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Dr. Mandelbaum Discusses with Medscape Orthopedics How Patients Can Ski Safely This Winter


Help Your Patients Ski Safely This Winter

Reducing Skiing Injuries

On a winter day at the Snowbird ski resort in Utah a dozen years ago, I paused on my skis to watch my 6-year-old taking a lesson. I didn't notice the snowboarder hurdling out of control on the hill above me.

By then, I had already taken a keen interest in injury prevention in skiing. And I was already coaching others in proper technique, fitness, acclimatization, and equipment.

In fact, concepts that I later helped integrate into the Fédération Internationale de Football Association 11+ (FIFA 11+) soccer injury program started with a skiing program.

In the 1970s, orthopedic surgeons Robert Johnson, MD, and Carl Ettinger, MD, at the University of Vermont, and engineering professor Jasper Shealy, PhD, at the Rochester Institute of Technology, started researching anterior cruciate ligament (ACL) injuries in snow sports.[1]

They realized that a large proportion of ACL tears occurred when the tail of the downhill ski, in combination with the stiff back of the ski boot, act as a lever to apply both twisting and bending loads to the knee—a phenomenon known as the "phantom foot." This is particularly likely to happen when the skier was off-balance to the rear, with hips below knees, the uphill ski unweighted, weight on the inside edge of the downhill ski, and the upper body facing downhill.[1]

They discovered that they could significantly reduce this type of injury if they coached skiers to keep their hips above their knees, feet together, and arms forward. The researchers' phantom-foot videos explaining these principles proved highly successful.[1]

Innovations such as this, as well as better bindings, have decreased the rate of injury in skiing and snowboarding. The rate of serious injury is now about 1 per million skier/snowboarder visits, a decline of 50% since the 1970s, according to the National Ski Areas Association (NSAA).[2]

Preparing to Ski Safely

The success of the phantom-foot program inspired me to carefully study patterns of injury in other sports and develop injury prevention techniques based on them. But it also taught me how to be a more careful skier.

Thirty inches of snow had fallen the day before I stood watching my daughter on the bunny slopes. I'd been skiing steep and deep but keeping these principles in mind to avoid a knee injury.

I was in good shape as well. I teach skiers and snowboarders to prepare for the slopes with a series of neuromuscular exercises.

Such a routine might include:

  • A running mash-up—run forward, backward, left, and right for 15 seconds each;
  • Standing hip rotations—raise your knee and rotate to the side and back again;
  • Planks—hold 15 minutes on facing down, then on each side and finally facing up;
  • Good mornings—hold a small kettlebell behind your head and bend forward at the waist;
  • One-legged dead lift to row—standing on one leg, bend at the waist until your torso is parallel to the ground, then slowly raise a kettlebell to one side and then the other;
  • Kettlebell overhead clock lunges—hold a lightweight kettlebell overhead in your left hand, elbow locked; then lunge forward on your right leg; press through your heel to return to standing; then lunge to the right, gradually working your way around the clock from 12 o'clock down to 9 o'clock, with backward lunges for 8, 7, and 6 o'clock; rest and repeat with the right arm holding the kettle bell;
  • Goblet squats—holding a kettlebell at the chest, squat down, pushing your hips back and as low as possible with your chest up and back flat; push through your heels to stand, rise onto your toes, hold for three beats, then lower back down, holding for three full beats, and repeat; and
  • Moving tuck jumps—stand with your knees soft, arms at your sides; jump up and forward as high as possible, bringing your knees toward your chest, to land a couple of feet in front of where you started; then jump and tuck backward to the right and to the left.

Twelve repetitions is a good goal for these exercises, but depending on their fitness level, your patients might want to start with fewer repetitions and work their way up.

The Importance of Acclimatization

Acclimatization helps a lot in snow sports. Most people live at or near sea level. When we travel up to a ski resort at 6800 to 12,000 feet, fatigue becomes really important. At the high end of this range, it can take up to 3 weeks to completely acclimatize and produce more 2,3-diphosphoglyceric acid to compensate for the lower levels of oxygen in the atmosphere.

Most people don't have that much time for a ski trip. So I recommend taking it easy. I tell my patients to ski only until lunch the first day, then knock off for the rest of the day to go snowshoeing or for a bike ride. It can be hard to resist trying to squeeze all their money's worth out of an expensive lift ticket and a long trip to the mountains, but pushing too hard on the first day can set patients up for an injury that will end their entire ski trip.

Remember that skiing is a physically demanding sport. Think of how seldom most people exercise for more than 4 hours at a time. Unless they are distance runners or cyclists, your patients probably work out for only an hour at a time or less.

Dress for Success

The next item on the injury prevention checklist is proper equipment. Advise patients to get boots, helmet, and bindings that are snug but not too tight. The NSAA's Lids on Kids website[3] offers good information on helmets for children. I recommend having the skis themselves inspected from time to time. Skis move over abrasive snow, get dinged on rocks and stumps, and are exposed to the elements. They require regular maintenance.

Dressing in layers, wearing sunscreen, and staying hydrated will help avoid potential skiing hazards as well.

The NSAA's 'Heads Up!' Campaign

A final piece to skiing safety: constant awareness of the hazards around you. A snow-covered mountain is a dangerous environment, with rocks and trees and patches of ice. Some hazards are marked; some are not. Falling snow can turn everything so white that you can't see your hands in front of you.

In its Heads Up! campaign,[2] the NSAA recommends the following principles:

  • Always stay in control;
  • People ahead of you have the right of way;
  • Stop in a safe place for you and others;
  • Whenever starting downhill or merging, look uphill and yield;
  • Use retention devices—brakes and leashes—to help prevent runaway equipment that can harm others on the slopes;
  • Observe signs and warnings, and keep off closed trails; and
  • Know how to use the lifts safely.

I might add that it's important to keep an eye out for what's coming down hill, even when you feel like you've stopped in a safe place.

I certainly thought I had gotten out of the way. It was 3 PM that day at Snowbird. I was standing with my poles behind me, and I never saw the snowboarder coming. He must have been 6'3" and weighed maybe 240 pounds. The impact threw me to the ground. My whole left leg was on fire. I immediately knew a disc was avulsed. I remember thinking, "So this is what an L5 injury feels like."

I somehow made my way off the slope, but I knew already that I was headed for surgery. It took me about a year to a year and a half to get back to 100%. I had to give up running after that, becoming a bicyclist instead.

But I'm back on the slopes these days, always looking over my shoulder.


1.Vermont Ski Safety. Tips for knee-friendly skiing: a program to help reduce the risk of serious knee injuries among alpine skiers. 2010. Accessed November 16, 2016.

2.National Ski Areas Association (NSAA). NSAA fact sheet: facts about skiing/snowboarding safety. October 1, 2012. Accessed November 16, 2016. Accessed November 16, 2016.

Medscape Orthopedics © 2016 WebMD, LLC

Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this article: Help Your Patients Ski Safely This Winter. Medscape. Nov 30, 2016.

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