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Glenn D. Braunstein, M.D. Headshot

On the Slopes, Take Smart Steps to Prevent Ski Knees, Skier's Thumb, Serious Head Injuries

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Brad Pitt made headlines when he arrived at the Palm Springs International Film Festival early this year, walking the red carpet with a cane. It turns out the actor had suffered a knee injury, taking a tumble on the ski slopes.

So maybe he is just a regular guy. As snow sport enthusiasts from California to Vermont invade ski resorts this winter, two to three in every 1,000 ski visits and nearly seven snowboard visits will result in an injury.

Fortunately, most ski and snowboarding injuries, while painful, are not serious or life threatening. Despite the well-publicized deaths of Sonny Bono, Michael Kennedy, actress Natasha Richardson and, most recently and tragically, free skier Sarah Burke, over the past decade there have been around 39 deaths per year from snow sports.

Overall, ski-related injuries have actually decreased by 50 percent since the early 1970s, thanks to the improvements in bindings and boots, shorter skis and the use of helmets.

Still, 144,000 snow skiing-related injuries were treated in hospitals, doctor's offices and emergency rooms in 2010. The incidence of snowboarding injuries has increased and now outpaces those sustained by skiers -- 148,000 injuries in 2010.

Most importantly, many injuries sustained in both sports can be avoided with proper precaution and preparation. Prevention ought to start before the first snowfall with a conditioning program that focuses on endurance, strength, flexibility and balance. Before hitting the slopes, equipment should be inspected by a ski shop technician. Even top-of-the-line bindings are only as good as their settings. If they release too easily or too late, you risk injury. Take the time, too, to warm up each day before your first run. And if you're a novice, invest in lessons. Beginners suffer almost three times more injuries than the more experienced participants in skiing and snowboarding.

ACLs, MCLs - Common Woes

Among skiers, the most common injury is to a knee ligament -- either to the medial collateral ligament (MCL) or the anterior cruciate ligament (ACL). These account for 20,000 ski injuries annually and have increased significantly with the advent of the same equipment that has decreased other injuries.

The MCL is a wide, thick band of tissue that runs down the inner part of the knee from the thighbone to the shinbone about four to six inches from the knee. Its main function is to prevent the leg from extending too far inward. But it also helps keep the knee stable and allows it to rotate. Beginning skiers, because they typically employ the technique known as the "snow plow," often sustain MCL injuries when they fall, usually after their stance suddenly widens or their skis cross.

The ACL is the smallest of the main knee ligaments and the most important in keeping your leg stable when you twist your body. It connects the thighbone to the largest shinbone at the center of your knee. When the shinbone and thighbone rotate too far in opposite directions -- or when the knee is bent in the wrong direction, the ACL can be sprained or torn, partially or completely.

Most often an ACL injury is caused by a scenario dubbed "the phantom foot." This is when the tail of the ski, which acts like an alternate (or "phantom") foot, combined with the stiff back of a ski boot, functions as a lever to apply a distinctive blend of twisting and bending weight-loads to the knee. Knee ligament injuries vary in severity and pain. Often a skier hears a "pop" as the injury occurs, followed by the leg buckling when trying to stand on it. It's not uncommon for both the MCL and ACL ligaments to be injured simultaneously.

The best way to prevent knee injuries is to learn to fall properly, which means resisting the instinctual urge to throw out your hand to stop yourself. Besides creating an acute angle with your leg that will put pressure on your knees, falling on outstretched hands and not releasing your ski poles also can tear thumb ligaments -- resulting in so-called "skier's thumb," the most prevalent upper extremity injury among skiers.

Other causes of ACL injury are attributed to skiers sitting back too far, landing jumps stiff legged and trying to stand after a fall while still sliding. While popular, perhaps as a visible and macho badge, knee braces have generally proven unhelpful in averting ski injuries, though they may prove useful to those rehabbing an injury.

After Oops, Ow, What?

If you hurt your knee, stop skiing, apply ice and gentle compression with an elastic bandage and elevate the leg to minimize swelling. Swelling can be substantial and occurs within the first six hours. While some ski areas may offer excellent emergency treatment, many in the sport when injured not only manage to get back home but actually prefer to consult with specialists there for care.

An orthopedist can determine the specific nature and severity for your knee injury, likely offering a diagnosis with physical examination. In some cases, a magnetic resonance imaging (MRI) scan may be necessary to assess damage.

A torn MCL is usually treated with rest, a brace and physical therapy -- not typically with surgery. If surgery is called for, it now often is done in minimally invasive fashion via a small incision on the inside of the knee. This is not usually an arthroscopic procedure, because this ligament is not inside the knee joint. If the MCL has been torn where it attaches to the thighbone (femur) or shinbone (tibia), the surgeon will re-attach the ligament to the bone using large stitches or a metal screw or bone staple. If the tear was in the middle of the ligament, the surgeon will sew the torn ends together.

A torn ACL does not necessarily require surgery either, but does so more often than a torn MCL. The ACL often can be reconstructed during an arthroscopic exam. Sometimes the existing ligament can be sewn together. Other times a graft replaces the ligament; this tissue can come from your own body, such as the tendon of the kneecap or one of the hamstring tendons. Another choice is allograft tissue, from a cadaver. Physical therapy follows surgery. Most patients recover totally in three months to a year; they will be at higher risk of arthritis in the future.

ACL injuries are more prevalent in women than men across all sports. There are no consistent data on differences between the sexes in the incidence of ACL injuries in recreational skiing. But female competitive alpine skiers have an incidence rate twice that of male competitive alpine racers. Other studies have reported that recreational skiers have the highest incidence of injuries, while expert skiers have the lowest incidence. The research is inconclusive but has suggested a variety of factors for the disparity, including: hormonal differences, differences in joint motion and strength.

Snowboarders suffer knee injuries, too, but are much likelier to injure an upper extremity. Among snowboarders wrists account for nearly 20 percent of all injuries and 50 percent of all fractures. Other common snowboarding injuries involve shoulders, elbows and the head. Wrist guards or gloves with wrist support have been shown to reduce wrist injuries by 50 percent.

There is a glimmer of good news about snowboarders' injuries: They have a lesser risk than skiers of sustaining a serious or fatal injury. That's because the risk of collisions with fixed objects, while also going at a relatively high speed, increases on skis. Snowboarders are more likely to fall while landing jumps. A greater percentage of snowboarders are teenagers, who suffer the highest overall rate of injury in any one age group in either sport

Wear a Helmet

Head injuries pose serious problems in both skiing and snowboarding. They account for 10 to 20 percent of all snow sport injuries. And though most head injuries are minor, serious head injuries are the biggest cause of snow sport-related deaths.

Helmets are strongly recommended and, experts estimate, they could prevent 44 percent of head injuries sustained during skiing and snowboarding and up to 53 percent of those traumas suffered by children. Further, recent studies have shown that, contrary to concerns raised by some, helmets do not appear to be associated with an increased incidence of cervical spine or neck injury.

Despite these statistics, New Jersey, so far, is the only state to pass a ski helmet law. A California law requiring kids to wear ski helmets was vetoed by Gov. Jerry Brown, just as it was by his predecessor, Gov. Arnold Schwarzenegger.

The good news is more and more skiers and snowboarders are wearing them anyway. In 2011, 61 percent did so at U.S. ski areas, up from only 25 percent during the 2002-2003 season.

Common sense dictates there are other smart ways to curb injuries on the slope: Don't booze it up or use other intoxicants. Don't go out in icy or stormy conditions, unless you know what you're doing. And don't ski alone, especially in deep powder or in restricted or out-of-bounds areas.

We know that injuries occur more often when skiers are tired, such as at the end of the day or the end of a ski vacation. So if you're beat, take a break -- don't suffer one. The slopes will be there next year and you want to be on them, so, relax a little. Cultivate the art of après ski, sitting with a good book, friends, food and having fun by the fireplace in the lodge.