Ski Season.

The cold winter air on your face, fresh powder under your feet, stillness of the wilderness… Whether you tackle the slope on skis or a snowboard nothing quite compares to the feeling of that first run of the day. But as with all sports, injuries can ruin what started as the perfect alpine morning.  Read on to learn about the most common issues snow seekers face and what can be done to stay as safe as possible. 

Common Injuries

For winter sports enthusiasts of the skiing type, the most prevalent injury is in the knee.  With the feet and ankles locked in a hard sided ski boot, the force is directed to the knees means when you fall on the slope.  This force can cause a variety of knee issues, one of the most feared is the ACL Tear (which I wrote about in depth here… LINK), but you can also injure other areas including ligaments such as the MCL or LCL, the menisci, or even the bones (femur/tibia) as they join at the knee.  

For snowboarders, knee injuries can also occur. However, given the orientation of the board on the slope and the single-sled positioning (feet both fixed to the same board), the most common area injured is the wrist. When a snowboarder starts to fall, they instinctively reach for the ground causing injuries ranging from minor sprains to fractures of the wrist bones. 

For all alpine lovers, injuries to the shoulder can also occur.  During a fall you can easily land on your shoulder or outstretched arm causing injuries to the tendons, muscles, or ligamentous structures in and around the shoulder. Shoulders can stretch out of place (subluxate), dislocate, or break with this mechanism. 

Other areas of the body are also prone to injury from a fall on the slope including the hips, spine, and chest wall. 

The most traumatic snow sport related injuries are those to the head or neck. For experienced and novice skiers alike, barreling down a slippery slope can be hazardous. Conditions that make this worse are crowded areas and other obstacles like trees or rocks.  Hitting another person or a tree can have devastating consequences as can your head on the hard packed snow.  Injuries can range in severity from concussion  to bleeding or fractures to severe traumatic brain or spinal cord injuries.

How to stay safe

Staying safe on the slopes makes for a much better day then ending a run with an injury.  

My recommendations: 

1- know your limits and the trail maps

2- train before you ski

3- save the alcohol for the après

4- wear a helmet, always

1. Know your limits

Staying safe on the slopes requires a level of understanding of what you are getting yourself into as well as a knowledge your ability. If you are a beginner or novice, look at the trail map ahead of time and stick with the runs appropriate for your skill level. You are not competing for a spot on the Olympic team… Even if you are more advanced, remember to avoid putting yourself in a position where you feel out of control.  The number one reason I see patients in the office with an injury is getting themselves into an uncomfortable position.  If you end up in this scenario, it is best to stop and ask for help. Ski patrol is always available to keep you safe.  They would much rather help you down the slope than find you injured. 

Another great tip is to take a lesson. No matter how advanced of a skier you are, lessons can be extremely helpful! During my last ski trip, I took a lesson, and it was worth every penny. The instructor was a true gem, helping me (more novice) and my husband (more intermediate) at the same time by challenging each one of our levels safely.  He was so great that when he ran into us the next day while skiing with his daughter, he skied with us for a bit for follow up tips.  These instructors live for skiing, know the terrain, and know how to teach you to be better. Everyone can learn!

2. Train before you go

If you were going to run a half marathon you wouldn’t just show up race day and expect to finish without problems.  Same goes for snow sports. Even if you are in great physical shape at baseline, some activity specific training can be beneficial.  Skiing and snowboarding are physically demanding sports. You need strong legs, great control of your upper and lower body, and stamina to survive the day.  I can’t count the number of patients who describe their injury as something like, “I was tired, out of control and crashed but can’t remember what actually happened.” Don’t be that person. 

3. Save the Après

Ah yes, the time-honored tradition of that first amazing post-ski après beverage at the lodge. It may be my favorite part of the ski day.  However, studies have shown that alcohol increases the risk of injury for both skiers and snowboarders. (As does any illicit/mind-altering substance use). Save the après festivities for after you are done skiing for the day. 

4. Wear a helmet, always

This one cannot be stressed enough. Head injury can be a devastating outcome of a crash on the slopes. No matter how well you ski, a fall can still happen. It is sort of like driving, even if you drive perfectly, someone else can hit you or cause you to crash. So, we were seatbelts, right? Wear a helmet every time you ski or snowboard. Protect your skull and brain and decrease your risk of tragic outcomes. 

If an injury occurs

Ski patrol is always available for injured skiers. They are all over the mountain and at the base, and most resorts employ trained medical staff. Some even have physicians available. Every ski town I have been to has a local urgent care as well with a team that is used to seeing slope related injuries. If you need follow up after a day on the slopes for a bone, muscle or joint problem seek out your local sports medicine orthopedist. It is always helpful to bring any images (Xray’s, MRI’s, etc…) that were taken on the slopes or after.

And of course, enjoy the snow!

Orthopaedic Injuries of Pregnancy

It is no secret that pregnancy comes with a host of changes for your body. These changes allow you to accommodate making a new life but also can put you at risk for musculoskeletal issues along the way.  This is often because of some combination of loosening of ligaments due to hormones, changes in the center of gravity due to your new “bump”, added weight in general, and increases in overall body stress.

Most common Issues I see in practice:

#1 Injuries from a Fall:

As a specialist, I usually see a patient when they hurt something that needs further investigation.  Injuries happen to even the healthiest of pregnant patients.  One of the most common I see is an ankle sprain (see my full post here on all things ankle sprains) Pregnant patients often feel unbalanced.  A movement as simple as stepping off a curb awkwardly can lead to an ankle injury. The great news is the treatment for ankle sprains during pregnancy is very similar to the average patient, and most do very well without long term issues. 

Another common injury from a fall is a broken kneecap (patella).  Again, these tend to happen because of being a little off balance.  With a slip or fall, you can land directly on the knee causing the patella to break. This is painful! The injury is not usually subtle and makes it difficult to stand or walk.  X-rays will show us the problem, and sometimes the problem needs to have surgery to fix, but often you can get better with a period of resting your leg in a straight position. Though keeping your leg fully straight for weeks is not easy while pregnant… something I appreciate even more now that I am pregnant! But my patients have made it through, and you will too! 

Other broken bones can also happen during pregnancy from falls. The second most common fracture in my practice is a broken wrist. When you start to fall you naturally reach for the ground to brace yourself. Unfortunately with this motion, you can land on your outstretched hand break a bone in your wrist called the distal radius. Again, sometimes these need to be fixed with surgery. The ones that do not are treated in a cast for several weeks. Being in a wrist cast while pregnant also seems absolutely no fun, but it is achievable and safe.  Keep in mind these things can happen in pregnancy (just like outside of it), and orthopedic doctors are trained to do what is best to make sure your bones heal well, and your pregnancy stays safe. It is key to let your OB know if you have had a fall or are seeking care with another doctor. This allows us to all work together to be sure we are optimally treating you and keeping everything as pregnancy safe as possible.

#2 Aches and Pains

Ah yes, the joys of pregnancy…  Sometimes if feels like everything hurts whether you move or sit still! Joint pains, achy muscles, and stiffness all over are very common.  Muscle imbalance mixed with a growing belly often leads to a very common complaint, back pain.  It is estimated that 50-80% of patients experience back pain during pregnancy (2). Other super common areas of pain are the hips/pelvic girdle, knee, and neck. Most of this can again be attributed to the normal changes that occur during pregnancy, and keeping active throughout is the absolute best way to keep these issues at bay.  

#3 Wrist and Hand issues

Again attributed to the changes of pregnancy, wrist and hand pain is also very common. One specific condition that plagues pregnant patients is carpal tunnel syndrome.  This condition usually experienced as hand numbness and tingling in the thumb, index and middle fingers and has been estimated to occur in up to 62% of women who are pregnant (1). Great news, this most often resolves on its own after delivery. Until then, stretches and braces for the wrist usually help relieve the symptoms. 

How to stay safe:

First and foremost, listen to your body! The changes of pregnancy alter so much about your function and physiology. You should avoid risky activities where falling could occur, be careful on wet ground and ice, and always be extra vigilant of where you are walking. Stepping off a curb requires attention as does hurrying across a street or walking on a dirt road/path. Be careful! 

Another great tool is a daily body “check in” to see how you are feeling. Is your back tighter today? How do those hips feel? If you can catch an ache or pain early before it becomes severe, you can likely fix it faster. Add in stretches or targeted exercises for your problem areas, and keep moving throughout pregnancy.  Another tip is to remember to take a break if you are sitting for a prolonged period. This helps keep your body from becoming stiff.  It is important to avoid heavy lifting, and be sure you are using proper techniques to lift with your legs (not your back) to stave off further back pains and injuries.  Avoid reaching far away from your body as much as possible to keep your center of gravity stable.  Sadly, since your balance is a little off, retiring your high heels short term is the safest thing to do. 

As always on this website I preach an overall healthy, active lifestyle. In pregnancy this doesn’t change! If anything, it means more focus on these techniques to keep you fit as everything changes. Daily stretching, strengthening, and cardiovascular exercise help keep your body healthy and strong all pregnancy long. This helps you avoid injuries, keeps a better mind-body connection to avoid falls, and keeps aches and pains away.

Finally, what to do if you have pain or get hurt:

First, think about the severity (how bad is it?). If on your daily body check you noticed some general soreness and aches and pains, start with easy-to-do changes at home. Sit in a more proper position while working, remember to take standing breaks, and be sure you are getting proper exercise and stretching.  Always keep in mind your daily routine and that you may need to change something if your body is aggravated by these activities. Also, as always, talk to your OB! Bring up these concerns at appointments or even before if you feel they are significant.  Many small aches and pains are common and not a big deal, but you should always discuss with your doctor to be sure something further doesn’t need to be evaluated. Also know that even for general aches and pains, sometimes braces or other supports can be used to ease the discomfort.  Sometimes your doctor may recommend a pregnancy-safe medication such as Tylenol or even refer you to physical therapy to aid in your recovery.

If you have a larger amount of pain related muscle or joints or if you have had a sudden injury, an urgent/emergency evaluation is the way to go. You should also absolutely reach out to your OB as they can work with your orthopedic team to be sure you are optimally treated as a whole by coordinating specific recommendations based on pregnancy. If you need an X-ray, don’t panic. You can use a shield, and the doctor will do everything possible to keep you safe by only taking x-rays that are necessary to treat you properly. Trust your doctor, and ask questions along the way. I never feel bad when a pregnant patient asks about the necessity of a test or treatment. 

Sources:

1. https://pubmed.ncbi.nlm.nih.gov/19753825/

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3306025/

3. https://www.cedars-sinai.org/health-library/diseases-and-conditions/b/back-pain-during-pregnancy.html

Need to know: Ankle Sprain

The ankle sprain… One of the most common reasons patients see me in the office. Here is all the information you need to know if this happens to you.  It will be just like if you were visiting me in the office!

An ankle sprain occurs when your foot rolls in or out putting extra stress on the ligaments.  This causes the ligaments to stretch/tear, which is by definition an ankle sprain. If your ankle rolls where sole is facing in, it is called an inversion injury (most common). If your ankle rolls where with your sole facing out, it is an eversion injury. These injuries can happen during sports, basketball and volleyball are common, or in any setting when athletes can land awkwardly from any jump or step. Sometimes though for the unlucky patient the injury can occur during day-to-day activities, something as simple as stepping off a curb wrong at the grocery store.  I have seen all of the above (and more) in my office!

During the sprain, the ligaments are stretched/torn which causes pain and swelling. The great news is these ligaments are not typically the type we need to fix with surgery, and most people heal quickly without long-term problems.  However, more complex types of sprains do exist that take longer to heal or may need more intervention.  For example, a “high ankle” sprain results from a more forceful twist that injures the ligaments above the ankle between the lower leg bones in an area called the syndesmosis. With other high energy injuries, you can also injure ligaments lower down in the foot or even break the bones.  If you are a kid and still growing, your growth plates are weaker than the ligaments.  Because of this when you twist your ankle, the bones may be more likely to break than for a ligament to tear.  This is a commonly missed injury by non-orthopedic physicians, can take longer to heal, and needs a correct diagnosis to be treated properly.

 Today we focus on the essential adult ankle sprain, the inversion (sole of foot turning in) injury that tears ligaments mainly on the outside part of the ankle. The most common injured ligament is called the ATFL, or anterior talofibular ligament.  If you look at your right foot it is that approximately at the 2 o’clock position on the top of your foot about 1 cm from the ankle joint. 

The injury causes a tear/stretch of this ligament resulting in pain, swelling, and bruising. 

 Treatment is usually very straightforward. I recommend starting with ice for the first 24-48 hours with rest (doing as little as possible) and elevation (at or above the level of the heart) for swelling. You should only do light activities that do not increase pain. If you have a more significant injury and you cannot walk normally, sometimes I recommend using a brace or other support device like a medical grade boot short term.

The timeline for recovery is variable and depends on how bad the injury is and what your goals for return to activity are. If you have a small injury and are doing low impact movements (sitting/walking) a full recovery is quicker than if you have a larger injury and play sports that require cutting, jumping, or pivoting. 

The biggest risk with an ankle sprain is repeat injury. Once the ligaments are injured, your ankle is more unstable and weaker.  You are more likely to sprain it again or injure it further if you have not fully regained all your strength, balance, and coordination lost with the initial injury.  Your body normally controls ankle stability (balance and strength) with proprioception. Proprioception is a protective sensation where your brain sends a signal to a joint and the joint responds with position updates.  Think of it like you brain asking your ankle, “Hey, how’s it going down there, which way are you pointing, how stable is that ground?” And your ankle responds, “I am okay, pointing straight ahead, ground stable no cause for concern.”  This happens constantly and nearly instantaneously with movement.  Consider this – don’t you always know where your ankle is without even having to think about it?  When you have an injury that feedback communication does not work as well.  The ankle’s response can be slowed and inaccurate.  This causes an increased risk of a second injury.

We can improve the ankle’s ability to communicate via proprioception, as well as its strength and our balance with physical therapy. A physical therapist can assess how the ankle is moving and what needs to happen to retrain it to be pain free and moving well. In my office I see people with the initial injury and then depending on the degree of injury will either send them straight to physical therapy or will send after a period of rest. It takes several weeks to get the ankle back to moving normally, but most often after doing so people do very well.  

One common question I get is why the swelling lasts so long after the injury, even if they are progressing well otherwise. This is usually not cause for concern. In addition to injuring the ankle ligaments the other soft tissues around the ankle were injured.  Because of this, swelling can persist for many months even after your ankle feels better.  Another common question is why the ankle feels stiff or not quite like the other ankle.  The stiffness is from the lack of movement in the early recovery and from scar tissue that forms during healing. The great news as that the stiffness dramatically with time and work with physical therapy. 

My goal with treating an ankle sprain is to get patients safely back to all the activities they love as soon as possible.  At my initial evaluation we make a plan for what one should expect in the next few days to week and schedule a follow up to assess progress.  Having two visits helps me understand your trajectory for healing – two data points helps me see the line of how quickly you are progressing much better than single point.  Once physical therapy is started, I continue to monitor progress and help determine when one can return to sport activities. 

A final word on return to sport.  I return most people cautiously.  As I mentioned, recurrent injuries happen.  I unfortunately see patients that have long term chronic ankle pain or instability due to having multiple sprains.  This is a harder problem to fix and may even require surgery.  Getting the physical therapy right from the first injury can help prevent this problem.  For those with recurrent sprains, optimizing a physical therapy program and integrating ankle rehab into your exercise will absolutely be helpful and may also prevent the above. 

Any questions about ankle sprains? Let me know!  Share this with anyone you know that may find this useful.