Winter Sports Safety Q&A with Meredith Ehn, DO, DPT

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Atraumatic knee pain during and after skiing is a common complaint across all age groups and ability levels. For clarification, we’re not talking about knee pain that results from an acute traumatic injury like an ACL tear or tibial plateau fracture, but rather pain that comes on without a known injury. Causes of this type of atraumatic knee pain can by separated into two different categories: factors extrinsic to the skier and factors intrinsic to the skier. Extrinsic factors are easily modifiable and include boot fit, boot stiffness, ski size and shape, snow hardness, and terrain selection. Intrinsic factors are innate to the skier’s body and include lower limb biomechanics, cartilage health, strength, and neuromuscular control of the lower limb.

Biomechanics such as hip, knee, ankle, and foot alignment are difficult to change but can be optimized by a well fit boot and/or foot bed. Professional boot fitters can make modifications to the boot or create a foot bed to compensate for suboptimal limb mechanics. Insufficient lower limb strength, especially of the thigh and hip, can lead to overload of the joints, most commonly the knee. This can be improved upon by a good preseason strength and conditioning program developed by a physical therapist or knowledgeable trainer. Similar to poor lower extremity strength, impaired neuromuscular control (think: the ability to balance on one leg while squatting on a balance board) can overload the joints, especially when the body is fatigued. This too can be remedied by working with a physical therapist who is knowledgeable about skiing rehab and injury prevention.

Of the intrinsic factors (in fact, all), cartilage health is the most challenging to address. Cartilage wear (osteoarthritis) is often referred to as degenerative joint disease or “wear and tear” arthritis. The knees are among the joints most commonly effected. Treatment options for arthritis include medications like Tylenol or NSAIDs, physical therapy focused on strengthening the hips and thighs, and injections such as cortisone or viscosupplementation (hyaluronic acid). Sports medicine physicians, such as those at Shirley Ryan AbilityLab, can guide you through the treatment options. Some people may require surgical intervention, such as a total knee replacement. But many do come back to ski after knee replacement.

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Overall, injuries to the knee and shoulder are the most commonly seen injuries in skiers and snowboarders. But injury types vary between skiers and snowboarders, by age, and by ability level. Males have a higher risk of injury than females. The average age of injured skiers is higher. Skier suffer more lower extremity injuries while snowboarders suffer more upper extremity injuries. Children and recreational snowboarders most commonly experience injury to the wrist and shoulder while elite athletes more often injure the knee or ankle. Concussion is the second most common type of injury for all snowboarders. In skiers, knee injury is the most common for all ages and ability levels. 

Injury prevention starts with properly functioning equipment. In snow sports, an increase in helmet usage over the past 20 years has seen a steady decline in serious head injuries. According to the National Ski Areas Association, the rate of helmet usage reached 90% of all skiers/riders during the 2021/22 season. Improvements in binding technology over the past 20 years have decreased the rate of knee and lower leg injuries. It is commonly recommended that bindings be checked by a professional at the start of every season or every 15-30 days of use.

Adequate strength and conditioning of skiing/riding specific movement patterns is equally as important in prevention of injury. Research has shown the rate of ACL injury to be lower in those treated with an ACL injury prevention program. Wrist braces have been shown to decrease the rate of wrist and hand injury in snowboarders. Additionally, maintaining good cardiovascular fitness may lead to lower injury rates overall and certainly a more enjoyable skiing/riding experience.

And finally, skiing/riding within your ability level is an integral part of minimizing injury risk. Pick runs that are not above your ability level. Ski/ride in control. If new to the sport, consider taking a lesson from a professional ski or snowboard instructor.

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1. Know the skiers/rider’s code. This is often printed on the back of every lift ticket and is part of the release from liability that everyone "signs" when they purchase a ticket to ski/snowboard.
2. Ski/ride within control.
3. Ski within your ability level.
4. Dress appropriately for the conditions. Hand and foot warmers can be helpful. Boot heaters, heated gloves, and heated vests are an option. Take frequent rest breaks inside to warm up, especially when skiing with children.
5. Stay hydrated, especially if you’re at altitude.
6. Apply sunscreen. Not only is the sun stronger at higher elevations but the snow reflects the sun, making you more prone to sunburn. You basically get double the dose of sun when on snow- the sun’s direct rays and those reflected off the snow. Snow can reflect up to 90% of UV radiation.
7. Wear a properly fitting helmet. If it has been crashed or there is visible damage, it should be replaced.
8. Consider a preseason conditioning program that includes cardiovascular and ski specific strength training. ACL injury prevention programs have been shown to decrease the rate of ACL injuries. 

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Event coverage is one of the best parts of a sports medicine physician’s job, in my opinion. You get front row seats to some of the most spectacular shows of athleticism. It helps if you really enjoy the sport. When I provide medical coverage for a skiing event, I watch with equal parts awe and apprehension. You never want an athlete to fall but in reality, that’s why you’re there. You have to be prepared for all weather, sometimes standing on the side of a steep and icy race course in skis boots in the bitter cold for hours at a time. You also need to be a solid skier, able to navigate the course with a heavy medical bag when attending to an injured skier. Despite this, there’s no better place to spend the (work) day.

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Exercises that emphasize strength and endurance of the thighs and hips, a long-term core and pelvic stabilization program, as well as skiing specific neuromuscular control activities are equally important when designing a preseason ski/snowboard conditioning program. Gyms and sports medicine clinics often offer group or individual programs each year in the fall. If having knee pain prior to the start of the season, consider an evaluation by a sports medicine doctor and/or physical therapist before beginning a program.

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1. Find the right helmet size. Measure your head circumference in cms by wrapping a flexible tape measure around the largest part if your head. If you’re between sizes, it’s best try on different sized helmets to find the best fit.
2. Your helmet should feel snug but not tight. It should stay put if you shake your head up and down or back and forth. Fine tuning the fit can be achieved by adjusting the restraint system integrated into the harness portion of the helmet (usually a dial at the back or other tension adjustment).
3. Next, buckle the chin strap and adjust it so that if you open your mouth widely, your helmet presses lightly into the top of your head. You should be able to snugly fit 2 fingers between the strap buckle and your chin.
4. Always ski and ride with your helmet adjusted snugly and chin strap fastened.

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To learn more about treatment options for knee osteoarthritis or knee pain associated with skiing, call (312) 238-1000 to schedule an appointment with Dr. Ehn.