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Protect Your Knees While Skiing this Winter
For many, the approach of winter brings the excitement of returning to the slopes for downhill skiing. Unfortunately, that also means a risk of injuring the anterior cruciate ligament (ACL) in the knee. Alpine, or downhill, skiing has a long association with ACL injury and treatment. ACL injuries have been shown to make up a sizable proportion of all ski injuries, with a stable or even increasing prevalence over the last several decades. These injuries strike skiers of all levels and both sexes, with conflicting data on whether males or females have a higher rate of injury.
ACL injuries most often occur while skiing through a forward, twisting fall, often via the “slip-catch mechanism”. In the “slip-catch” mechanism, the inner edge of the outer ski catches the snow during a turn, forcing the knee into valgus and the tibia into internal rotation. Poor conditions have been shown to be associated with a higher risk of ACL injury for novice and experienced skiers alike. Skiers have been shown to have a higher risk for ACL tears if either parent has a history of this injury. Also, the risk for ACL tear has been shown to vary in association with the menstrual cycle for female skiers, with higher risk in the preovulatory phase. Female recreational skiers have also been shown to be at greater risk for ACL tears on their non-dominant lower extremity.
While there is limited evidence that a subset of recreational skiers can return to skiing without surgery, patients are usually treated with ACL reconstruction after tearing their ACL, especially if they want to return to the slopes. Autograft is likely preferable for skiers over allograft, but there has been conflicting opinions regarding whether hamstring or bone-patella tendon-bone is optimal for these athletes. Upon return to skiing after ACL reconstruction, there is an elevated risk for re-tearing the graft. Fortunately, there is at least some evidence that bracing may benefit skiers with a history of previous ACL reconstruction.
Considerable effort has gone into efforts to reduce the risk of ACL injury among skiers. Bindings designed to reduce the risk of leg and ankle injuries have paradoxically been associated with an increased risk of ACL injury. While at least one study demonstrated that targeted training can reduce the risk of ACL injury in skiers, there is little data on the effectiveness of ACL injury prevention programs for this population.
In summary, skiers are at risk for ACL injury on the slopes. Poor conditions are associated with a higher risk of injury and ACL tears are often treated with surgical reconstruction of the ligament. More effort should be focused on identifying modifiable risk factors for ACL injury among skiers, particularly in skiers with a history of previous ACL reconstruction.
ACL Patient Story
ACL Injuries Video (Rick Wright, MD)
Sports and ACL Blog (Rick Wright, MD)