While many people dread the cold weather and snowfall, there are a select group of people (many of which are New Englanders) who live and breathe for fresh powder and cold temperatures. While most weekends on the mountains are fun and problem free, unfortunately many people are all too familiar with taking a tumble and finding themselves at the doctors office being assessed for a torn Anterior Cruciate Ligament (ACL).
To begin, knee injuries are certainly the most common injury seen in skiing. In fact, they comprise 30-35% of all skiing injuries. This comes to no surprise to anyone who is familiar with the cutting motion of turning and the kind of stress that the knees take when an individual lands a jump or falls. While it is more common to sustain sprains and strains that will heal in a relatively shorter period of time, medial collateral ligament damage as well as anterior cruciate ligament damage often prove to be common season-ending injuries.
Though ACL damage may occur with coexistent MCL issues, we will examine the solitary ACL injury in skiing, the treatment options and the latest data regarding outcome and prognosis.
The solitary ACL injury typically occurs when a skiier falls backwards and his or her hips subsequently drop below the affected knee. This kind of mechanism essentially drives the femur backwards and the tibia forwards and will generate a shearing force that can overcome the tensile strength of the ACL.
Though it may sound terrible, this is a less traumatic tear of the ACL when compared to the mechanism of injury seen in other sports commonly associated with ACL tears such as soccer, football, or basketball. It is actually somewhat rare to see a solitary ACL tear in one of those previously mentioned sports due to the fact that most of the injuries occur in association with pivoting movements that subsequently put strain on the collateral ligaments as well.
So what does all of this mean in terms of treatment options? Well, this is where some new data may prove to be good news for injured skiers that are hoping to avoid surgery. A recent study published by researchers at the Hospital for Special Surgery in New York City in the journal, Knee Surgery Sports Traumatology Arthroscopy examined 63 ACL cases from 2003-2008 and found that some patients (29 of the 63) who tear their ACLs while skiing may be able to get away without surgery. In fact, the study showed that at 6-12 weeks post-ACL tear, the results from the physical manipulation tests of the knee can identify those skiers who will likely recover without surgical repair.
These researchers further elaborated and recommended that “patients who tear their ACL during recreational skiing should not rush to schedule surgery right after injury. They should wait and be evaluated at six to 12 weeks unless there is some other obvious reason to do surgery like a displaced meniscal tear or other ligament injuries.”
The study was performed by Dr. Robert Marx after he realized that some of the recreational skiers that were coming to him for solitary ACL tears (diagnosed by MRI) with lachman scores (manipulation test) of 0-1 somehow displayed healed ligaments at 6-8 weeks post-injury. None of the patients complained about knee instability, and 8 of the 29 even returned to skiing without the use of a brace. Furthermore, the study showed that the average age of the patients examined was 43, which further helps solidify the importance of these findings because, often times, it is the patients that are over 40 years old whom have the most surgical complications and recovery issues because of their decreased muscle mass.
Though most would agree that it’s almost always best if we can recommend to our patients non-surgical treatment plans, it is probably even better when we can offer tips to our patients to help prevent them from getting injured in the first place. In terms of skiing, there are several tips that may prove to be helpful in preventing knee injuries:
- Ensure that you have enough physical fitness to accomplish your skiing goals – A weekend warrior may often try things that he or she probably should progressively work up to.
- Warm up – Recent studies have shown that colder muscles are more prone to injuries
- Use the appropriate gear and check your bindings often to ensure they are of the proper size and length for your height and weight.
- When you realize you’re going to fall, try not to fall backwards, but rather, try to fall to the side to prevent that shearing force on your knee.
- Keep your ankles flexed and your weight centered
- Remember if you unweight well, you will be less likely to catch an edge or loose your balance.
Well what if I’ve torn my ACL and I’m not a candidate for surgery?…What next? Well, unfortunately many times this means an early end to one’s skiing season because it typically takes 8-12 weeks for patients to heal. Furthermore, it should be noted that it would be encouraged that patients try to strengthen their knees via specific exercises to help improve the overall stability of the knee joint. The good news is that most of these patients are able to return to skiing the next season with a larger number of patients able to ski, as previously mentioned, without a knee brace.
Though it’s never fun to be injured, it’s great that more efforts are being put into being able to devise a set of criteria to help better judge those in need of surgery versus those who would benefit better from allowing one’s own body to heal on its own. Being aware of injury prevention methods and treatment options are always important in any sport. It helps athletes, parents, and coaches, alike, to be best prepared for an unfortunate event as well as to aid in expediting a recovery. With skiing being one of the biggest winter pastimes in New England and the Boston area, there is no doubt that this kind of information will be interesting and useful to someone throughout our long northeast winters. Hopefully this review not only helps to explain Skiing-specific ACL injuries, but also to help clarify the newest treatment options, prognosis and prevention tips to keep everyone’s knees safe and sound when they hit the slopes!
Happy winter to those of you who enjoy the snow! And to those of you who cannot wait until the warmer months, don’t worry they’ll come soon enough, but please remember to keep exercising and staying fit to keep away the winter blues and to keep the extra pounds off as well!
For more information about ACL injuries requiring surgery check out our own Beth Israel Deaconess Medical Center’s Site
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Hetsroni I, Delos D, Fives G, Boyle BW, Lillemoe K, Marx RG.(2012). Nonoperative treatment for anterior cruciate ligament injury in recreational alpine skiers. Knee Surgery, Sports Traumatology, Arthroscopy.
Moore KL, Agur AM. (2007). Essential Clinical Anatomy. Philadelphia, PA: Lippincott Williams & Wilkin.
Plowman, SA., Smith, DL. (2008). Exercise Physiology for Health, Fitness, and Performance. Philadelphia, PA: Lippincott Williams & Wilkin.