Ski and Snowboard Related Injuries

As the winter months and holiday season approaches, many of us begin to think about skiing or snow boarding season that lies ahead.  However, many of us do little preparation for the season which ends up setting us up for a potential for injuries.  According to Damon Petty, MD, Sports Medicine physician in Nashville, TN, “Every year, from December to March, I have 8-10 patients a month come into my office who have been injured during skiing or snowboarding”.  Many of these injuries could be avoided all together with the proper preparation and safety equipment.  Here we will discuss some of the most common ski and snow boarding related injuries and how to avoid them. 

 

Snow Skiing/Snow Boarding

Skiing and snow boarding are two of the common sports that people think of when the snow starts to fall.  Each of these sports brings its own inherent set of injuries, many of which can be avoided.  Some of the most common injuries include:

 

1. Concussion/closed head injury:  According to the National Ski Areas Association (NSAA), during the past 10 years, about 38 people have died skiing/snowboarding per year on average. During the 2004/2005 season, 45 fatalities occurred out of the 56.9 million skier/snowboarder days reported for the season. Thirty of the fatalities were skiers (39 male, 6 female) and 15 of the fatalities were snowboarders (14 male, 1 female). With the introduction of helmets, there has been an associated 50% reduction in head injuries for those wearing helmets.  However, only 35% of males, 30% of females and 66% of children currently wear a helmet while skiing or snowboarding.

2. Knee injuries:  This joint and the associated ligaments, menisci and bony structures accounts for 30-40% of all ski related injuries and ~50% of these occurring later in the day.  “The most common injury I see in my practice associated with skiing is anterior cruciate ligament tears and ruptures” says Dr. Petty, “Most of these end up as surgical patients and require 4-6 months of post-operative rehabilitation”. With the introduction of quick release bindings and carving “super sidecut” skis, there has been a dramatic reduction of injuries to this joint. 

3. Wrist fracture or injury:  With falls more common in snowboarding vs. skiing, snowboarding accounts for a higher percentage of wrist fractures.  The natural reaction in response to falls is to stretch out your hand to break the fall.  This results in a fall onto an outstretched hand or FOOSH which leads to scaphoid and colles fractures.  It is for this reason that these falls account for 100,000 wrist fractures world wide among snowboards each year.  The introduction of wrist supports has reduced these by 50% for those who wear them. 

4. Low back pain:  Although little data is reported to the incidence of low back pain, some authors report frequency of back pain among skiers was 64% in those 16-24 years of age and even higher in snow boarders.  Low back pain was more common in men than women and was highly dependent on ski style and for snow boarders dependent on level of experience (with less experienced having more associated with increased incidence of falls).  

Most skiing and snow boarding injuries are avoidable and we can do things now in order reduce our risk for those that can not be prevented with protective equipment.  Some of the preventive techniques:

 

1. Use protective equipment.  As reported in the statistics above, use of protective equipment can drastically reduce your risk for season ending or life threatening injury.  Some suggestions include:
1. Wear a helmet.  This reduces the risk for closed head injury or concussion by greater than 50%.  Whether you are snowboarding or skiing, a helmet should be an essential part of your attire.  This is especially important for children.
2. Check your bindings.  Make sure your bindings are quick release and not too stiff.  This reduces stress to the lower leg and knee when you fall.
3. Use carving skis or super side-cut skis.  This reduces stress to the meniscus and knee with cutting and maneuvering.
4. Wear wrist splints with snow boarding.  Much like the use of these with roller blading, this should be an essential part of your snowboarding attire.
2. Pre-season conditioning.  Because both of these sports are so physical, you should prepare your body for this level of physical exertion.  The fact that the frequency of falls increases as the day progresses is a direct reflection on strength and endurance.  The more strength and endurance you have, the less falls you have.  Keeping that in mind, you preseason training should include (you should be cleared by you physician prior to starting any exercise routine):
1. Cardiovascular training – should be 30- 60 minutes or greater at 60-80% of heart rate max.  Sample workout:

Workout 1: Interval training, 20 to 30 minutes
Workout 2: Medium-pace workout, 40 minutes
Workout 3: Short, intense workout, 20 minutes
Workout 4: Medium-pace workout, 45 minutes
Workout 5: Long, slow workout, 60 minutes

2. Flexibility training – should include stretching for the quadriceps, hamstrings, low back, and shoulders.  For some good stretches log onto http://www.youtube.com/watch?v=oZS6qWy1I4I
3. Strength and endurance training – should include strength training for the entire body with large focus on the lower quarter (core and legs).  As season gets closer, doing less rest time and higher repetitions brings in more of an endurance component.  For a well rounded ski specific program refer to http://exercise.about.com/library/blskiworkout.htm
4. Balance training – should include some single balance activities and dynamic balance activities.  With the introduction of the Wii Fit, there are numerous balance exercises on here that would be beneficial for skiing.
5. Plyometric training – should only be done for the more advanced training and skier.  Examples of plyometrics include:

Squat jumps
Hopping
Two legged jumps

Jumping side to side

 

3. Prepare for the day of.  All the proper equipment and pre-season conditioning aids you tremendously in preventing injury but what you do the day of can also have a huge impact on your potential for injury.
1. Get plenty of sleep the night before
2. Proper nutrition and hydration the day of.  A well rounded diet with complex carbs (granola), protein and water plays a big role in your endurance throughout the day.  Avoiding high sugary foods, alcohol and high levels of caffeine will assist in preventing from your energy “crashing” half way through the day.
3. Listen to your body.  When you are tired, rest.  Most injuries occur when you are fatigued.

Hopefully by following the suggestions above, you to can enjoy a great ski/snow boarding season without injury. 

References:

 

Eriksson, K; Nemeth, G; Erickson, E.  Low back pain in elite skiers.  Scan Jour Med and Science in Sports 2007 Jan:6(1): 31-35

 

Idzikowski JR, Janes PC, Abbott PJ. Upper extremity snowboarding injuries. Ten-year results from he Colorado Snowboard Injury Survey. Am J Sports Med. 28(6): 825-832, 2001

 

Levy AS, Hawkes AP, Hemminger LM, Knight S.  An analysis of head injuries among skiers and snowboarders.  J Trauma 2002 Oct; 53(4): 695-704.

 

Rossi MJ, Lubowitz JH, Guttmann D. The skier's knee. Arthroscopy 2003 Jan;19(1):75-84

What is the Injury Risk for Amateur Soccer Players

Injuries are an inherent part of participation in any organized sport.  Certain sports are more susceptible to injuries than others.  For example, high impact sports have a higher rate of injury than low impact sports.  Athlete’s participation in some sports also makes them more susceptible to certain kinds of injuries versus participation in other sports.  As an example example, concussions are more common in football than they are in basketball.  When looking at risk, most will rank risk based on # of injuries per # of athletic exposures (AE).  An athletic exposure is typically defined as including the number of practices and/or games an athlete participates in.  So a sport with a risk of 20 XX injuries/1,000 AE has a much higher rating than 2 XX injuries/1,000 AE.  In one such study performed in 2006, Mihata et al compared ACL injury rates in women’s basketball, lacrosse and soccer to men’s over a period of 15 years.  What they found was:

·        Women’s

o   Soccer .32 per 1000 AE

o   Basketball .28 per 1000 AE

o   Lacrosse .18 per 1000 AE

·        Men’s

o   Lacrosse .17 per 1000 AE

o   Soccer .12 per 1000 AE

o   Basketball .08 per 1000 AE

Soccer is a very physically demanding sport.  The average collegiate and professional soccer runs an average of 6 miles per game.  Soccer is also a sport which there is a fair amount of physical contact during the game.  As such, soccer is one sport that has an inherent risk of injury.  When most people think of soccer and injuries, they typically think of concussions, ankle sprains, hamstring strains and ACL injuries. According to the previously mentioned study, women soccer players are 3 times more likely to suffer an ACL injury than their male counterpart. 

With the growth of the sport of soccer in the US and abroad, it has led to a lot of focused research looking to determine the mechanisms for the majority of ACL injuries in the sport and what is the injury rate amongst recreational players so that we can develop better intervention strategies.  With over 265 million players worldwide, when considering the previously published risk ratings, conservatively, this could equate to potentially 5.3 million ACL injuries a year.  Knowing the increased risk for a 2^nd ACL injury and risk for OA 12 years later, it is important for this kind of research so that we develop strategies that effectively reduce the risk of the 1^st ACL injury.  In an article published online before print in the American Journal of Sports Medicine, Herrero et al did just that in a study entitled “Injuries Among Spanish Male Amateur Soccer Players: A Retrospective Population Study”. 

Methods:  In this study the authors performed a retrospective epidemiological study of injuries sustained in Spanish amateur soccer during the 2010-2011 season.  During this time, any injuries that were recorded for the 134,570 soccer players ages 18-55 years old that were registered with the Spanish Football Federation were reported.  Using standardized FIFA medical questionnaire, injuries were classified according to the type, severity, location and treatment that was provided.

Results:  A total of 15,243 injuries were recorded during this time.  This resulted in an average of .11  injuries per player per year.  From this total, 67.2% resulted in time lost and 32.7% required medical attention.  Rate of injuries per 1000 hours of play was double during games (1.15/1000 hours) compared with injuries during training (.49/1000 hours).  Of the injuries that were recorded, 7.7% were goalkeepers, 24.2% were forwards, 33.8% were defenders and 34.3% were midfielders.  The majority of injuries occurred in the knee (29.9% of all injuries) and ankle (12.4% of all injuries).  32.1% of all injuries were ligament sprains or ruptures. 

Discussion:  Reviewing studies like this provide us with some valuable information.  Information which we can take onto the field and, if used correctly, have a potentially significant impact on injuries in the sport.  However, one must critically analyze the data to make comparison to use in the US.  First is the culture.  Soccer in many countries is more than a sport, it is a way of life.  As such, children often get involved in the sport much younger in countries (such as Spain) than they do in the US.  Earlier involvement in the sport leads to improved skill acquisition, training, conditioning and would theoretically lead to lower injury rates. 

That being said, the information gained should not be lost.  Knowing that 32% of injuries were ligamentous in origin and that 30% of injuries were to the knee, we can use this in our program development.  We know that if you improve the mechanics associated with ACL injuries, you also reduce the risk for other lower kinetic chain injuries by as much as 60%.  Therefore an intervention designed to do just that will aid tremendously in reducing all lower kinetic chain injuries which accounts for ~40% of all the recorded injuries noted in this study.  We also know if we could individualize our program to group by position, defenders, forwards and midfielders.  Doing so, may assist in addressing some common deviations noted by position and target specific injuries by position.  Using in this fashion should assist in reducing overall injury rates across the entire team and if widely implemented across the sport of soccer.

References:

Mihata L, Beutler A, Boden B.  Comparing the Incidence of Anterior Cruciate Ligament Injury in Collegiate LaCrosse, Soccer and Basketball Players: Implications of ACL Mechanism and Prevention.  Am J Sport Med.  34:899-904. 2006

Herrero H, Salinero J, Del Coso J.  Injuries Among Spanish Male Amateur Soccer Players: A Retrospective Population Study.  Am J Sport Med.  Published online before print Oct. 17, 2013.

Does Excessive Lateral Trunk Lean Lead to Injury in Baseball

The impact of lateral trunk lean in an athlete, whether basketball player, football player or soccer player has often been speculated to have an impact on injuries.  There has been some recent data that even suggests there is also an impact on overall athletic performance.  The impact that lateral trunk lean has on injuries and performance have most often associated to the running and jumping sports (basketball, football, soccer).  That is, until now.  In the October issue of The American Journal of Sports Medicine, Oyama et al published a paper entitled “Effect of Excessive Contralateral Trunk Tilt on Pitching Biomechanics and Performance in High School Baseball Pitchers”.

Before we get into the specifics of the paper, we should first define contralateral trunk lean.  Some authors will define it as contralateral trunk lean and some as retro-trendelenburg.  For the purposes of this paper, those two terms are synonymous with one another.  Diagram A demonstrates how the authors define it in this study as it appears during the throwing cycle.  The ideal position is to “keep the head balanced over the stride foot” at maximal shoulder external rotation.  When the head is not balanced over the stride foot (as in this picture here), valgus stress at the elbow is increased.  This lateral trunk lean “not keeping head balanced over stride foot” was shown by Fleisig et al in 2006 to increase valgus load to the medial elbow.  It is this increase in valgus stress that leads to medial elbow pain and puts the athlete at risk for ulnar collateral ligament (UCL) injury.  The purpose of this study was to see if this could be observed on 2D video and  whether or not this movement resulted in greater loading to the joint and slower ball speed.

Methods:  In this study, 72 high school baseball pitchers 3-dimensional pitching biomechanics, ball speed and frontal view pitching technique was captured with both 2D cameras as well as a 3D vicon system.  Each pitcher was fitted with reflective markers and performed 5 to 10 submaximal pitches.  After warm up, each was asked to pitch as fast and as accurate as possible at an X in the strike zone. It was considered a strike if they hit the strike zone.  Each pitcher pitched until 5 qualifying pitches and minimum of 3 strike pitches were captured.  For each pitch, kinematic and kinetic data, videos and ball speed were all captured.  The point of maximal shoulder external rotation was identified and at that point, the amount of contralateral trunk lean was also identified. 

Results:  Pitchers who demonstrated excessive contralateral trunk lean pitched with a higher ball speed than those who did not (32.6 m/sec or 72.9 mph vs. 31.1 m/sec or 69.6 mph).  Those with excessive trunk lean also experienced greater proximal elbow force (103.9 N or 23.4 lbs vs. 93.2 N or 20.9 lbs) and proximal shoulder force (104.8 N or 23.6 lbs vs. 94.3 N or 21.2 lbs). There were also greater loads noted at ball release with an increase in valgus loading at the elbow and an increased shoulder internal rotation moment. 

Discussion:

Although this excessive lateral trunk lean was associated with increases in velocity, there was also an increase in loading at the shoulder and elbow.  Although, upon initial review, these load variances might not seem that significant, a 2-4 lb load increase to the shoulder and elbow joint, when done repetitively over time can lead to shoulder injuries (labral tears, rotator cuff tears, etc.) or elbow injuries (UCL tears, elbow pain, etc.). 

Although this study showed some positive performance gains (3 mph) with this altered position, there could be other factors fitting into that.  Some factors to consider are the average time of play for those who had increased speed, height and age of the players.  When looking at these factors, there is not much variance between those with trunk lean and those without.  Two other factors not mentioned in this study was if there was a previous report of injury or pain in those with trunk lean and those without and training (specifically coaching on pitching technique) amongst the two groups. 

So the question becomes, do you correct the technique at the expense of velocity.  This could and would be a hotly contested debate between clinical call (yes to decrease risk of injury) and coaching call (no as performance would suffer).  Whether right or wrong, when making that decision one must consider:

• Increased stress to the elbow and shoulder increases risk for shoulder and elbow pathology.  Injury will shorten career and have a much larger impact on long term performance.
• Lateral trunk lean or retro-trendelenburg (demonstrated above) has also been shown to increase stress to the lumbopelvic region (highlighted) and increase risk for knee pathology.
• Lateral trunk lean or retro-trendelenburg at the hip in single leg stance is commonly associated with gluteus medius and core weakness.  Improvement in strength and endurance in these areas has been shown to have a direct impact on transfer of kinetic energy. 

Considering the above, if addressed both from a coaching perspective (improving the throwing biomechanics) and addressing the strength/proprioceptive deficits, then one should see improvements in both performance as well as decreased loading to the shoulder and elbow (hence reduce risk for injury).  That considered, then core and hip strengthening could be and should be a critical component of pre-season and in season training for pitchers.

Reference:

Oyama S, Bing Y, Blackburn T, Padua D, Li L, Myers J.  Effect of Excessive Contralateral Trunk Tilt on Pitching Biomechanics and Performance in High School Baseball Pitchers.  Am J Sport Med.  41:2430-2438. 2013