Skiing and the lower limb

Skiing & the Lower Limb

Sports Injury Fix Winter is coming has been a famous phrase this year and now it’s

here it’s estimated that over 1 million of us Brits will go on a winter sports holiday with about 80% skiing, 16% snowboarding and 4% skating, climbing, sledding etc1 .

Sadly, injuries are part and parcel of winter sports for a multitude of reasons such as crashes, overuse, lack of fitness, equipment failure or just bad luck. Injuries associated with winter sports affect the whole body but for the purposes of this article we’ll give an overview of the most common and focus on those affecting the lower limbs. We certainly won’t be mentioning the helmet vs non-helmet debate.

How frequent are injuries?

There are a number of studies of injury rates for skiers and snowboarders with results ranging from 1-6 injuries per thousand skiing days to 2-16 injuries per thousand snowboarding days2. For the more adventurous ice climbing only has estimated injury rates of 4 per thousand hours3 . Over the last ten years sledding has increased in popularity with moonlight sledding being an increasing popular past-time and thus injury rates here have increased too. Indeed, one insurance company4 found their breakdown of claims related to winter sports injuries was as follows:

34% snowboarding 33% skiing 21% sledding 12% skating

Written by Malcolm Sloan, Sports Injury Fix

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So, what are the main injuries?

The knees are the number one injury and typically account for around 30%5 of all winter sports injuries. This is not just because of how much they are used in most winter sports but the number of ways they can be injured. Most people only have one winter holiday a year so it’s an intense amount of exercise on muscles and ligaments in a way they may not be used to. As such the strains and pains that come from overuse are common but also medial collateral ligament (MCL) or anterior cruciate ligament (ACL) injuries account for the majority6 of knee injuries. The harder boots used in skiing protect the ankles, but give a higher chance of knee injuries. ACL damage tends to happen when trying to stop falling by squatting with arms out and the weight goes on the inside edge of the downhill ski causing a twisting motion. MCL injuries tend to happen during crashes when an edge is caught and it stresses the medial ligament. Dislocations and knee fractures also occur along with leg fractures although these are less common. With no poles for balance and both feet connected to the board without an automatic release mechanism then for learners a bruised bottom is the most embarrassing injury when learning to snowboard but wrist injuries are the most commonly recorded accounting for over 20%7 of snowboarding injuries. The impact of landing often causes shoulder problems too. Knee injuries in snowboarders are less common than skiers, accounting for 16% of injuries8 and most knee injuries tend to happen not whilst snowboarding but from getting on and off ski lifts when one foot is fastened to the board and the other is pushing. Twisting while falling over risks injury to the knees as does the impact from crashing, particularly at speed and on icy ground. The softer boots used in snowboarding are easier to walk in and feel more flexible but offer less protection and as such lead to increased vulnerability to ankle sprains and fractures. ‘Snowboarders ankle’ refers to a fracture of the lateral process of the talus due to the fact it is 15 times9 more likely in snowboarders than the general population. The lateral process of the talus is above the heel bone on the outer side of the ankle. In sledding then, lower leg injuries are very common with knee sprains accounting for 13% of injuries followed by ankle sprains (11.5%), and ankle/leg fractures (9%).10 It’s thought the increase in sledding injuries is down to the rise in its popularity and particularly that of ‘moonlit sledding’ and the potential effects of après ski. It’s estimated that with the rise of winter time temporary ice rinks that at least 4%11 of the UK population ice skates which is one of the few winter sports that is done predominantly in the UK and not abroad. Skating injuries tend to be focused on the upper body from outstretched arms trying to break a fall. Ankle and knee injuries do still occur but account for just 7%12 each of total injury numbers and tend to occur from twisting to avoid falling leading to strains and tears.

There are many treatment options dependant on the severity or type of injury, and which ligaments are affected. Low-moderate grade injuries may benefit from active physiotherapy or rehab techniques, utilising proprioception, strengthening taping etc. Low grade to moderate injuries may also benefit from one or more of the various injectable treatments available for knee ligament injuries. Here are some known examples listed, many of which require further in depth discussion to fully appreciate potential value, effectiveness and pathomechanics of how they actually work.

Corticosteroid injections

These are powerful synthetic antiinflammatory drugs, used to help reduce pain from inflammation. Whilst they may be useful for reducing inflammation and pain, there is no significant research to suggest they specifically help in healing injuries of tendons or ligaments.

Prolotherapy, Proliferating therapy

Glucose is currently the hyperosmolar agent of choice of many prolotherapy practitioners and research supports its efficacy as a cytokine expressant due to its interference with cellular osmolality (28) (29). A solution of 20% W/V glucose for injection combined with 1% W/V Lidocaine Hydrochloride (formerly Lignocaine) is advocated by many acknowledged experts including the Australian prolotherapy tutor, Dr Margaret Taylor. Prolotherapy resulted in safe, significant, progressive improvement of knee pain, function and stiffness scores among most participants through a mean follow-up of 2.5 years and may be an appropriate therapy for patients with knee OA refractory to other

conservative care. (Rabago et al., 2015).

Hyaluronic acids

Hyaluranon is a glycosaminoglycan (essentialy a protein) widely found in connective, epithelial and neural tissues. Also a natural component found in synovial fluid, said to help lubricate synovial joints and give temporary pain relief. Whilst the main bulk of research in this area is for osteoarthritis of the knee for example, (Aksari et al., 2016) This could be useful to help repair injured, non torn ligaments, the research is limited in this area.

Prp/autologous bloods

Platelet and white blood cells. Whole blood is centrifuged to separate red blood cells from the protein rich plasma, which provides a higher yield of growth factors, than whole blood. This serum is usually injected at, or around the point of injury to help stimulate and promote faster healing and regeneration within the injured structures. (Yuan, Zhang and Wang, 2013) Completed a more detailed study into the use of Prp for tendon and ligament repair, more research has and is being conducted, purporting Faster recovery times and no adverse

reactions. (Taylor et al., 2011)

Stem cells

Usually derived from the mesenchymal cells taken from bone marrow. These cells are harvested and processed to produce an injectable solution with regenerating properties. New cells are born from stem cells and are essential in healing and repair. Although not widely utilised just yet, this technology appears promising, the research and evidence is beginning to emerge worldwide and seems promising in the use of musculoskeletal conditions, amongst many other potential applications.

Surgery/operative treatments

For the most severe, or non responding to conservative treatment cases, surgical options, (Usually orthopaedic) may be required. This may involve allograft, or autograft from another tendon in the body, usually harvested from Achilles tendon, patella tendon or biceps femoris tendon, or even synthetic grafts. There is no “ideal” graft to be used in anterior cruciate ligament reconstruction surgery and each of the four major graft choices has its advantages & disadvantages. Success or failure of the procedure depends heavily on surgical technique. Surgeons should be aware of the evidence behind the use of each graft and thus be able to make an informed decision of its appropriateness. (Shaerf, 2014).

REFERENCES

Aksari, A., Golami, T., Nagizadeh, M., Farjem, M., Kouhpayeh, S. and Shabafard, Z.

(2016). Cite a Website - Cite This For Me. [online] Ostenil.trbchemedica.co.uk. Available at: http://ostenil.trbchemedica.co.uk/data/documents/Askari%20HA%20compared%20with%20 corticosteroid%20injections%20for%20knee%20OA%20(1).pdf [Accessed 4 Dec. 2017]. Rabago, D., Mundt, M., Zgierska, A. and Grettie, J. (2015). Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis: Long term outcomes. Complementary Therapies in Medicine, 23(3), pp.388-395. Shaerf, D. (2014). Anterior cruciate ligament reconstruction best practice: A review of graft choice. World Journal of Orthopedics, 5(1), p.23. Taylor, D., Petrera, M., Hendry, M. and Theodoropoulos, J. (2011). A Systematic Review of the Use of Platelet-Rich Plasma in Sports Medicine as a New Treatment for Tendon and Ligament Injuries. Clinical Journal of Sport Medicine, 21(4), pp.344-352. Yuan, T., Zhang, C. and Wang, J. (2013). Augmenting tendon and ligament repair with platelet-rich plasma (PRP). [online] Muscles Tendons and Ligaments Journal. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3838322/ [Accessed 4 Dec. 2017].

REFERENCES

1 www.globelink.co.uk/news/Globelink-Travel-Insurance-News/winter-sports-injuries-statistics 2014 2 Ekeland, Sulheim, and Rodven, “Injury Rates and Injury Types in Alpine Skiing, Telemarking, and Snowboarding,” Journal of ASTM International, Vol. 2, No. 5, 2005, pp. 1-9, 3 Schöffl et al. “Injury Risk Evaluation in Water Ice Climbing” Med Sport 13 (4): 210–218, 2009 4 www.globelink.co.uk/news/Globelink-Travel-Insurance-News/winter-sports-injuries-statistics 2014 5 www.ageas.co.uk/intermediaries/news/almost-heads-shoulders-knees-and-toes 6 Jordan et al. Anterior cruciate ligament injury/reinjury in alpine ski racing: a narrative review

Open Access J Sports Med. 2017; 8: 71–83

Paletta and Warren Knee injuries and Alpine skiing. Treatment and rehabilitation. Sports Med. 1994 Jun;17(6):411-23. 7 Kim et. al. Am J Sports Med. 2012 Apr;40(4):770-6. 8 Worldwide Insure research 2017 https://www.worldwideinsure.com/travel-blog/2017/01/ common-snowboarding-injuries-avoid/ 9 Mussman and Poirer J Chiropr Med. 2010 Dec; 9(4): 174–178 1 Corra and Di Giorgi Sledding injuries: is safety in this winter pastime overlooked? A three-year survey in South-Tyrol J Trauma Manag Outcomes. 2007; 1: 5. 11 Barr et al. Int Orthop. 2010 Jun; 34(5): 743–746. 12 US National Electronic Injury Surveillance System data - www.product-injuries.healthgrove. com/l/88/Ice-Skating

New podiatry orthotics manufacturing lab for NHS Trust

A new state-of-the-art laboratory manufacturing custom-made podiatric orthotic insoles has opened in Kent.

Discovery Orthotics is a department of Kent Community Health NHS Foundation Trust and has the capacity to manufacture bespoke insoles for both NHS and private podiatry services to help patients with a range of foot, ankle and gait problems.

Department manager Rhys Toghill said; “This is a oneof-a-kind facility which can provide a full service from computer-aided design through to full production. We can manufacture all types of insole and podiatric orthotics that can transform the lives of patients across the UK.”

Current clients include several large NHS Trust as well as private podiatry practices from across the UK. The facility was until recently located in the Queen Victoria Hospital in Herne Bay but the new purpose-built lab will allow production to expand.

For more information on Discovery Orthotics call the team on 0300 123 1540 (option 2) email kcht.podiatryorthotics@nhs.net or visit www.discoveryorthotics.nhs.uk