing injury.  This type injury occurs when the skier attempts to break a fall with the outstretched hand containing a ski pole, thus causing the thumb to hyperextend.  By simply releasing the pole during the fall protects the skier from this type of injury.  Therefore, it is advisable to grip the pole to separate from the hand when the grasp is released.

Fortunately, some ski injuries are on the decline.  Ankle sprains were one time the most common skiing injury, but are less frequent today.  Improved equipment, including high, firm plastic boots and improved release binding, is the main reason for the decrease in ankle injuries.

Also declining in frequency over the last 20 years are tibia (lower leg) fractures.  This injury is caused when the ski’s bindings fail to release, causing the ski to act as a lever to bend or twist the lower leg.  Again, improvement in equipment design is credited for the decrease in the number of ski-related leg fractures.  Today a well-designed binding features a “twist release” mechanism at the toe.  Properly padded and designed boots also protect the skier against lower leg injuries.

It is apparent that properly adjusted and fitted equipment certainly plays a major role in injury prevention.  However, a skier can buy the finest ski equipment available today and still end the ski season with torn ligaments or a broken leg.  Equipment is not the only answer to ski injury prevention.  There is much skiers can do to physically prepare their bodies to adequately endure the great physical demands of skiing.  The serious and health conscientious skier should consult with an experienced Sports Medicine Clinic prior to participating in skiing.  At the Sports Medicine Clinic, an experienced specialist should objectively and reliably evaluate your unique anatomical and physiological needs as related to skiing.  Any and all predisposing physical risk factors should be identified and effective remedial measures suggested.  An overall preparticipation conditioning program should also be prescribed so to improve your ski performance levels.  Detailed equipment and conditioning education should be provided and demonstrated.

GRAPH/PICTURES

Figure 1. The side Release Check cycles the toe piece of the binding in an internal twist. (a) Place weight equally on both feet, move the ski to be tested slightly forward, and place ski poles out in front for balance. (b) Bring the test ski up on its inside edge, and apply force using the muscles that turn the toes toward the opposite foot. (c) The binding should release. You can reverse the test by placing the ski on its outside edge and turning the toes outward.

GRAPH/PICTURES

Figure 2. The Heel Release Check tests the mechanism that allows the ski boot to release upward at the heel. (a) Place the ski you are not testing forward, putting most of your weight on this leg. (b) Place poles out in front for support, or grasp a firm object such as a tree. Lean forward, pulling upward with the calf muscle to raise the heel of the boot from the ski. (c) The binding should release.  Be sure the poles are properly planted so that you don’t pitch forward when the binding releases.

GRAPH/PICTURES

Figure 3. The Toe Release Check tests those newer bindings that have the toe release mechanism. (a) Bring the test leg forward, and place the other leg to the rear for support (b) Place ski poles behind the weight-bearing area, and lean back on the support ski. (c) The binding should release.  To keep from falling, quickly move the ski poles back.

Release, yet the skis, tethered by safety straps, may repeatedly strike the skier.  The use of ski brakes in place of safety straps should diminish the incidence of these injuries.  Ankle sprains, which used to be the most common skiing injuries, are occurring less frequently in recent years (Table 2). Ankle fractures have also diminished markedly in frequency.  This trend in ankle injuries seems to reflect improved equipment, particularly high, firm plastic boots and improved release bindings.  Below, we shall discuss the other injuries listed in Table 1, with the exception of soft tissue shoulder injuries; since this category includes several different entity’s (as well as cases where precise diagnoses cannot be made), a meaningful analysis is beyond the scope of this article.

Knee Sprains

Pathogenesis:  The incidence of knee sprains remains high over the years.  Improvements in binding design and function have been unable to better protect the knee.  This is not surprising when one considers that the breaking strength of the tibia has been the sole criterion used in designing recent bindings.  By far the most common mechanism of injury results from a skier catching the inside edge of the ski during a fall, thereby producing sudden external rotation of the leg; injury forces are magnified at the knee by the ski acting as a moment arm (Figure 1).  The medial collateral ligament is the most commonly injured structure in this sort of accident.  These and other types of falls may also damage additional structures about the knee joint

FORCIBLE EXTERNAL ROTATION OF THE LEG:

GRAPH/PICTURES

When the inside edge of the ski is caught (A), the ski acts as a moment arm(B) magnifying forces at  the knee that produce primarily external rotation of the leg (C). (Note also the potential for abduction of the leg.)

Typical injuries resulting include tears of the medial collateral ligament (D) and the medial capsular ligament (E); when the force is severe enough, the anterior is by far the one most commonly involved.

Figure 1

SKIING TIPS TO BEGINNERS

Spend at least half of the first skiing day taking supervised lessons.  A professional ski instructor will build your confidence as you learn basic techniques and practice successfully on short, smooth courses.

Mental attitude is important.  You shouldn’t feel as though you’re in competition with other skiers.  Relax and feel good about skiing.

Only do what you are ready for – don’t be talked into going down a course too advanced for you.

Dehydration is common in high altitudes, as your veins tend to dilate, losing moisture more rapidly.  Even though you may not feel thirsty, it is important to hydrate your body with water and juices.  Alcohol and sugary soft drinks should be avoided as they may promote dehydration.

Eating light is advised during the skiing day.  Overeating causes your body to spend energy digesting food and less energy in keeping warm and providing adequate muscular function.

Special attention should be given to your skin and hair when you’re on the slopes.  The high altitude and sun’s reflection off the snow increase the intensity of harmful ultraviolet rays.  Use a sunscreen with a high sun protection factor on your face and hands.

Protect your lips with a lip balm that contains a sunscreen.  Keep tubes of balm and sunscreen in your jacket pocket for quick application throughout the day.

Avoid exposing your hair to the damaging wind and cold by tying it back or tucking it under your cap.

Call ahead to get specific information regarding weather conditions, dressing accommodations, dining, hours of operation, inclement weather transportation, costs of rental equipment and lift tickets.

WHERE TO GO

Now that you’ve taken steps toward being “Fit To Ski”, what’s next?  As in planning any vacation, you must decide where to go.  The information following briefly describes some of the more popular Southern ski resorts.  If you decide to travel farther, resort information for any state can be obtained by writing to that state’s Department of Tourism.