The Challenge & Common Injuries in Winter Sport
Luke Fogarty

Hi, my name is Luke Fogerty. I’m a sports medicine physiotherapist here at UPMC SSC and today I’ll be discussing the challenges and some of the common injuries with winter sports. So just a brief overview of what we’ll be going through today. We’ll be completing a quick needs analysis of skiing and other snow sports. We’ll be looking at some of the challenges of these trips, both physical and logistical, we’ll be looking at some of the common injuries and diving into the common lower limb injuries a little bit more. We’ll then look at the pathophysiology; we’ll look at the risk factors and then some tips for prevention and rehabilitation as well.

So, in terms of our needs analysis, skiing is a sport that involves high intensity aerobic bursts coupled with sustained aerobic capacity. So, you will have a low level of energy expenditure consistently throughout the day as well as short bursts of your more high intense activity. Some of the biomechanical stressors involved, so due to the fixation at the ankle, due to the ski boot, this causes immense torque and pressure further up the chain at the hip and knee and so, this is something to be aware of when we’re considering the prevention and rehabilitation side of things as well as some of the common injuries. It also requires a significant amount of core stability and lumbopelvic control and during our I suppose speed regulation and force absorption we require a lot of eccentric quad control as well.

So, some of the challenges with these trips are generally the high density. So, when we’re away for three to seven days, generally we’ll be skiing back-to-back days. There is a day three phenomenon where day three is statistically the most likely day that you’ll be injured due to the decline in physical and mental performance over the days of the trip. Some of the other challenges are lack of preparation so poor physical preparation for the demands of the trip, poor recovery. So, I suppose après ski is quite popular and a lot of people do like to burn the candle at both ends when they’re away and this can result in poor recovery which limits your capacity for the following days. Then physiologically then we do have to consider the altitude as well as the cold temperatures. This results in reduced VO2 as well as increased peripheral vasoconstriction. What this basically means is we have an increased rate of muscular fatigue so our muscles will tire quicker.

So, if we look at the most common injuries lower limb we can see is the most common and of that knee is the most common. We also have upper limb and head and cervical. So some of the upper limb injuries we might see in recreational orally skiing are our kind of traumatic rotator cuff tears, shoulder and elbow subluxations, glavvicular fractures, AC joint pathologies as well as hand and wrist fractures. Inner head and cervical injuries, these will generally be due to impact so, whether that’s from falls or collisions. and what we’ll see here is fractures, concussion, lacerations, and so on. I suppose diving a little bit deeper into the common lower limb injuries, our most common are our ACL ligamentous and meniscal injuries, so MCL and NCL, we’ve fractures, so our tibial plateau tibial shaft and then we also have ankle injuries which generally tend to be higher in snowboarders. I suppose due to the recent advances in equipment thankfully the rate of fractures has reduced significantly, however, our ligamentous and particularly our multi-ligamentous knee injuries are still quite prevalent.

So if we dive a little bit deeper into our ACL injury, generally I suppose there’s two main mechanisms, we have our contact or non-contact. So our contact injuries are where there’s an external force either making direct or indirect impact with the person. So I suppose to compare our pivot sports which is generally where our most common cause of ACL injury versus skiing in pivot sports will generally see a lot a lot more kind of lateral compartment bony bruising and this kind of, I suppose indicates that the mechanism may be slightly different. So generally, in pivot sports you’ll have that pivot shift mechanism whereas skiing a lot of the time we’ll see that we’ll have our I suppose anterior tibial translation due to our fixed ski boots and that causes the rupture of the ACL. Generally, the mechanism will be actual compression anterior tibial translation and then valgus stress and internal tibial rotation.

So, some of the common mechanisms we’ll see are snowplough mechanism. So, this is where the tips of the skis come together. The tails come apart and then the inside edge of the ski catches causing a valgus force on the knee. We can also see a boot induced anterior drawer. So, this is basically where the person lands kind of in a backseat position or their weight shifts backwards and then due to the rigid boot that shifts the tibia forward causing, I suppose increased pressure on our ACL. We also have our slip catch mechanism. So, this would be more common in our elite skiers. So, this is generally seen in in more high intensity carved turns. It’s basically where the inside edge of the ski temporarily loses grip and then catches again causing the knee to fall inwards while the body continues to rotate. So, they’re kind of our more common mechanisms.

Then if we’re looking at MCL and meniscal injury, so I suppose the most common mechanism is our valgus stress and external rotation and then also in relation to MCL which is less common but can be seen we have direct lateral blow as well. And so with our meniscal injuries we’ll kind of see a similar mechanism and we’ll just get that scraping of the meniscus with the femoral condyle. So a lot of the time we’ll see these injuries in conjunction with our other ligamentous injuries in particular ACL and so it has been identified that a lot of evidence will show that I suppose 50% of ACL injuries will have comorbid either MCL meniscal or condal pathology as well. A lot of these pathcomorbid or multi-ligamentous knee injuries will more often be seen in elite skiers. and generally, it’s hypothesised that’s due to I suppose the higher energy falls that they would be in due to the increased demand of the skiing that they’re potentially doing or the increased I suppose difficulty.

Then if we look at tibial fractures so I suppose the tibial plateau fractures would be our most common and so skiing is actually the most common cause for tibial plateau fracture, so generally this will happen with a valgus and either internal or external rotational force, due to the rigid boot again and the long lever of the ski this will amplify the torque at the knee and then we’ll get that kind of impacted femoral condyle into the tibial plateau causing fracture. Generally, you’ll see this in conjunction with other ligamentous injuries. We can also get tibial shaft fractures as well, so, we may have a spiral fracture where it’s a pure tor torsional force on the tibia. We can also get oblique fractures where we’re getting torsion and bending and then transverse fractures as well where it’s a direct blow to the tibia and so again due to the kind of higher energy falls that you’ll see in the elite population this injury is more common for them and I suppose return to skiing at three year follow-up was estimated at around 46%, so it can be quite low and in the population that did return it was often at a lower level and I suppose the rehabilitation process was often quite difficult in these injuries as well.

Some of the risk factors for these injuries, I suppose skill level does play a huge role. It’s more common I suppose I’ve alluded to the elite population being more likely to have your meniscal and condal pathologies as well as the tibial shaft fractures. However, overall being a novice or beginner is associated with a higher risk of injury. Another risk factor that is controllable is our neuromuscular control and fitness level. So, if we I suppose fail to prepare going on these trips and then we’re asking of these huge demands on our bodies often they can fail us when we need them and then another risk factor is obviously previous injury, females are at a higher risk of knee injury. Also, poor equipment setup and so I suppose during our falls it’s important that there’s adequate release of our boots and our DIN settings are set properly so that we’re not resulting in that kind of rigid fixation causing force to transmit further up the limb. And so, this is why it’s important to be quite honest and modest with your when you’re getting your DIN settings done because it will stand to you then when you’re on the slopes. Another factor then is sloping difficulty and conditions as well. It might be days where conditions are less favourable maybe stepping down in terms of difficulty level and then again, it’s also being honest with yourself about your level not to overestimate it.

In terms of prevention and rehabilitation I suppose the big factors are due to the high density of the trip can we reduce that so that’s taking breaks during our high intensity periods it may mean say adopting a high low model where day one you might have a day where you’re expending yourself a little bit more intensely enjoy your après ski and then you take the following morning off allowing yourself to rest and recover and have a shorter session on the slopes and then the following day you may be a little bit more recovered to go for a longer day. Again, another factor then is fuel and hydration. So, it’s making sure you’re kind of eating well, hydrating, and making sure you’re topped up in terms of that. And that may mean bringing certain snacks and preparing that for when you’re up on the slopes. In terms of physical preparation, completing a block of kind of strength and aerobic fitness work before going. These qualities are things that do take I suppose weeks and even months to build. So, it’s kind of being aware of that coming up to your trip. It doesn’t necessarily need to be anything extreme, but even a low level of strength and aerobic work in the number of in the few months leading up to your ski trip can stand you then. And then, as I mentioned earlier, accurate DIN settings. so that your boot does release when you are folding and being honest in terms of your experience level. So that’s everything in terms of I suppose the challenges of skiing calming injuries as well as some of the prevention and rehabilitation tips.

Definitely, I suppose postoperatively people can get back to high levels of activity after either meniscectomy or meniscal repair. So, I suppose the biggest thing is having a good, planned rehab block, making sure you’re kind of progressing through the stages and gradually getting back to everything. and then it’s kind of managing load as well. It is something that it can become irritated down the line, but by managing kind of how often you’re loading it and the intensity of what you’re doing that can definitely help as well. And I think it becomes more about managing symptoms. So, if you do have a flare up of symptoms, doesn’t necessarily mean you can’t do an activity you might just need to change you’re doing it and then having a good kind of base of strength, making sure the muscles around the knee are kind of supporting you as well when you are getting back to things like skiing or more intense activity.

It’s similar principles that apply. So, it’s really just having a good foundation of building strength and making sure you’re not provoking symptoms. The biggest thing going into surgery is you want your knee to be nice and calm, you want swelling to be in a good position so that after surgery, which there inevitably will be a little bit of pain and swelling, that it’s not already on the back foot going into that. So, that’ll be the big thing.

I suppose like the big thing with knee replacement is generally the joint will be quite irritated, you’ll have a loss of range, a lot of stiffness. So, I think addressing a lot of those things h pre-surgery can help after because I suppose the big issues we see with knee replacements is if someone can’t fully extend their knee or straighten it, so trying to work on that pre-surgery and get that in a good position, that can help after as well as again kind of building your quad strength and other lower limb strength just because that’s generally what tends to I suppose decondition a little bit after surgery. So yeah, if you’re in a good place there it can set you up well.

I suppose it kind of depends on the level of skiing you’re looking to go back to as well as I suppose your kind of base strength beforehand, if it’s one where you had a good base of strength, like definitely within 12 months probably wouldn’t be going any sooner than that but definitely if you have a good base and you’re following a good structured rehab plan, it’s definitely within the realms of possibility.

It can be helpful because I suppose we have a lot of sensors around the skin of the knee that I suppose providing some taper support can give us that little bit of feedback that does give us a little bit of extra comfort. I don’t think it replaces kind of building actual strength around the knee but definitely can help kind of get you through days of maybe more intensive skiing and stuff like that and just kind of reduce symptoms a little bit.

A brace like it’s I suppose it depends on the situation why you’re wearing it, I suppose if the knee is stable enough to go skiing I think definitely it can be a good adjunct to kind of help support that a little bit as well but it is one if it is kind of highly unstable it’ll kind of be considering you know is it a good option but definitely can be helpful yeah.