Skiing and Snowboarding Injury Prevention and Treatment

1. Jeffrey Moore MD Elisha Powell MD Skiing and SnowboardingInjury 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