‘Beware of the slippery slope & management of common Knee problems when skiing.’
Professor Brian M Devitt

Good evening ladies and gentlemen. I’m going to speak this evening on common knee problems when skiing.  The title of my presentation is ‘Beware the slippery slope’ My name is Brian Devitt. I’m a Professor of Orthopaedics at Dublin City University and I’m a consultant Orthopaedic surgeon at the Sports Surgery Clinic.

This is a common scenario when we’re skiing if your friends are like those who need enemies! I’m just going to replay this video clip in slow motion and you just see how a common Knee injury can occur, so he’s going through it in very deep snow, and he has slipped back, and that crack you here is not a ski coming off but his ACL rupturing. Unfortunately, knees and skis injuries are very common. I did one of my fellowships in Vale Colorado which is a ski resort and it’s essentially a conveyor belt for knee injuries and one of the forefathers of ski treatments in terms of knee injuries is this gentleman called Dr Richard Stedman and he told me when I was there that ‘if you were to design a device to rupture the ACL you couldn’t get much better than a ski’, now skiing is good for business in ACL surgery and that’s why they have a big hospital at the foot of the ski hills and the reason it’s good is that skiing has become hugely popular it used to be just a sport for the wealthy but now most people have access at least can go skiing once in their lives but many people go a couple of times a season but it’s a risky sport we look here at some of the statistics of which joints get injured you see that the upper limb happens in seventeen percent of cases you get forearm and hand injury in seven percent of cases you can get some neck or back pain less commonly but then you get an awful lot of knee injuries which represents up to 35 percent of injuries and these relate to the ski and the devices that the equipment you use for skis.

If you think back to the olden days when people used to strap themselves in their boots to two wooden flanks and go down a mountain, things have advanced quite a lot with respect to knee injuries and equipment and skiing equipment. We have boots that are fixed and the boot allows a little movement at the ankle but it’s fixed to the ski, and unfortunately, when the ankle is fixed that all the rotation occurs around the knee, and that’s where you get a lot of injuries the skis themselves have improved and you look at the binding of the ski and this allows the boot to come out so when you’re going to a ski shop to get fitted for skis they’ll often ask you your level of expertise being novice, advanced or expert and really what they’re doing in this scenario is they’re tightening your boot or the dim they call it to the extent to which you have to move or pivot for your boots to come out of your skis. So expert skiers have their boots fixed into the skis, and therefore, if there’s any twisting, it goes through the knee and the boot doesn’t come out, so if you’re any way apprehensive when you’re going to get your skis fitted ask them to keep the din low so your boots can come out of the skis and not your ACL rupturing in your knee.

We also recognize that terrain and the conditions are very important for knee injuries, and obviously, steeper slopes or heavier snow or slushier snow can develop injuries we also know that the après ski is quite popular, and it’s when you can combine alcohol with risky behaviour that you can get unpredictable behaviour and this is often very common in ski resorts and is a major source of ski injuries so when we look at the specific type of mechanisms and these are often Involuntary and particularly when you’re starting you can’t stop it well you very much see that the person leaning back under skis the skis off balance your hips are below your knees or your uphill ski is on weighted and these put an increased torque or twist through your knee which can cause some injuries so the key issue in terms of avoiding injuries is getting lessons and sticking to your ability level so that you can decrease the risk of twisting your knee if you’re on a slope that you’re not experienced or able to manage.

We also know the unpredictable behaviour with drinking and that can be a huge factor, as I’ve previously mentioned and we also realize there’s no legislation for stupidity, so you can’t prevent those types of injuries, unfortunately, so when you’re on the mountain what can you do well we use the phrase in medicine ‘primum non nocere’ first do no harm so be careful don’t try to hurt yourself stay in your lane don’t ski beyond your level of expertise which is really critical and oftentimes it’s a husband or a boyfriend bringing their partner up on the slope that they’re not able for so do stick to your level of ability because it’s really important.

Beware of the hazards when you’re on a slope. There are lots of people on the slope you need to slow down the uphill skier is responsible for avoiding the downhill skier, so it’s really important that you are aware of your surroundings and those people who are surrounding you, and sometimes, it’s not just on the slopes, it’s getting to the bottom of the slopes where injuries can occur and I think that was more of a head injury rather than a knee injury but equally someone is going too fast and not being aware of their the hazards in their environment so return to your comfort zone it’s often best when you’re starting off, particularly in a week’s worth of skiing that you start easier get your ‘ski legs’ as we refer to it as opposed to going right up the top of the mountain on the black slopes.

When we’re in the clinic, unfortunately, when people injure themselves, they may need to be taken down from the mountain by the ski rescue and they’re often reviewed in one of the ski clinics at the bottom but when you’re in the clinic as we assess people we normally aren’t doing it on the mountain that we have the cold light of day which allows us to assess things more appropriately so this is an article I really feel is very effective in terms of how to manage someone with a knee but it was written in 1964 by a gentleman called Professor Appley and it’s referred to ‘Intelligent Kneemanship’ so I’m going to give you some of the hints and tips that we as surgeons utilise when we’re assessing someone who’s injured their knee following an injury. First, We Take a History, so “To listen is to learn… we all pay lip service to a careful history, but how many of us are patient enough to elicit one?” so this is the real key when you’re taking a history you want to figure out what happened to the person on the slopes so typically they involve a twisting injury where they may hear a pop as we saw in the video earlier on we ask for the patient or could the individuals ski down the mountain typically if you can ski down the mountain the injury may not be too severe but if you’re taking off the mountain it likely is we also want to recognize did the knee swell up within 12 hours of the injury and that would give us a good idea that normally if you have swelling, it relates to bleeding and if you have a knee that’s bleeding it typically indicates an ACL injury or something and quite severe within the knee.

We perform a clinical examination so this is really important you do this appropriately and this is another quote from this article “to look at one at only one knee is absurd man is biped – and how considerate of nature to provide a normal for comparison. But nature did not provide trousers and these must be removed.” so you often come to a clinic and I insist the patients to wear shorts so I can see both legs we can compare the good side with the bad side it makes for a much more accurate clinical examination we then have to recognize the surface anatomy around the knee so we go on a systematic approach to assess the ligaments at the side of the knee and also the ligands in the middle of the knee through our clinical examination you can see very clearly looking at this lady’s knee that she has an injury to the right knee which is extremely swollen but if you look more careful you’ll see that she also had a previous injury to the left knee but this is typically what you see following an injury you see a big swollen knee which is difficult to bend and quite stiff in terms of further investigations when someone comes to the clinic we would always get an x-ray the x-rays can be very helpful I’m going to show you on this x-ray where you see there’s a little flake of bone just on the outside of the knee which indicates that person has torn their ACL more commonly however we get MRI scans and these are hugely important in terms of looking for knee injuries we see this area of whiteness within the bone and this indicates a bone bruise so there’s two areas of bone bruising one on the femur here in the middle and another one at the back on the outside so if you imagine at the time of that injury this part of the bone and the femur was in touch with that part of the bone on the tibia so for that to happen something has to give and that’s typically the ACL.

You can use ultrasound; however, with the Advent of MRI, it’s not as effective and it’s best for superficial injuries. The most important thing is to get a referral, and once you suspect having a knee injury get a referral to an orthopaedic surgeon or a sports medicine physician who can assess your knee and determine whether you require any further treatment and at least come to a diagnosis which is very important so in the cold light of day that’s the time that we should manage these injuries I’ve often heard stories of people getting operations the following day following a knee injury and having a knee reconstruction and it’s not really best advisable I think you’re best off returning to your country of origin having things assessed and dealing with the injury in the cold light out of day with all the information available.

So early diagnosis is important, but often delayed treatment is necessary; the reason we do this is that the knee may not be ready for surgery following an acute injury, and the reason for that is it does become swollen and it’s not a good environment to operate in a knee that doesn’t move fully so it’s really important we get people’s legs moving immediately after the injury to ensure that we can operate on when it is appropriate. We also look at non-operative versus operative intervention I’ll give you some case examples later on to define when we would treat something non-operatively versus when we require an operation and not all knee injuries require operations that’s really important we try to remove splints as soon as possible to get motion so the only reason we would leave a splint on is if we’re very concerned that a ligament is lacks and therefore is going to not heal in the right position but typically we take the splints that keep the legs straight off so we can get the knee moving as soon as we can as I said range of motion is critical weight bearing is tolerated it’s important so a lot of times people try to offload their knee by not putting the weight through the knee but weight bearing is very important to load the cartilage and it allows the cartilage to be nourished but also improves your range of motion and where appropriate and in most cases it is appropriate we encourage patients to start weight bearing again.

I’m going to go through some common scenarios that I would see in my clinic on a regular basis and hopefully, these will be helpful for you to understand the common knee injuries. I saw a novice snowboarder so this is the letter I received ‘Dear Brian thank you for seeing Ben age 14 years with a snowboarding injury one week ago the mechanism of injury wasn’t clear so he didn’t appreciate what happened but they were swelling within 12 hours and he was able to toe touch weight bearing on his toes only so he’s obviously very sore he couldn’t fully extend his knees I couldn’t straighten it out and he had an x-ray which was unremarkable showed a little bit of fluid and MRI was performed and revealed a small medial condyle fractured so that’s a small fracture at the outside of his knee with the grade two MCL which is the medial ligament or the ligament inside of the knee so he’s currently in a brace i’ve advised him to be non-weight-bearing’ and so the mother will bring on the images this is a very common injury so it’s a contact injury while turning there was no pop when I took his history he didn’t hear or feel anything pop he fell to the ground but he couldn’t wait there it had to be taken off the hill no immediate swelling and but swelling within 12 hours which is very common so when I looked at this young man I saw his knee was flexed he had a limp, he had swelling within his knee, he couldn’t fully straighten his knee but he could bend it pretty well and he had a laxity on his medial ligament was somewhat loose but he had a negative Lachman that’s the test we used to assess for an ACL so that wasn’t and I wasn’t concerned about that when we look at his X-ray he sees a young man so these areas are his growth plates but there’s no evidence of any significant injury within his knee on x-ray we then looked at his MRI and you can see in the MRI there’s increased signals so that’s increased fluid on the inside of the knee so this indicates that he had a medial class of ligament injury so for this young man it doesn’t require any surgical intervention we need to get his knee moving and we need to allow that ligament to heal and thankfully he avoided any surgery and was able to return to snowboarding the following season. This is just an example of his ACL being intact, and it’s this nice ribbon-like structure going from the tibia all the way to the femur, so that was absolutely fine.

Our second scenario is an experienced skier so the history of this individual is he at a high speed fall while turning on a steep slope he heard a loud pop just like the guy in the video at the start, he couldn’t stand, his knee buckled and he had to be taken off the mountain with immediate swelling so on examination his knee was bent unable to weight bare there was a big effusion or lots of fluid within his knee and he had lots of bleeding or bruising on the inside of his knee so when I examined him his knee was opening up hugely on the inside so he had a big medial sided or inside knee injury and the Lachman test his ACL was positive so looking at this guy’s x-rays he doesn’t show any significant injury on x-ray on the left which was the uninjured side but you look in the right he has this flake of bone on the right side which indicates that he has torn his ACL so we look at his MRI scan first of all you see the whiteness within the knee so this is his femur here this is the tibia and you see all this fluid within his knee which indicates he has bleeding within his knee and if you look at this structure here which looks a bit like a bow tie that’s its meniscus that’s sitting off the back of his knees so that indicates that his tibia is too far forward so he’s torn his ACL and you can see that here this is the ACL so we saw the previous image with a nice ribbon and you can see that there’s no continuity of that structure so unfortunately he’s torn his ACL and he also has a big site medial sided injury or inside injury where this should be like a black line but it’s grey and there’s lots of fluid around that area suggestive of a big injury so unfortunately this gentleman required an ACL reconstruction and medial class ligament reconstruction to get him going again.

The final case is a recreational skier so the history of this individual is that he twisted his knee trying to remove his boots from the bindings so we’ve often seen this scenario where you’re tired at the end of a long day and you get lazy and you twist your boot to get out and he felt a crunch at this time he used a different form of analgesia however to what we recommend and he said it was fine after a wine so he managed to persevere, but the knee became very painful that night but he did manage to ski on he said he lasted the week through Gritted teeth so the examination showed a normal alignment of the knee but he did have a limp while walking there was some fluid within the knee but the range of motion was excellent however, once I flexed his knee to the maximum extent he did have some tenderness over the inside and all the ligaments examination was normal so we look at this MRI scan here and we see the inside meniscus so the shock absorber and this should be like a black triangle like we saw previously but you see that this white line through the meniscus and based on this individual symptoms if they had a lot of displacement at that meniscus and what’s causing some issue so unfortunately they had to undergo an arthroscopy and just remove the torn portion of the meniscus to get them back on the mountain the following season this is just a view from the side where you see that that meniscus has flipped and it’s stuck down the outside of the tibia here which causes quite a bit of discomfort, unfortunately, these type of injuries aren’t going to heal with just rest as you have a displaced fragment which is the key factor so thank you very much I would urge you to be cautious on the slopes and ski within your level of expertise and if you are injured however we’re very happy to see you and we’ll hopefully get you back on the slopes as quickly as we can okay thank you very much.

 On average, how many weeks of pre-operation Physio are required?

A- yeah, that’s an interesting one, so a lot of things that come down to this is kind of objective testing and how the patient is performing themselves, so rather than a definite timeline if you need six weeks, it’s more so how long does it take to get what we call a quiet week where we can maintain full extension getting the knee fully straight maintain an amount the same as the other side and have good quad muscle activation in that we can lift our leg straighten that leg straight up off the bed and we can tick all those along what walking normally that we have no limp I think that’s a suitable time then that we can suggest they can go in for surgery.

I’ve had an ACL reconstruction and several cartilage tears from soccer and rugby during skiing this season, struggling with a lot of swelling; the baker cyst was painful at age 62. How do I know when it’s time to think about the replacements?

B- well, I think it’s similar to the last question again when it affects your quality of life, so it’s yes, you’d expect someone who’s skiing that you know more low is going through the knee they may have more swelling but it’s in their day-to-day activities and you know remember we only ski at best a couple of weeks a year or more if you’re lucky so it’s more in your day-to-day how much it’s affecting you and particularly night pain as I mentioned and you know I ended up having an assessment with someone who’s going to you know look do some weight-bearing x-rays to see how bad the arthritis is and they’ll be able to give you advice on that.

Andrew, would those rehab exercises be beneficial for a patellar injury?

A-I suppose we need to be a bit more specific in the injury, so there are a couple of Patella based injuries; there could be a patellar fracture, or it could be a patellar dislocation. I suppose the key to those injuries is they’re General exercises for, you know, the injuries that we talked about in skiing which were predominantly ACL MCL and meniscal injuries, but if we want to tailor them to a patient outside of those iron injuries, it’d be pretty important just to get a tailored program by a physiotherapist on that because it’s very hard to give general advice when we haven’t assessed them.

We’ve spoken about how going to go back after an ACL surgery but they’re saying if they don’t opt for surgery and it’s non-operative ACL management, how long then should they return to Skiing?

A- yeah, again, that’s an interesting one and it comes back to how the patient is doing themselves; so if a patient was going back to skiing and they were conservatively managing the ACL, which we see a lot of in here, again I would advise doing the testing so that we have some measures under quad strength some measures under their hamstring strength have a look at their jumping and Landing to see are they going to be able to tolerate the forces of skiing and if they can tolerate those forces there would be no problem with skiing.

B-I also add that I think it’s important that you check the symptoms and whether someone feels unstable, and I think that you know if you might be fine in a straight line, but then if someone twists and that can cause a sense of instability to the knee, so I think you’d want to be symptom-free from an instability perspective as well.

Dislocated in the knee 18 months ago since having patellar stabilization surgery with ten months recovery, returned to playing Gaelic football at the start of the season in 2022 without any recurring injuries; what precautions should I take for skiing?

B-That person seems to have done it very well following surgery which is successful, and be able to return to sports, so if there’s a good level of fitness and they, you know, a good deal and quad strength, I think that they should be able to return to skiing and I wouldn’t advise any precautions if they’re fit and healthy.

Do you see an increase in ACLS in females compared to males?

B-From skiing or from other sports? Yeah, we certainly have seen an increase in female patients and I think one of that is it’s been a big epidemic in Australia where I was recently working, and we see a huge increase as more when we’re paying ladies AFL and so yeah, we see it a lot and we see in younger patients as well quite a lot and with skiing it’s like a conveyor belt for ACL injuries whatever the gender so it’s a very common injury for both genders.

What is the importance of flexibility in comparison to strength training for Skiing?

A-I suppose the two of them go hand in hand, you know, the stronger we are in our muscles, the more range or, the more flexibility we tend to have, so both of that kind of go hand in hand. I wouldn’t pick one over the other and I certainly wouldn’t work on a stretching program when strengthening is what we want; you know, strength is what would outweigh the flexibility arm for knee injuries and skiing anyway.