Conditioning for Downhill Skiing Conditioning for Downhill Skiing CP1080418-1 Edward R. Laskowski, M.D. Co-Director, Mayo Clinic Sports Medicine Edward

Conditioning forConditioning forDownhill SkiingDownhill SkiingConditioning forConditioning forDownhill SkiingDownhill Skiing

CP1080418-1

Edward R. Laskowski, M.D.

Co-Director, Mayo Clinic Sports Medicine

Edward R. Laskowski, M.D.

Co-Director, Mayo Clinic Sports Medicine

Scope of ProblemScope of ProblemScope of ProblemScope of Problem

CP1080418-3

• ~80,000 ACL ruptures/year; 50,000 surgeries

• $30,000/rupture (incl lost wages & “opportunity costs”)

• $1.2 billion/yr (equivalent to 60 Solitude ski resorts)

• $24/ski pass sold in USA added to cover insurance/liability

• ~80,000 ACL ruptures/year; 50,000 surgeries

• $30,000/rupture (incl lost wages & “opportunity costs”)

• $1.2 billion/yr (equivalent to 60 Solitude ski resorts)

• $24/ski pass sold in USA added to cover insurance/liability

Types of InjuriesTypes of Injuries

• 2-9 injuries per 1000 skier days

• ACL: 47% of all ski injuries myers, 2007

• Head and neck injuries: >50% of skiing related hospitalizations and fatalities myers, 2007

• Majority of injuries: collisions and falls

• 2-9 injuries per 1000 skier days

• ACL: 47% of all ski injuries myers, 2007

• Head and neck injuries: >50% of skiing related hospitalizations and fatalities myers, 2007

• Majority of injuries: collisions and falls

Patterns of InjuryPatterns of InjuryPatterns of InjuryPatterns of Injury

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Isolated ACL injuries 644%!

Shoulder

8% of total

• 52% dislocation

• 18% AC (majority grade I)

• 1.5% clavicle

Isolated ACL injuries 644%!

Shoulder

8% of total

• 52% dislocation

• 18% AC (majority grade I)

• 1.5% clavicle

Competitive SkiersCompetitive SkiersCompetitive SkiersCompetitive Skiers

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Canadian Women’s National Team, ’84-’92

Risk/year/skier

%

Knee injury 50

ACL 17

MCL 17

Fracture 11

Surgery 29

Canadian Women’s National Team, ’84-’92

Risk/year/skier

%

Knee injury 50

ACL 17

MCL 17

Fracture 11

Surgery 29

French National Team 1980-2005

French National Team 1980-2005

• ACL: 28% of female members, 27% male members

• 19% re-injury rate

• 39% of ACL injured required at least 1 repeat ACL surgery

• More injuries in world top 30 group

• ACL: 28% of female members, 27% male members

• 19% re-injury rate

• 39% of ACL injured required at least 1 repeat ACL surgery

• More injuries in world top 30 group

Competitive SkiersCompetitive Skiers(cont)(cont)

Competitive SkiersCompetitive Skiers(cont)(cont)

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• Worldwide: 6% per year with season ending injuries

• Severity: Tibial plateau smash with T12 fractureACL/MCL patellar dislocation/patellar tendon rupture

• High forces15 ft stop: 2 G2 ft stop: 15 GInstantaneous stop: 139 G

• Worldwide: 6% per year with season ending injuries

• Severity: Tibial plateau smash with T12 fractureACL/MCL patellar dislocation/patellar tendon rupture

• High forces15 ft stop: 2 G2 ft stop: 15 GInstantaneous stop: 139 G

Causative/ContributingCausative/ContributingFactorsFactors

Causative/ContributingCausative/ContributingFactorsFactors

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Equipment

Skis

• Prolong feet = longer lever arm

• Decreases force necessary to break or tear

Equipment

Skis

• Prolong feet = longer lever arm

• Decreases force necessary to break or tear

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• Bindings: Moräus, ’73: 3.6% had binding “correctly” tuned –

46% so bad, foot was “nailed to the ski”

Improving:

’84: 26% bindings “tuned” correctly


• Bindings: Moräus, ’73: 3.6% had binding “correctly” tuned –

46% so bad, foot was “nailed to the ski”

Improving:



Can a binding prevent ACL injuries?

Can a binding prevent ACL injuries?

Rocker SkisRocker Skis

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• Boots: Greenwald, ’93; 68% all skiers (injured & control) use rear entry (RE) boots

77% of all females injured use RE boots

88% of tibial plateau fractures in RE boots

• Boots: Greenwald, ’93; 68% all skiers (injured & control) use rear entry (RE) boots

77% of all females injured use RE boots

88% of tibial plateau fractures in RE boots

“Boot top” ACL: Would break-away back help?

“Boot top” ACL: Would break-away back help?

Wear a helmet!!!Wear a helmet!!!

• Incidence of TBI and SCI in skiing and snowboarding increasing

• Head injuries most common cause of death

• Helmets reduce risk of head injury by 22-60%

• Incidence of TBI and SCI in skiing and snowboarding increasing

• Head injuries most common cause of death

• Helmets reduce risk of head injury by 22-60%

CP1080418-20

• Skier

• Fatigue

injuries at end of day

Vastus lateralis: 50% glycogen on Wed/Thurs compared to previous Saturday

• Risk: Children cannot drive but are allowed to ski at 40-50 mph

• Skier

• Fatigue

injuries at end of day

Vastus lateralis: 50% glycogen on Wed/Thurs compared to previous Saturday

• Risk: Children cannot drive but are allowed to ski at 40-50 mph

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Experience: Park City

• 32% Knee injuries in Utah residents

• 44% nonresidents

• Locals with much less serious injuries

• Residents of Park City: 25% of skiers, but 19% of injuries

Experience: Park City

• 32% Knee injuries in Utah residents

• 44% nonresidents

• Locals with much less serious injuries

• Residents of Park City: 25% of skiers, but 19% of injuries

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Quadriceps induced ACL

• Recovery from falling back

• Eccentric/concentric contractions

• Usually experts

• Bindings may not release

• May not fall (“the injury that caused the accident”)

Quadriceps induced ACL

• Recovery from falling back

• Eccentric/concentric contractions

• Usually experts

• Bindings may not release

• May not fall (“the injury that caused the accident”)

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Passive vs active ACL injury

Passive

• “Phantom foot”

• Beginner

• Hyperflexion & IR

Active

• Recovery from fall, accelerating upper body

• Expert

• Quad extension

Passive vs active ACL injury

Passive

• “Phantom foot”

• Beginner

• Hyperflexion & IR

Active

• Recovery from fall, accelerating upper body

• Expert

• Quad extension

Respond Quickly and EffectivelyRespond Quickly and EffectivelyRespond Quickly and EffectivelyRespond Quickly and Effectively

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• Arms forward

• Skis together

• Hands over skis

• Arms forward

• Skis together

• Hands over skis

Recognize PotentiallyRecognize PotentiallyDangerous SituationsDangerous SituationsRecognize PotentiallyRecognize PotentiallyDangerous SituationsDangerous Situations

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• Uphill arm back

• Skier off-balance to the rear

• Hips below the knees

• Uphill ski unweighted

• Weight on inside edge of downhill ski tail

• Upper body generally facing downhill ski

• Uphill arm back

• Skier off-balance to the rear

• Hips below the knees

• Uphill ski unweighted

• Weight on inside edge of downhill ski tail

• Upper body generally facing downhill ski

Routinely Correct Skiing TechniqueRoutinely Correct Skiing TechniqueRoutinely Correct Skiing TechniqueRoutinely Correct Skiing Technique

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• Maintain balance and control

• Keep hips above knees

• Keep arms forward

• Maintain balance and control

• Keep hips above knees

• Keep arms forward

Avoid High-Risk BehaviorAvoid High-Risk BehaviorAvoid High-Risk BehaviorAvoid High-Risk Behavior

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• Don’t fully straighten legs when you fall – keep knees flexed

• Don’t try to get up until you’ve stopped sliding

• Don’t land on your hand; keep your arms up and forward

• Don’t jump unless you know how and where to land; land on both skis with knees flexed

• Don’t fully straighten legs when you fall – keep knees flexed

• Don’t try to get up until you’ve stopped sliding

• Don’t land on your hand; keep your arms up and forward

• Don’t jump unless you know how and where to land; land on both skis with knees flexed

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• Begin early (May): Cross training “off the slope”

• Physical preparation

StrengthStrength

PowerPower

Sports-specificSports-specificenduranceendurance

• Begin early (May): Cross training “off the slope”

• Physical preparation

StrengthStrength

PowerPower

Sports-specificSports-specificenduranceendurance

Performance limited by weak link

Performance limited by weak link

Preseason ConditioningPreseason Conditioning

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•Psychological

•Tactical

•Technical

•Physical

•Psychological

•Tactical

•Technical

•Physical

Preparation

CP1080418-29

Train all energy systems

• Explosive power(ATP-PC system)

5-10 sec; improves speed, quickness

Train all energy systems

• Explosive power(ATP-PC system)

5-10 sec; improves speed, quickness

TrainingTrainingTrainingTraining

CP1080418-30

Intermediate power (glycolysis)

• 60-90 sec; improves speed endurance

• 220, 440 yd sprints; stair runs; intervals on bike, skates

Intermediate power (glycolysis)

• 60-90 sec; improves speed endurance

• 220, 440 yd sprints; stair runs; intervals on bike, skates

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Endurance (aerobic; fat & CHO)

• Sustained intervals

• Enables quicker recovery

• Helps in sustaining aggressive skiing

• Helps in maintaining high tempo

Endurance (aerobic; fat & CHO)

• Sustained intervals

• Enables quicker recovery

• Helps in sustaining aggressive skiing

• Helps in maintaining high tempo

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Strength Training PearlStrength Training Pearl

90% of strength gains can 90% of strength gains can be achieved withbe achieved with

90% of strength gains can 90% of strength gains can be achieved withbe achieved with

1 set1 set1 set1 set

2 times/week2 times/week2 times/week2 times/week

12-repetition program12-repetition program12-repetition program12-repetition program

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• Symmetry is key

• Avoid co-contraction, substitution

• HC, HS, hip groups, ITB, back, shoulder groups

• If use bicycle, be careful to avoid hip flexor tightness

• Symmetry is key

• Avoid co-contraction, substitution

• HC, HS, hip groups, ITB, back, shoulder groups

• If use bicycle, be careful to avoid hip flexor tightness

FlexibilityFlexibilityFlexibilityFlexibility

©2011 MFMER | 3124042-29

Flexibility Pearls

“Range of motion about a joint”

Flexibility Pearls

“Range of motion about a joint”

• Stretching increases muscle blood flow

• Enables more efficient movement

• May be injury protective

• Genetic differences

• Stretch after exercise; consider dynamic movement prior

• Hold for 30 seconds

• Stretching increases muscle blood flow

• Enables more efficient movement

• May be injury protective

• Genetic differences

• Stretch after exercise; consider dynamic movement prior

• Hold for 30 seconds

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©2011 MFMER | 3124042-31

Don’t Forget the “Core!”Don’t Forget the “Core!”

• Core is the platform from which LE force applied

• Core is also the acceptor of force from the legs and transmitter of force to the arms

• Core is the platform from which LE force applied

• Core is also the acceptor of force from the legs and transmitter of force to the arms

©2011 MFMER | 3124042-32

Practical Assessment: Core Strength Screening

Practical Assessment: Core Strength Screening

• Ability to hold plank• Ability to hold plank

©2011 MFMER | 3124042-33

Core Strength ScreeningCore Strength Screening

• Ability to hold reverse plank position

• Ability to hold reverse plank position

©2011 MFMER | 3124042-34

Core stabilityCore stability

©2011 MFMER | 3124042-35

mayoclinic.orgmayoclinic.org

• Fitness Healthy Lifestyle Center

• Stretching Slide Show

• Core Training

• Strength Training videos: body weight, free weights, tubing, machines

• Fitness Healthy Lifestyle Center

• Stretching Slide Show

• Core Training

• Strength Training videos: body weight, free weights, tubing, machines

CP1080418-37

Legs: Ski-specific muscle groups

• Hamstrings: Important in ACL protection and if deficient

• Quads: include eccentric

• Gluteus maximus

• Hip ab & adductors

Legs: Ski-specific muscle groups

• Hamstrings: Important in ACL protection and if deficient

• Quads: include eccentric

• Gluteus maximus

• Hip ab & adductors

StrengtheningStrengtheningStrengtheningStrengthening

ACL tearACL tear

©2011 MFMER | 3124039-38

Non-Contact ACL InjuriesNon-Contact ACL Injuries

• Risk FactorsEnvironmental (external)

Weather, surface, footwear, bracesAnatomic

Q-angle, BMI, pronation, notch/ACL size, ACL material properties

HormonalProgesterone, estrogen

GenderFemale > Male

GeneticNeuromuscular

Movement patterns, muscle activation patterns, fitness





GenderFemale > Male



©2011 MFMER | 3124039-39






GenderFemale > Male







GenderFemale > Male



©2011 MFMER | 3124039-40


• NeuromuscularMen tend to undergo a “neuromuscular spurt” that occurs at the time of their growth spurt, while women do not (Hewett et al. 2006, Yu et al. 2005)

• NeuromuscularMen tend to undergo a “neuromuscular spurt” that occurs at the time of their growth spurt, while women do not (Hewett et al. 2006, Yu et al. 2005)

Dynamic/Functional Knee ValgusDynamic/Functional Knee Valgus

©2011 MFMER | 3124042-42

TRAINING THE LOWER BODYTRAINING THE LOWER BODY

Abnormal Normal

Functional Hip Abductor Strengthening


©2011 MFMER | 3124039-45

Functional movement trainingFunctional movement training

©2011 MFMER | 3124039-46

Functional movement trainingFunctional movement training

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Upper body: Helps balance & ability to withstand turning forces without unwanted upper body rotation

• Scapular stabilization

• CKC: Push-ups, pull-ups

• Triceps (pull downs): Helps with race start and poling

Upper body: Helps balance & ability to withstand turning forces without unwanted upper body rotation

• Scapular stabilization

• CKC: Push-ups, pull-ups

• Triceps (pull downs): Helps with race start and poling

CP1080418-41

Template for Sports-Template for Sports-Specific StrengthSpecific Strength

Template for Sports-Template for Sports-Specific StrengthSpecific Strength

CP1080418-45

• Isolate

• Integrate

• Skill/sport-specific “perfect” practice

• Isolate

• Integrate

• Skill/sport-specific “perfect” practice

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©2011 MFMER | 3124042-64

Lower Extremity Stability Training“Good balance is the ability to react to

imbalance”

Lower Extremity Stability Training“Good balance is the ability to react to

imbalance”

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• Slalom course (± rollerblades)

• Slide board

• Wobble board

• Trampoline

• Tight rope

• Skier’s edge/fitter

• Run/cut

• Rollerblade

• Slalom course (± rollerblades)

• Slide board

• Wobble board

• Trampoline

• Tight rope

• Skier’s edge/fitter

• Run/cut

• Rollerblade

Skiing SpecificSkiing SpecificSkiing SpecificSkiing Specific

Foot Quickness/AgilityFoot Quickness/AgilityFoot Quickness/AgilityFoot Quickness/Agility

CP1080418-63

•Tennis & racquet sports

•Touch football

•Basketball

•Soccer

•Fencing

•Aerobic dance

•Tennis & racquet sports

•Touch football

•Basketball

•Soccer

•Fencing

•Aerobic dance

““Fitness is a journey,Fitness is a journey,not a destination.”not a destination.”

““Fitness is a journey,Fitness is a journey,not a destination.”not a destination.”

CP1080418-65

Ken Cooper, MDKen Cooper, MD

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©2011 MFMER | 3124042-83

Dynamic/Functional Knee ValgusDynamic/Functional Knee Valgus

©2011 MFMER | 3124039-84

Training the Lower BodyTraining the Lower Body

Abnormal Normal

©2011 MFMER | 3124039-85



Core Strength ScreeningCore Strength Screening

• Ability to hold supine hollow body

(reverse arrow) position

• Ability to hold supine hollow body

(reverse arrow) position

What You Need to KnowWhat You Need to KnowBefore you Hit the SnowBefore you Hit the SnowWhat You Need to KnowWhat You Need to KnowBefore you Hit the SnowBefore you Hit the Snow

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Abdomen

• Core stabilization

• Enables more effective upper and lower body movement

Abdomen

• Core stabilization

• Enables more effective upper and lower body movement

Difficulty with Epidemiologic DataDifficulty with Epidemiologic DataDifficulty with Epidemiologic DataDifficulty with Epidemiologic Data

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• Different populations at risk

• Different terrain

• Different snow conditions/environment

• Different equipment

• Different exposure rates

• Different experience

• Different populations at risk

• Different terrain

• Different snow conditions/environment

• Different equipment

• Different exposure rates

• Different experience

ACL Injuries in General PopulationACL Injuries in General PopulationACL Injuries in General PopulationACL Injuries in General Population

CP1080418-6

• 38/100,000/yr – Miyasaka, ’91

• 50/100,000/yr – Jensen, ’83

Football: 60/100,000 players/day – Hewson

Skiing: 70/100,000 skiers/day – Feagin, ’87

50/1000,000 skiers/day – Johnson

• 38/100,000/yr – Miyasaka, ’91

• 50/100,000/yr – Jensen, ’83

Football: 60/100,000 players/day – Hewson

Skiing: 70/100,000 skiers/day – Feagin, ’87

50/1000,000 skiers/day – Johnson

Ski Injury Trends, ’72-’92Ski Injury Trends, ’72-’92B. Johnson, U of VermontB. Johnson, U of Vermont

Ski Injury Trends, ’72-’92Ski Injury Trends, ’72-’92B. Johnson, U of VermontB. Johnson, U of Vermont

CP1080418-7

Injury rate

• 7/1,000 skier-days before 1970

• 2-3/1,000 skier-days currently

Study population, ’72-’73 to ’89-’90

• 6,139 patients

• 6,171 injuries

2 million skier visits

Injury rate

• 7/1,000 skier-days before 1970

• 2-3/1,000 skier-days currently

Study population, ’72-’73 to ’89-’90

• 6,139 patients

• 6,171 injuries

2 million skier visits

Ski Injury TrendsSki Injury Trends(cont)(cont)

Ski Injury TrendsSki Injury Trends(cont)(cont)

CP1080418-9

Decline for all injuries: 48%

• Mean days between injuries (MDBI)

‘72: 214 MDBI

‘90: 408 MDBI

Decline for all injuries: 48%

• Mean days between injuries (MDBI)

‘72: 214 MDBI

‘90: 408 MDBI

Ski Injury Trends (cont)Ski Injury Trends (cont)Ski Injury Trends (cont)Ski Injury Trends (cont)

CP1080418-10

Patterns of injury

• LEs: ~50% of injuries

• Decrease: Ankle & tibia fractures, upper body injuries, lacerations

• Increase: Clavicular fractures

• Knee sprains

Patterns of injury

• LEs: ~50% of injuries

• Decrease: Ankle & tibia fractures, upper body injuries, lacerations

• Increase: Clavicular fractures

• Knee sprains’72-’73 ’89-’90

Total 20% 26%

Gr III 15% 66%

’72-’73 ’89-’90

Total 20% 26%

Gr III 15% 66%

CP1080418-18

Documents

Conditioning for Downhill Skiing Conditioning for Downhill Skiing CP1080418-1 Edward R. Laskowski, M.D. Co-Director, Mayo Clinic Sports Medicine Edward