1. Skiing and Snowboarding Injury Prevention and Treatment
Jeffrey Moore MD
Elisha Powell MD
Skiing and Snowboarding Injury Prevention and Treatment

2. Skiing vs Snowboarding
Different injury patterns
More upper extremity injuries in snowboarding
More lower extremity injuries in skiing
Increased rate of injuries in snowboarding, especially in beginners

3. Injury Patterns Snowboarding Skiing
Wrist injuries – Fractures, Sprains 27.6%
Concussions
Clavicle fractures
Ankle injuries
ACL injuries: 1.7%
ACL Sprains/Tears – 17.2 %
MCL / LCL Sprains
Tibia Fractures
Wrist Injuries: 2.8% of skiing injuries
Most common upper extremity skiing injury is to the thumb
American Journal of Sports Medicine, April 2012, Kim, Endres, et al

4. Clavicle Fractures

5. Snowboarding Wrist Injuries
Fractures in 56%, Sprains in 27%
Beginners at highest risk, young females with highest rate of injury
Wrist guards decreased risk of injury up to 50%
Recommend wrist guards especially in beginning snowboarders

7. Skiing Injuries Lower extremity injuries more common
Knee Ligament injuries predominate – especially ACL injuries

8. Knee Anatomy
4 Main Ligaments ACL PCL MCL LCL

9. Medial Collateral Ligament (MCL) Injuries
Injured with valgus (medial directed) force
Tender medial knee, Opening to lateral force
Grade I-III injuries
Excellent healing potential

10. MCL Treatment
Isolated Tears – Non-Operative treatment, Bracing for 3-6 weeks
Combined Ligament Instabilities - do well treating the main ligament stabilizer; allowing MCL to heal
Multi-ligament injury patterns occasionally require MCL surgical reconstruction

11. Anterior Cruciate Ligament
One of 4 main ligaments in the knee
Primary stabilizer to prevent anterior translation of tibia
Important in cutting / twisting activities

12. Anterior Cruciate Ligament Tears
Signs – swelling, “pop”
Important functional stabilizer
Partial vs Complete tear
Complete tears will not heal
Recurrent instability

13. Skiing ACL Injury Patterns
ACL injuries reviewed from videos at large Vermont ski area
Two main injury patterns determined
Phantom Foot Injury Profile
Boot Induced Injury Pattern

14. Phantom Foot Injury Profile
Uphill arm back
Skier off-balance to the rear
Hips below the knees
Uphill ski unweighted
Weight on the inside edge of the downhill ski tail
Upper body generally facing the downhill ski

15. Boot Induced ACL Injury Pattern
Skier begins jump off-balance to the rear
Downhill arm is placed up while uphill ski knee is extended
Forward energy of boot drives the lower leg forward, rupturing the ACL

16. Injury Prevention in Alpine Skiing
Maintain balance and control
Keep hips above knees
Keep arms forward

17. Responding to Dangerous Situations
Arms forward
Feet together
Hands over skis

18. Avoid High Risk Behavior
Don’t fully straighten knees when you fall Keep your knees flexed
Don’t try to get up until you’ve stopped sliding When you’re down - stay down
Don’t land on your hand Keep your arms up and forward
Don’t jump unless you know where and how to land

19. Acute Knee Injury Physical Exam
Common causes of acute (within minutes to 24 hours) knee swelling
Hallmark of ACL tears is acute knee swelling with a history of a “pop”
Fracture
Patella dislocation
PCL tears
Common causes of chronic (after 24 hours) knee swelling
Meniscus tears
MCL or LCL injury

20. Female Athletes and ACL Tears
Female athletes who participate in high-risk sports such as basketball, soccer, downhill skiing and volleyball have a two- to eightfold greater rate of ACL injury than do male athletes.
Knee abduction appears to be the predominant risk factor for ACL injury in female athletes.
Descriptive and analytic videotape reviews of female athletes with ACL injury found that these athletes were commonly injured during a deceleration maneuver, whereas male athletes were usually injured during more strenuous jumping maneuvers
Journal of American Academy of Orthopedic Surgeons, Sept 2010

21. So…What can we do about Female Athletes and ACL tears?
High intensity plyometrics coupled with balance training and strengthening improves neuromuscular feedback, which appears to reduce ligamentous strain during pivoting and landing activities”
American Journal of Sports Medicine, 2006

22. ACL Reconstruction
Surgical treatment involves replacing the ligament with a tendon graft
Newer techniques and rehab have allowed for excellent stability with these injuries

23. Most Common ACL Grafts
Hamstring (Semitendinosis / Gracillis) Autograft
- Newer graft source
- Quadrupled strands have excellent tension strength
- Concerns regarding initial fixation
- Less graft morbidity
Newer techniques involve placing tunnel on femoral side more laterally

24. ACL Rehabilitation
Progressive strengthening and rehab to allow return to sports at 6-9 months post op
Skiing puts increased stress on ACL reconstruction
Some studies have recommended post-op use of ACL brace for skiing after reconstruction to reduce retear rate

25. Skier’s Thumb Injury
Ligaments are soft tissue structures that connects bones to bones
The inside or ulnar collateral ligament of the thumb is the most commonly injured
Chance of getting a skier’s thumb is decreased by releasing your ski poles when you fall

26. “Sochi's slopestyle course questioned again after Shaun White and another snowboarder sustain injuries”

27. Common Shoulder Injuries
Shoulder Separations
(A-C Joint)
Shoulder Dislocations
Rotator Cuff Injuries
SLAP / Labral Tears

28. Shoulder Anatomy Designed for motion, little bony stability
Ligaments, capsule, labrum provide static stability
Rotator cuff muscles, tendons provide dynamic stability

29. Shoulder Separation (A-C Joint)
Direct blow on top of shoulder
Strong ligaments connecting the acromion to the clavicle disrupted (Grades I – III)
Lesser injuries (Grade I-II) have had excellent results with non-operative treatment
Initial immobilization, followed by shoulder strengthening program
Time off varies depending on the severity
Younger skiers and snowboarders may fracture their clavicle (collar bone) instead

31. Anterior Instability (Trauma)
High recurrence rate – especially in younger age group
Initial dislocation –Arthroscopic surgery vs. sling and immobilization
Often treat surgically – sometimes after the season

32. Anterior Traumatic Dislocations
90% of traumatic dislocations
High recurrence rate in younger patients 50 to 90 %
Bankart lesion (torn anterior labrum from glenoid socket) most common capsular injury
Hill-Sachs lesion (bony indention in posterior humeral head) also common

33. Arthroscopic view of Bankart (Anterior labral tear) of Shoulder

34. Arthroscopic Shoulder Stabilization
Newer techniques to fix capsule with sutures, absorbable tacks
Less tissue dissection, better visualization, quicker recovery

35. Surgical Treatment Often done Arthroscopically
Repair / tighten capsule
Long recovery, usually out of sports for at least 6 months