‘Rehabilitation of common skiing-related Knee injuries.’
Andrew Gilsenan-Kavanagh

Let’s talk about these most common injuries, as we as we discussed the MCL or the medial collateral ligament this is the most common injury so a sprain or a tear in this ligament. The Anterior Cruciate Ligament is the next most common and again we can have sprains which is a more minor injury or a tear, complete rupture and then we also have meniscal injuries which are the shock absorbers in the knee that can be injured from skiing related falls.

Medial collateral ligament injury, as discussed earlier this is the most common injured ligament in the knee while skiing. A typical injury from this can result from a blow from upslope on the outside of the knee. We can see here in the diagram there’s a direction of force coming from the outside of the knee which is pushing the knee inwards. In turn, this will stress the ligament or strap-like ligament along the inside of the knee which can cause either a sprain which is a stretch or a tear, complete rupture which is when the ligament is severed. Following an injury like this we can have some perhaps delayed swelling, immediate pain depending on the severity of the injury and a sense that the knee is unstable or inability to weight bear through the knee.

The second ligamentous injury then is the Anterior Cruciate Ligament. This injury typically is a more forceful injury when we have some rotation of the knee with ski getting caught perhaps landing awkwardly from a jump. Typically, with a complete tear of the Anterior Cruciate Ligament we will hear either a pop or a snap and we will have some immediate pain and immediate swelling with this. Again, inability to weight bear can be a sign of a higher-grade injury.

Finally, we have our meniscal tear injury, in this diagram we can see a picture of the meniscus from a frontal view of the knee. We can see this is the shock absorber that’s sandwiched between the big bones in the knee and on the right-hand side of the screen we can see a tear in the meniscus. These injuries can typically occur from some sort of rotational based injury so this can be an awkward fall, it can be a ski getting caught or it can be from a trauma from an upslope collision. Some of the tell-tale signs of these type of injuries are symptoms that disappear as we straighten out the knee and that reappear as we bend the knee. This is as we compress that shock absorber when the two bones come together.

Now we’ll move on to factors that lead to knee injuries. Level of ability, skiing at a level that is too fast or too steep for our ability can inevitably cause injuries. Another point is incorrect ill-fitting or damaged ski equipment perhaps boots that are too loose, ski bindings that are not adjusted to our weight and come off while we’re skiing at speed can all cause injuries. Our fitness levels and strength levels and we will touch on our strength levels as we move on through this presentation. As with any sport taking too many risks and ski conditions can have a big part to play when we talk about skiing injuries.

Now we’ll move on to reducing the risk of sustaining a potential injury. We touched on strength in a previous slide and now we’re going to look at some targets and some things that perhaps you at home can aim for to see how strong is strong enough. For our front squat we’re looking for 50 to 75 percent of our body weight and we can see that the bottom corner of our picture here. Wall sits, again we will see them later on in the presentation we’re looking for four sets of a one-minute hold and leg press we’re looking for 1.2 to twice our body weight. For our posterior chain then for our big bum muscles and hamstrings we’re looking at our deadlift which we’re looking for at least a body weight lift on this. Our hip thrusts, again this should be our strongest exercise so we should be aiming for one to 1.5 times body weight on this exercise. Then if we talk about our upper body so a consecutive round of 10 to 12 push-ups can be a measure used here. One to three pull-ups or a single arm row, where we’re pulling at least 30 to 40 percent of our body weight. Now these are quite general targets which can be used in the general population as we progress into maybe more athletic or more elite. Key themes, we’re looking for higher levels of strength.

Now we move on to our initial injury management. If we’re unlucky enough to pick up an injury like this what should we do? In the first instance we need to stop skiing, we need to use the police method for swelling management. Some of you at home may be familiar with this method previously known as the rice method. We’ll talk through it now so protection is the first thing so again we want to remove ourselves and rest ourselves up so let’s take a break from the slopes. Optimal loading, so this is more our rehab-based stuff which we’ll talk about later in the presentation. Ice, compression and elevation. These are going to be our big three to try and manage that swelling and manage that pain early on. Again, we reassess this after 24 hours initial swelling and pain should start to subside pretty significantly if we’re using this method after 24 hours. However, if we’re struggling to get the pain and swelling under control it’s a good idea to seek some medical professional in the locality of the ski resort.

What are the urgent signs and what are the non-urgent signs that we need to see our physiotherapists?

Again, that pain and swelling that persistent high levels of pain and swelling which hasn’t subsided, inability to weight bear particularly a day or two after the injury and a knee locked in a certain position. We discussed earlier with the meniscal tears when we’re straightening and bending our knee sometimes those symptoms can reappear and then sometimes they can subside so particularly with our meniscal injury sometimes the knee can get locked in a certain position and we can struggle to straighten or bend this. Some of the non-urgent signs if we’re struggling to get back to full function, so we just feel like this injury is lingering we’re able to manage on a daily basis but perhaps we can’t get back to more higher-level tasks. Unable to regain full movement in the knee so perhaps we’re struggling to fully straighten out the knee or fully bend the knee, and a decrease in strength and endurance.

Let’s move on to some rehabilitation or rehab ideas for some of these most more common injuries. Here in the Sports Surgery Clinic we use a six-step approach so we move from our diagnosis and assessment so if you come in first from from a ski injury or from a ski holiday first of all we want to get a diagnosis and get a good assessment and then we can build our program on top of that. Step two then we want to get our mobility back, we want to be able to bend and straighten our knee fully, get full control in our quad and optimize our strength back to normal levels. Thirdly, then once we have our strength in order we want to build on top of our power and our reactive strength particularly some people who are maybe going back to high level sport or back to high level skiing. Then we bring in our linear running and our multi-directional running and then we’re back into sports specific and fatigue ability and this is the end stage before we go back to performance.

Now we’re going to move on to some rehab ideas and some rehab exercises for the more common knee injuries. Here you can see my colleague Vanessa who’s performing a wall sit exercise so we’re going to start off with a double leg wall sit, 90-degree position at our knees back flat against the wall or even to hold this position for 20 seconds by four sets. Progression of this can be moving on to one leg and holding for the same amount of time. Next, we have a leg extension exercise. We can see Vanessa here doing a single leg, leg extension which could be completed in a normal gym. We’re straightening out the leg keeping the toe pulled up towards the sky. All the way up and slowly back down, so slow and controlled with this motion again aiming for somewhere between three sets of eight and three sets of ten. Here we have our pistol squat exercise so we can do this in a gym or using a banister at home something that we can hold on to having a chair behind us around knee height. We’re going to slowly lower ourselves down on to the chair and then come slowly back up the key to this is that our knee doesn’t drive out over our toes or we’re trying to maintain our knee in the same position and finally we’re going to move on to our crab band exercise so the previous three exercises we focused on the quad muscle along the front of the leg. Again, after knee injuries our quad muscle is the most affected muscle so inevitably we’re going to be decreasing our strength in this muscle so it’s vitally important that we work hard to build that strength up to the same strength as the other side. Another important muscle following an injury like this is our lateral hip muscle along the side of our bone. Here we can see Vanessa performing a crab band exercise so we have our feet hip distance apart we have a black band just above the knees we’re going to sit back into this. We’re trying to keep our feet flat along the floor and we’re going to push our knees apart hold for three seconds and come back to the start position. Again, this can be done in a gym or it can be done at home using a banister or a door frame so. These are the main exercises that I would focus on post injury after skiing but also these can be used as prehabilitation or before we go skiing to build up the muscles around the side and hip and the muscles around the leg.

That concludes today’s presentation on knee injuries and skiing, feel free to ask any questions.

 I have osteoarthritis in both knees would that prevent me from taking up skiing and are there exercises I can do to prepare for that? Are there things that can help you?

Yeah, some of the videos that we touched on in the presentation focused around quad strength of lateral hip strengthening the stronger we are in these areas the more pressure we’ll take off the knee and the easier skiing is going to be for us. I suppose age will come into this, the age of the of the patient who’s skiing or the person who’s skiing and the level that they want to get back to so obviously the more intense or the higher level skiing the harder it’s going to be if there’s a high level of arthritis, if there’s a lot of arthritis in the knee. As an off the bat answer. I’d say absolutely not you can certainly ski with arthritis in the knee.

Should you avoid skiing totally with arthritis?

No, I think you know within moderation as well I think you have to look at the period of time you are going to ski for. It’s a fairly active exercise puts a lot of pressure on the front of the knee so one would try to be a bit judicious how long you spend on the slopes and perhaps have a few anti-inflammatories ready with you on your trip just in case you do get a bit sore. I went skiing a couple of weeks ago my mother who has some arthritis in her knees and I was chasing her down the slope so I don’t think it’s a contraindication whatsoever.

Due to wear and tear I had a full knee replacement 12 months ago should I be expected to be able to ski?

I think it depends on what level you’re skiing at and how much you want to ski and the degree of difficulty with the slopes but certainly there’s no reason why someone can’t go back to skiing following a knee replacement. I think once again you want to maintain your level of fitness and the same muscle groups the quadriceps, your gluteal muscles, you need to be fit and active to be able to do so and I would suggest if one is going back that they don’t go on a black slope to begin with and start relatively easily and just have reasonable expectations but Andrew might want to offer some other advice from a physiotherapy perspective.

I think a lot of that comes down you know we see a lot of patients post-operatively here from a rehab point of view having had a knee replacement with Brian or some of his colleagues and I think it comes down to the level of rehab and what they want to get back to so what the patient puts into it they  get out of it. The higher the level they want to get into it the more intense rehab is going to be involved but as Brian says, I think it’s certainly achievable but just having your goals and ambitions in line.

What is the usual time for returning to sport after an ACL injury or tear, and skiing as well?

I think we’ve probably changed our outlook on that over the last number of years because we recognise that the most vulnerable time for someone to re-injure is within the first year after ACL reconstruction, so we tended to push back the time a little bit in terms of they’re looking at anywhere between nine months and twelve months typically now. We’re a little bit more objective about that as well I think that the advantage within the sports medicine department is we do ACL testing so we look at an individual’s strengths compared to their other leg and also look at their ability to perform tasks. Andrew or his colleagues would do a full battery of tests to see how someone is coping after an ACL reconstruction but typically it’s in the region of around 9 to 12 months. We love to return to sport all going well.

Someone had ACL surgery actually just in October. They started a hematoma at the time as well, which is bleeding into the leg and the consultant has given them the all clear but they wanted to know would they be fit to go by the end of March?

I don’t know, I think that’s a little bit too soon from my perspective but you’d have to assess the individual but I’d be a little bit concerned to go in March I think perhaps next year or go to the southern hemisphere to ski in late June or July elsewhere but I think that’s a little bit premature personally.

Someone fully tore their ACL almost fully to her MCL she has bone bruising and a small fracture. How soon should you see a consultant? She’s in a brace and it happened on the 2nd of January.

From my perspective, I think a reasonably accused consultation, so within the next couple of weeks I think would be appropriate but more importantly as well I think that you need to get to see a physiotherapist to get moving that leg. I think one of the fears we have once someone’s had an injury of that nature is that they don’t move and get stiff and that’s a really important. Maybe Andrew could give his opinion regarding the effective rate of the importance of range of motion pre-operatively.

We see a lot of these what we call pre-op ACLS and the first thing they come in is crutches. Perhaps in a brace you know very fearful of moving, very fearful of putting weight through their knee. If a patient moving like that was to go straight for surgery I think that they’d be in a little bit of trouble so what we want to do is reassure the patient that we want to get the knee moving, bending and straightening within normal ranges. We want to get the the quad muscle on the front of the leg working adequately and then get them into surgery so it’s kind of a case of the better condition they are going into the surgery with yourself Brian the better condition they are going to be coming out of it. I think that’s quite an important factor as well particularly with the ACLS and the younger athletes who are more fearful.

Hoping to ski regularly twice a year but have ACL damage in both knees not ski related. One has been repaired with a graft and the other one hasn’t had surgery to it just rehab about five years ago. Any advice, this is for Andrew, on strengthening exercises or preventative measures example supports to help prep while skiing.

I think as a general answer to this question there absolutely is and when we’re talking about general strengthening advice for ACLS a lot of it is going to come centered around the gluteal muscles and the quadricep muscles. It’s going to come from a strength point of view and also from a control point of view so how well can we control that muscle as we’re moving. Perhaps in a single leg squat motion something of that nature but for something like that it’s very hard to give individual advice on a query like that. Ideally we’d like to perform some sort of testing so we can have some kind of objective data to fall back on and then give them more of a concrete answer on that.

Someone’s just said I think probably from watching your videos, would the band crab exercise irritate the meniscus or the menisci?

No, it depends on what the degree of meniscal injury is. If it’s what we call a displaced meniscal tear, maybe where a piece of the meniscus has come out and is causing irritation in the knee something where the knee is perhaps locking that may be something that might have to be surgically excised or just removed but other than that the exercise can be adapted so that we wouldn’t irritate the meniscus.

Someone’s asking us does skiing increase their like likelihood of developing osteoarthritis?

I’m not aware of any studies that have shown it. I think if you rupture your ACL unfortunately the risk of developing arthritis is greater and skiing is a high risk sport for ACL injury. Typically skiing you’re downhill you know you’re just a bending motion within your knee normally if you ski well. Unless you get injured I wouldn’t think it would increase it significantly but if you’re injured perhaps it does.

I sustained a tibials fracture in my left knee no displacement on Christmas Day in France home last week and have been referred to a local hospital for the Fracture Clinic that hasn’t been seen yet. I’m still in a knee brace and on crutches when should I start Physio and be fit to return to skiing?

The important part of that last question is when they should start physio and I would say immediately. I think that the likelihood is this brace may not be a brace that moves and that can be problematic given that it’s almost four weeks now and since the injury so I’d certainly see a physiotherapist and likely get to see an orthopaedic surgeon reasonably soon to get moving. I would hesitate to answer the last part of that question without assessing the patients.

I tore my ACL skiing two weeks ago but waiting on an MRI result before seeing a consultant do you recommend the physio demonstrated in the video to do at this stage?

This is what fall into the category of a pre-operative physiotherapy for ACL. The exercises and the muscle groups that were working in the videos would absolutely be appropriate but it’s just the dosage is really important and that’s why it’s kind of important to see a physio maybe to get a tailored program to make sure that the exercise is at the correct level for the patient so some of those exercises particularly a single leg wall sit would be at too high of a level for a patient who’s perhaps just rupturing ratio today might be a little bit more advanced for for for someone who just ruptured their ACL.

I currently have no knee problems but I am over 50 is it wise to wear knee braces or straps to prevent injury?

I don’t think there are any proven knee straps that will prevent injuries while skiing I think that sometimes you know if someone has a sense of instability that they can get some feedback from straps Etc but my advice would be to follow a good prehab or prehabilitation program prior to going skiing so you know that your muscles are activating well and you have a general level of fitness I think that’ll be more important than any brace personally.

Someone is 15 months post total hip replacement they worked hard on fitness but still strength deficit is skiing safe even on blue slopes?

I would be a little bit concerned with the strength deficit. If an individual can’t walk properly and it’s noticeable that they have a limp or some type of altered gaze then I would be cautious about skiing in that scenario. If if they improve on their strength or they adjust their strength deficits you know there’s no reason that person couldn’t ski and they’d want to be able to kind of move or perform you know reasonably good twisting exercises prior to considering it and blue slopes are probably one of the more dangerous slopes, they tend to run into the village and where lots of people are coming so it might not be the easiest one to go for.