When snow-sports enthusiasts hit the slopes at the start of the new season, the last thing on most of their minds is any thought of injury. Still less when they are booking their holidays, or in the lead-up to what may be their first skiing trip in a year. The typical approach of the amateur skier or snowboarder will be more like: ‘I go to the gym – that should be enough’, which means there is slim chance of their considering any serious prehab or injury prevention effort ahead of their trip to the mountains.
Yet skiing and snowboarding are high-risk sports. So as the wintersports season approaches, it is a good moment to consider the causes and types of injuries that may well accompany your underprepared clients back home from their winter holidays. If you are lucky, you may even be able to persuade them to undertake a tailored programme of prehab ahead of time.
In setting up a suitable prehab programme, you will need to take into account the most likely types of injury and your client’s ability level. Skiers and snowboarders tend to get very different types of injuries, so tailor your programme appropriately.
Falls: Most ski and snowboard injuries result from falls. The surface is unique and varied and a minor loss of balance can result in a fairly dramatic fall. Snowboarders usually fall forwards or backwards, putting shoulders, wrist, cervical and lumbar spine at risk. Skiers tend to fall sideways and backwards, and when they do, the design of ski, boot and binding mechanism all increase the torsional stress on the knee. Ski poles are often hazardous for thumbs during a fall.
Collisions: High-impact collisions in either discipline can lead to head injuries. Low-impact ones can cause skiers anterior cruciate ligament injuries, as poorly stabilised knees are forced into rotation on a fixed base.
Fatigue: The vast majority of snowsport injuries happen at specific times: most occur towards the end of the day but a high proportion happen just before the lunch break.
Poor technique: increases the chance of a fall.
Loss of control: Often occurs when people ski or snowboard beyond their limits. But it may be as simple as a beginner losing control of the snow-plough position (beginners, to limit and control their speed, are taught to keep their skis pointing in a V shape, requiring them to maintain their legs in internal rotation with knees flexed).
Equipment failure: Damaged or inappropriate equipment (an enthusiastic improver buying advancedlevel kit which they are not yet competent to control, for instance) may contribute directly to an injury or to the severity of one.
Forward falls commonly result in shoulder-girdle injuries: anything from rotator cuff strains to clavicular fractures. Falls backwards more commonly produce wrist fractures or strains, spinal injuries (lumbar and/or cervical) and head injuries, usually from a direct blow to the back of the skull during a fall. All can happen at any ability level.
The types of injury are more linked to ability level than in snowboarding. Beginners spend their time in the snowplough position, in which their flexed and relatively fixed knees impose strain on the medial collateral ligament. The MCL comes under further strain as the snowplough width increases (when, for instance, ski tips cross and lock).
As the skier learns to adopt the parallel position (both skis pointing forwards) they get faster and tend to move in and out of greater degrees of flexion. On steeper slopes (especially with more expert skiers – and indeed, snowboarders) the knees can have to endure extreme ranges of flexion under load, placing stress on the patello-femoral joint (PFJ). At greater speeds and with acute turns, falls will have more rotational force, resulting in ACL or combined knee injuries involving the menisci and/or collateral ligaments.
Meniscal injuries are well documented. They happen most often as a result of rotation stress on the flexed, loaded knee. This knowledge is vital in setting up a prevention programme.
With both skiing and snowboarding, fitness requirements are multi-faceted: agility, endurance, quick reactions, flexibility, strength and well-developed proprioceptive and neuromuscular control. The movements involved are multi-planar.
Any fitness regime must include sport-specific exercises and take into account the ability level of the participant. This demands a highly individualised approach in designing a programme, which rules out formula-based prehab but gives you lots of scope for imagination.
Fatigue is an important factor in snow-sport injuries, so cardiovascular training is important. Good levels of CV fitness will help to raise the client’s concentration levels and allow them to read the conditions better. Higher-level skiers and boarders should to do some anaerobic work, to equip them for brief sprints or bursts when tackling more challenging terrain. Both sports tend to involve ‘high intensity-intermittent exercise’, which should be reflected in the CV training regime by including high-intensity interval work.
But it is also important at all levels to build a sound CV training base, not least to maximise local muscular endurance. Because skiing requires a lot of lower-limb work, the CV element needs to include activities such as cross-training or cycling. As snowboarders need more upperbody strength and endurance, it may be worth considering building swimming into the boarder’s workout along with the lower limb exercises.
Strength training needs to combine eccentric, concentric and plyometric muscle work. Skiers and boarders (especially intermediate and higher levels) repetitively overload and stretch the quadriceps muscles, which is thought to produce a quick, forceful ‘recoil’ in the muscle. Plyometric training should help to prepare the knees by giving them more ‘spring’.
Because novice snowboarders and skiers spend more time in relatively fixed degrees of flexion, they need good ‘holding’ or eccentric strength in their quadriceps. Isometric holds on the leg press in differing positions of flexion are good, as is the classic ‘sitting wall squat’ in the appropriate levels of flexion. Try to mimic the stance adopted by a skier or boarder, with a forward lean, rather than planting the back fully against the wall.
More advanced skiers and boarders work in and out of varying ranges of flexion, making a dynamic sliding wall squat more useful (maintain squat while flexing and extending the legs); or a conventional (isotonic) full-leg press. Snowboarders can mimic their action by facing the wall, using it for touch-balance with their hands while performing squats on the balls of their feet.
To help combat the stresses that both sports exert on the PFJ at all levels, strength programmes must include exercises that target the vastus medialis obliquus (VMO). Step exercises are simple and effective. Instruct the client to imagine that their board or skis are attached to their feet, and emphasise correct lower limb alignment to ensure VMO activation.
Undertake plyometric training with caution, taking particular heed of any previous PFJ problems, and tailoring the training to the client’s ability level. Bear in mind, too, that many people, once out on (or off) the piste, will be tempted to venture beyond their competence level and may well encounter more tricky circumstances than anticipated. With higher-level enthusiasts, for instance, consider increasing the depth of their jump landing or jumping from a height.
Factor in some training to improve responses to the ‘falling back’ loss of control that can precipitate a sideways/backwards fall. One way to retrain recovery from this loss-of-balance position (the pelvis thrown forward, the back extended) is to practice lying supine over a Swiss ball, back extended and head low, and curling up to neutral. For variations, change the angles of return to neutral.
To reduce the snowboarder’s risk of injury to the shoulder girdle in a forward fall, a good upper-limb and body workout is essential for all ability levels. Boarders will fall on outstretched arms, so push-ups – paying particular attention to full arm extension under control (avoiding fierce elbow lock-out) – are good. Standing facing a wall and ‘falling’ on to it with outstretched arms (an explosive form of a wall-squat) will improve the neuromuscular reaction required to ‘catch’ a fall, as well as working on rapid eccentric triceps and pectoral control.
A backward-falling snowboarder is at risk of damaging his or her wrists. To prevent this type of injury is obviously difficult. A modified, falling- type tricep dip is a way of plyometrically retraining the wrist flexors. But wrist protectors are recommended for all snowboarders.
Correct technique in snowboarding requires strong rotational control of the trunk, and it is a good idea to incorporate this aspect into as many exercises as possible. For instance, trunk rotation with medicine ball can be added to a freestanding squat. The Swiss ball is also very useful for rotation exercises. All it takes is good imagination.
Skiers and snowboarders need quick reactions to avoid danger. Sensorimotor training involves the proprioceptive and neuromuscular systems. Plyometrics and agility training will both improve subconscious control.
One useful tool is to alter the speeds of repetitions. And while it is impossible to reproduce the snow surface in a clinic or gym, it is advisable to do some sensorimotor training on an uneven surface, such as squats with upper-body rotation on a trampette.
Adding perturbation techniques will challenge reactions (another good example would be two-handed throwing and catching of a ball while balancing on one leg on a trampette).
Not surprisingly, core stability should be a fundamental aspect of the prehabilitation programme. Good core stability will provide the base upon which the client can build other skills and strengths. The sports professional’s role is, as ever, to emphasise correct posture and alignment appropriate to the specific needs of the individual.
Include flexibility exercises, both static and dynamic, for all the major muscle groups of the lower limb: the quadriceps, hamstrings, calves, adductors, gluteals and hip flexors. Pay particular attention to achieving good length in soleus and gastrocnemius, because of the position of the ankle in the boot in both sports.
Novice skiers need good adductor flexibility to cope with the snowplough, as well as a good range of internal hip rotation. Snowboarders must have good lumbar spine flexibility in all ranges.
Whether through a failure of good intentions or blissful ignorance, the fact is that many skiers and boarders will simply not do a prehab regime. Yet even at the last minute, some careful thought and preparation may still help ward off injuries. Much of it is common sense, but that’s a commodity that can fail miserably when fresh snow and sunshine beckon.
Helmets can help limit the extent of a head injury. Higher-level skiers and boarders tend to shy away from them but as the speeds are faster and the terrain more unpredictable the force of the fall or collision will be greater.
Wrist protectors are being modified and researched continuously, and there is strong evidence that they do prevent injury in snowboarders.
Bindings should be checked professionally every year. Large numbers of ski injuries to the knee occur because bindings fail to release. Skiers whose fitness levels have dropped or who haven’t skied for a while should consider setting the bindings lower.
Ski pole design is changing to improve pole grips to reduce the chance of thumb injuries, so it is a good idea to have the latest design and use the straps correctly. Novice skiers in particular need to watch out for this as they are most likely to rely on borrowed equipment.
Idzikowski, JR, et al, ‘Upper extremity snowboarding injuries: ten-year results from the Colorado snowboard injury survey.’ The American Journal of Sports Medicine 2000; 28(11)
Langran, Mike ‘Diagnosis and management of knee injuries.’ Sport Ex Medicine 2001; 7
Fukuda, O, et al, ‘Head injuries in snowboarders compared with head injuries in skiers.’ The American Journal of Sports Medicine 2001; 29 (4)
Ronning, R, et al. ‘The efficacy of wrist protectors in preventing snowboarding injuries.’ The American Journal of Sports Medicine 2001; 29 (5)