‘Don’t let your knees & hips go downhill! Management of ski-related injuries!’
Professor Brian Devitt

The title of my presentation today is ‘don’t let your knees and hips go downhill’ management of ski related injuries. So I’m going to start this presentation off with a video a little bit of a gory video so those who have any sensibilities you may wish to look away now, this is a man skiing and that snap is not his ski binding releasing but his ACL tearing and you’ll see it in slow motion now. He’s a good skier skiing in deep snow but you see he’s leaning back as he goes into the turn and that’s when his knee is in a vulnerable position, his right knee. You can hear the maniacal laugh of his friends so if you have friends like those who need enemies, but I’m sure he did get them off the mountain to a good orthopaedic surgeon.

I was privileged enough to do one of my fellowships in Vale Colorado and while there I worked with this gentleman called Dick Steadman and he used to look out for the US ski team and he had this phrase that if you were design a device to rupture an ACL you couldn’t get much better than a ski and I’ll tell you the reasons for that as we go ahead.

Well working in a ski resort is like a conveyor belt of injuries because it’s a high enough risk sport and a lot of them occur around the knee. It’s become hugely popular within society going away on an annual ski trip and oftentimes there’s alcohol included in these trips so it does make it equally hazardous.

It’s a great fun sport but risky and if you look at this little cartoon here we see that knee injuries are way more common related to skiing but shoulder injuries are more common with snowboarding so I’m sure Ms Delaney is going to speak to you about shoulder injuries and she’ll be able to show you example of those.

Why is it so risky? Well it relates to the equipment so if you’re careering down a hill on these two planks of wood with the poles in your hand there is a large element of risk associated with it. In the past they used to have boots that went up to the mid shin and were fixed to the ski, they were lashed onto the ski with leather.  Nowadays the equipment is a bit different, so initially the injuries used to occur around the tibia where you’d have fractures or ankle fractures but now they typically occur more around the knee. The reason for this is that the boots that we use are incorporate your ankle and go right up to the top of your shin so where rotation can occur is at the ski itself but when the boot doesn’t release from the binding or the ski the rotation typically occurs around the knee hence making it quite vulnerable.

The bindings are very important and these are set by the person who’s putting your skis together when you either buy them or more commonly when you rent them and the reason they ask you your level of expertise is so they can determine how easily or how more difficultly your ski boot comes out of the binding so that’s referred to as the din. So if you’re anyway suspicious or conscious of your knees ask the person to set your din at a low rating so your ski boost comes out a little bit easier.

Then it’s the ski itself so the ski’s have changed a lot since they were they were initially created and now they’re very easy, they’re actually conformed to how beginner skis as well so it makes it a lot easier to actually ski compared to what I would have started out on in the 1980s. It also has a relevance in terms of the terrain and condition, so we saw in the video at the start it was very deep snow and that makes people lean backwards so you’re more likely to lose control when you’re turning but also so in conditions like this where you very little snow and there’s exposed rock and it’s very common for the injuries to happen towards the end of the day when the snow is a bit slushy on the less difficult slopes where people are kind of relaxed but there’s lots of traffic so a lot of the injuries occur at the end of the day on blue slopes or green slopes which are regarded as being easy.

How do injuries occur? So we saw a fast video of how they occur at the start but essentially, it’s when people lose their balance and this example of images here shows when the skier is leaning backwards when their upper body is rotated into the mountain and the one of the knees get hyper flexed and then the ski acts as a lever so they say if you’ve a lever long enough you can move the world but a lever twisting on a fixed knee can tear an ACL pretty quickly and so this is how the injury occurs. Also occurs as result of stupidity so sorry about the volume here but you just can’t legislate for people like that so these people are going to injure themselves no matter where they are in the world or what pursuit they’re doing.

So what do we do when someone gets injured well on the mountain you really need to look for help and get off the mountain but before you get on the moutain the first thing we recognize in medicine is primum non nocere, first do no harm, so you really need to be conscious of where you’re putting yourself on the mountain so you don’t cause harm to yourself. It’s also key that you don’t chase after that person who’s an expert skier if you’re only a beginner and you need to be well aware of where you’re going to before you get yourself in harms way. Skiing is hazardous but it’s hazardous at the end of the mountain as well and you know it’s not so much that you as an individual need to look out for yourself but you have to look out for other lunatics on the mountain as well and typically this person was trying to get a drink pretty quickly but if you get in their way you’re in awful trouble so you do need to look out for yourself and for others around you. It tends to return to your comfort zone particularly when you’re going skiing I would advise that for the first run or two that you don’t go start doing a double black diamond or a black run if you’re inexperienced that you start off at an easy slope get your ski legs as we used to call it in our family and get confident and stay in your comfort zone when you begin, now you can go outside your comfort zone as the as the week progresses but certainly it’s advisable to start easily.

So what do we when someone has a an injury? So typically if it happens on the mountain that you’re taken off the mountain by an expert some people can ski down the mountain but the classic injury we hear about is someone who their ski binding doesn’t release they hear or feel a snap, they fall to the ground, they have difficulty skiing on and then when they get there they go down to the clinic at the bottom of the mountain or the medical centre they get an x-ray and they could put into a very overpriced brace. They’re told to either get an MRI straight away or they’re told to attend a doctor when they return home in some cases people are more avaricious and they try to encourage you to have surgery on the mountain, I would certainly advise against that because I think it’s important that you make the diagnosis first and then we decide upon what treatment is appropriate and have the appropriate resources around you.

What do we do in the clinic? First of all, we take a good history and I refer to this editorial, this is written back in the 1960s by a guy called Professor Appley and it’s still as relevant today as it was when it was written but one of the nice quotes from this editorial is “to listen is to learn we all pay lip service to a careful history but how many of us are patient enough to elicit one?” so I will say that in terms of taking a history it’s really important that you understand the mechanism of injury, whether the person has any previous knee injuries and very much you can make the diagnosis by history alone.

We then talk about clinical examination and one of the other great quotes from this editorial is “to look at one knee is absurd; man is biped and how considerate of nature to provide a normal for comparison. But nature did not provide trousers and these must be removed.” It’s really important when people are making assessments on the side of the mountain people are generally wearing ski boots they’re wearing Sala pets and it’s really difficult to do a proper examination with those paraphernalia on so when we get to the clinic we get the person to expose appropriately and you can very much see the damage and you see in this side this example here of a very swollen knee on the right side and a previous injury to the knee on the left side which is interesting. In terms of further investigation so clinical assessment we do an anatomical assessment of all the ligaments around the knee and we assess for laxity and we can typically determine how severe the injury is based on that, but we do like to get some further investigations.

A lot of the time patients will come with an x-ray which they got in the clinic the x-ray can be quite helpful and we see in this view that there’s a tiny little fragment of bone just on the outside of the knee and that’s indicative of an ACL injury and it will certainly tell you if there’s any major fracture but for the most part x-rays are more to rule out fracture than actually make a clear diagnosis.

So what else can they do? At the clinics they often can get an ultrasound that’s not that useful for us in that yes you can it’s very much the ability to understand the ultrasound is in the hands of the person doing it, but it’s not as transferable to other people who are looking at that scan. It’s not extremely useful for us, but the gold standard is for to do an MRI scan and this image here we can see the presence of bone bruising on the outside of the knee and at the back of the knee which is indicative of an ACL injury so we use MRI as a very helpful diagnostic tool. Then the next part is referral, so referral appropriately to either an orthopaedic surgeon who’s looking after these injuries but it’s important that we get the diagnosis and we’re able to then move forward with any management appropriately.

To manage these patients we do it in the cold light of day so as I alluded to anyone who’s pushing you to have intervention on a mountain unless it’s life-threatening you’re probably better off just being transferred back to your home country where things are available and we can look after you very well in that scenario. The key for us is to make early diagnosis so get the diagnosis right but often treatment is delayed and it’s delayed when the knee is ready for surgery, to go ahead with urgent surgery when the knee doesn’t move often results in poor outcomes so we try to avoid this as best as we can. We often would go down non-operative routes and I’ll give you an example in the cases below if they’re considered appropriate and sometimes we require operative intervention. One of the things I like to do is part of the assessment is to assess the person’s good side, so you look at their normal alignment and assess whether they require a brace. A lot of times people are putting braces unnecessarily, now it does give you a little bit of support when your knee is swollen but I try to remove braces as soon as possible to get the knee moving to get it ready for rehabilitation or surgery whichever is necessary. The range of motion I said is critical so you don’t operate on a on a knee that doesn’t move because it’s going to result in a knee that’s very difficult to move afterwards, so that’s really important in terms of early management. I try to get people walking as quickly as they can as well and to normalize one’s gaze is to get the muscles working appropriately and that’s very effective in terms of improving their rehabilitation afterwards.

So I’m going to give you a couple of examples of cases I’ve probably seen within the last week or so as to you know what we frequently see following ski injuries and during the ski season. The first case we see today is a novice snowboarder, so the typical letter I’ll get is thank you for seeing Ben who had a snowboarding Injury one week ago, unclear of the mechanism which is very common, he had swelling early doors, had difficulty weight bearing, he couldn’t fully extend his knee and that results from swelling, he did have some an affusion is the phrase we use for swelling in our in our parlons and he’s currently in a brace and I’ve advised him not to weight bear, so thank you for assistance in further management.

So part of the history I took further history, contact injury turning so he did strike someone and or was struck by someone, he didn’t feel or hear a pop which is important, he fell to the ground, difficulty weightbearing, had to be taken off the hill, was high speed contact, no immediate swelling but did get swollen a little bit later. Then on examination his knee was flexed so when your knee is flexed typically means there is flued within the knee, he had difficulty walking, he had an antalgic gait so like a lin, he did a swelling in his knee and he lacked an ability to fully extend his knee but there was no block there so I was able to do it passively and then he had some laxity of what we call a little bit of opening of the inside of his knee. So in in his situation these are X-rays of his knee so one of the things we see on these x-rays is that he’s a young man and his growth plates are still open so he’s a adolescent individual or pre-adolescent so he’s still a lot of growth remaining and this often bodes well for people’s recovery but it’s important that we respect that this is a growing child. There’s no obvious evidence of any fractures in these x-rays, the x-rays we do are from the front and from the side. We then get an MRI scan which is more helpful so an MRI anything that shows up as white indicates fluid and we see on the inside of his knee here that he’s sprained his medial collateral or what people will know as an MCL so he sprained his MCL. This is a view from the Inside of his knee and we see that his ACL is intact so any person who comes off the mountain with the swollen knee in my mind has an ACL injury until proven otherwise so thankfully for this young man he didn’t injure his ACL and he had an MCL injury. So in his situation that he was placed in a brace for a few weeks and was allowed full weight bear and he got his range in motion going and he’s black playing Gaelic football within three months following his injury without any long-term sequelae.

So the next case example is a little bit more serious so I’ve coined this legs akimbo, it was a 42y old female a recreational skier and she had an unsure mechanism injury as usual so she was skiing down the mountain trying to look after her children and she lost concentration and she slipped with her skis going one each way. She told me that the bindings didn’t release, she felt or she heard a tearing sensation within the middle of her knee and she had great difficulty skiing on, she tried to weight bear afterwards but needed to be taken off the mountain and she had immediate swelling in her knee and a really sense of gross instability that she couldn’t put any weight through this leg it felt like it was going to give way. So in terms of her clinical findings then she when I saw her in the clinic so this was probably five to seven days later she had great difficulty standing unassisted, she had gross swelling of her knee so the level of swelling typically indicates the level of injury to the knee because it means the level of bruising and she had large amount of laxity or very much a loose knee particularly on the inside and we do this test called the Lachman test which assesses for the stability of the ACL and she grows instability or increase laxity of her ACL and examination and most importantly she had a lot of bruising on the inside of her knee which would indicate damage to those structures.

I’m going to show you just an example of what we look at with an MRI so this example here we’ve seen the still image but I’m going to show you this MRI here where we look at the knee from the side, so at the front of the knee we have the kneecap, the top of the knee we have the femur and the bottom we have the tibia so I’ll go through it now more slowly. What we’re looking for here is the presence of fluid which shows up as white we then see that she’s an injury to her lateral meniscus, she’s got some bone bruising at the back of her knee and in the middle of her knee unfortunately her ACL is torn and as we go towards the inside of the knee you see this black structure the back is her PCL and the medial side of her knee or inside of her knee from the meniscus perspective looks normal but not from the ligament perspective. So over on the right side then we see there’s a lot of whiteness over the inside of her knee and we see here on the inside that she’s torn her medial collateral ligament so it’s completely torn through its substance so she had a serious injury to her medial collateral in addition to her ACL with a tear to her lateral meniscus.

I’m just going to show you a couple of examples and those for you were a bit squeamish this is looking inside this person’s knee with consent that we could show these images and what we see here is just the inside of the knee and we see that this is the meniscus on the inside but there’s lots of space here between the femur and the tibia so it means that this side of the joint is opening up so we see this is the ACL that is torn in the front here this orangey structure here so we need to reconstruct that and then we also see on the outside of the knee and this is the ACL again that she has a little bit of a tear at the back of her lateral meniscus as we saw on the scan. We clear everything out we repair the meniscus and then what we do is we put back in an ACL in her situation to reconstruct her torn ACL I’ll show you that in just one moment this is just assessing her knee and this is the ACL which we hold in with a screw there. She did very well following her surgery so she was placed in the brace this is her postoperative X-ray and we got her moving gradually with time with a brace for six weeks and she and go back to all her normal activities.

I’m going to go with a different tangent with the next case this is case three so this gentleman was affectionately known as Bandy legs not by me by the way, but by his family and he’s a 62y old male fanatical skier as he describes himself. I just imagine that this is what he looks like on the slopes. He had a obscure injury was quite innocuous that he injured his knee while getting out of his boots so you often experience this it’s probably the best part of skiing is taking your boots off at the end of the day well it wasn’t the case for him, because his bindings were stiff he had difficulty twisting getting into his boots after this and had a lot of pain over the inside of his knee. He did have swelling now this didn’t deter him he was able to ski after a few wines but presented with quite a bit of discomfort in this region. So anyone who comes to my clinic who’s over the age of 45 will get an x-ray because we want to out rule what is common and common things are common and in this situation his arthritis is common at this age. This is his left knee here and we see an x-ray which is performed initially so on the right side you’ll see that there’s nice space between the femur on the top and the tibia below on both sides of the joint but on the left side the inside of the joint is quite worn, so he has not just a meniscal tear but he has arthritis so he’s severe arthritis of the inside of his knee. In this situation the treatment for him is not to stick a camera in to take away some meniscus but ultimately he’s looking at a partial knee replacement so we counselled, we talked about what the surgery entailed and his symptoms really have been going on a lot longer than his ski accident and it’d be more chronic and he’d been suffering for quite a while so we went ahead and we did a uni compartmental or a partially knee replacement on this man here. So you see this on this view you can see the inside of the knee is resurfaced with a partial knee replacement. So the next question he asked is when can I go back skiing so in his situation I had no problem with him skiing, he’s functioning very well he no pain, no swelling after three months so he went back the following season so he took probably anywhere between 9 to 12 months to return but he was able to ski without any problems and it turns out he wasn’t wearing that outfit because he sent me a picture on the slopes. So it’s very possible to get back to the likes of skiing after a partial knee replacement or a total knee replacement, but it really depends on your level of general fitness at the time. This is a view of the knee from the side.

In terms of the final case then I’m just going to show another case of a gentleman who really wanted to get back skiing because he missed it, he said it was the best family holiday ever and the only time his kids wanted to spend time with him which was interesting but he’s probably right. He was getting progressive hip pain so once again struggling even getting his shoes and socks on but certainly couldn’t get his ski boots on without a lot of assistance. He was complaining of a lot of pain at night on his previous ski trip he really found a difficulty going up the inclines and he was waddling and wasn’t very happy on the ski trip. So we assessed him and we carried out some x-rays so he had formerly been quite a good rugby player and had a lot of injury to his hips throughout his rugby career but you see in this x-ray he’s got gross arthritis affecting not just his right hip but also his left hip. So he’s very keen to get back to skiing and asked he didn’t know what he could do after what was necessary for him which was a hip replacement but we did both of his hip replacements at the same time. I did them through an anterior approach the front of the hip which in my mind allows slightly easier recovery earlier but ultimately as the same result as the alternate which is the posterior approach but he was very keen to get back to skiing and his activities and I had no problem with him doing so once he recuperated fully. This is the final results for him so that brings us to the end of some case examples I hope you all stay safe on the slopes and should you have any issues in the cold light of day don’t hesitate to contact us so thank you very much.

Yeah well, I suppose it comes down to the length of the ski will determine the lever arm of the ski so that the torque that is you get from a smaller ski is not as large one thing I would say is the bindings can differ so that if you have shorter skis sometimes they’re fixed binding, so your boot doesn’t come out so depends on how long they are. So typically people who use the short blades are fairly advanced skiers and they go over kind of short like mogul runs and short kind of jump so they’re probably putting themselves in harm’s way a little bit more, but in general the shorter skis are probably a little bit safer but you’d have to be an experienced person to use them.

Yeah so if you look through the literature that they they’ve looked at a number of different sports and the use of braces to reduce the risk of ACL injury and its only in skiing that they’ve ever shown an advantage to using a brace when skiing. Now I will qualify that by saying the numbers were pretty small and in what we’ve looked at in further biomechanical studies is that these braces only really control the movement, the side to side movement so they protect the collateral ligaments, the inside ligament and the outside ligament but they’re not great at controlling rotation so I would say that they may be somewhat protective but they’re not going to be completely protective of sustaining a further ACL injury.

Yeah so as I mentioned at the end of my talk that you certainly can return to skiing I think Lindsey Vaughn is an elite level skier and she had a partial knee replacement and has returned to the ski circuit, so it’s certainly possible. I think that one of the things that we always tell people is you need to have you know good level of general fitness if you’re returning following joint replacement and really you need to give yourself some time to be able to get over that fitness and you need to have a knee that’s not angry or not going to be vulnerable when you ski so definitely possible. Time periods it varies between individuals typically I’d say at the very least I say around six months to ensure that you’re able to do a good level of activity before you get back. I didn’t answer one of the first part of the question that the question regarding when’s the most opportune time to have surgery if you have had an injury and you in in reality that it depends on the state of your knee so if a knee is very swollen and angry then it’s not appropriate to have surgery, we really would look for a knee that’s moving nicely that doesn’t have much swelling and there’s proper activation of the muscles around it that’s the most appropriate time and that can take up to six weeks on occasion sometimes longer to be ready other knees can be ready much quicker.

Yeah so there are a number of tests that we do and through the sports medicine department we subject most of our patient, most of my patients would go through postoperative testing so a lot of these revolve around assessing the strength of both the quadriceps and hamstring muscles. We do some jump tests to look that how your individuals behaving when they land on the leg, when they jump off the leg and we do change of direction tests now these are not specific to skiing but in general if someone has good balance and they’re allowed to take impact on the leg without any major issue then that determines that they’re reasonably ready we also use the kind of time period that typically you know it’s anywhere between kind of 9 to 12 months after you that you’re pretty much ready to go back but you should really have a  kind of sign off assessment from your surgeon or physiotherapist rehabilitation specialist before you go back.

Yeah so the best way as I mentioned is taking a proper history and just really ascertaining what the problem is now you know that doesn’t need to be with a surgeon or specialist your GP or health care professional can be able to look at that history. I think then the diagnosis comes down to clinical examination and the radiological investigations and you know they can be organized locally but we can also organize them for people if they need an appointment. It’s a very vulnerable time when someone gets injured abroad and as I said at the start we’re very happy to help out and very well able to take over that problem so just contact us and we’ll take all the hassle and make it easy for people when they’re in that vulnerable state.

Tendonitis can be tricky it’s a situation we typically involve or most of the time it’s non-operative management so involve you know rehabilitation and some particular stretching. So occasionally if it’s refractory or if it’s not settling with non-operative manager there are surgical procedures that can be done but we try to hold off on them until an individual has tried everything else. There can be injection therapies as well so it can be tricky enough tendonitis is not our favourite condition to manage because it’s tricky it can be hard to settle down.