History of Knee Pain
It's about this time of year, every year, that people living in north of California think about strapping on skis for the winter. The most common concern is regarding knee integrity and readiness to ski.
I like to group the concern into three groups:
Chances are that if you fall into group 3, you will likely ski and have an injury-free season (but unfortunately there is always a first time for everything…). If you fall into group 1 or 2, you’ll likely appreciate the remainder of the article. Knowledge is power – use the following information to shape your training and awareness!
Mechanism of Ski Injuries
The knee has two joints – the tibiofemoral joint and the patellofemoral joint. Skiing loads both joints tremendously, in different ways.
The two most common knee injuries from skiing include ACL (anterior cruciate ligament) tears, and patellofemoral dysfunction (knee cap pain).
ACL tears are acute, and often a result of catching an edge, crashes or poor landings. They often fall into one of three categories:
1) Slip Catch: Commonly seen while turning when the inside edge of the outer ski catches the snow surface, forcing the knee into a valgus collapse and internal rotation position (2).
2) Dynamic Snow Plow: When one of the ski edges accidentally engages the inside edge of the skis, and forces the lower leg to jerk inwards (valgus collapse). The tibia rapidly moves across the middle of the body and cause the valgus collapse of the knee. (1).
3) Landing Back-Weighted: A tactical error in jumping / landing and technique that leads to landing on the tails of the ski, which will stress the knee joint in an anterior/posterior shearing nature (1).
Patellofemoral pain often comes on from an accumulation of poor or excessive loading. The most common fault (and easiest to identify) is a valgus collapse of the knee.
You can also identify this by watching someone squat or lunge, or squat / jump, as seen below. If the knee has a tendency to collapse inwards, the hip is usually doing a poor job stabilizing the knee.
Other possible reasons for patellofemoral pain include overuse of the quads (anterior chain dominance, too much skiing too soon), tight quads (causing compression of the patella) or weak quads (causing poor stabilization of the knee cap for the load being placed).
Training for Healthy Knees and an Injury-Free Ski Season
An entire training program for proper knee function is outside of the scope of this article, however a couple good examples include:
General loading principles to abide by include:
A reasonable list of exercises (from basic to advanced) include:
Two Leg Focused Exercises
Hopping (forward/backwards, side to side, diagonals)
Burpees (with jump)
Lateral Box Jump Overs (side to side)
Single Leg Focused Exercises
Single Leg Hopping (forward/backwards, side to side, diagonals)
Single Leg Hopping (through cones or agility ladder)
Single Leg Hurdle Bounds
Perfecting Your Technique
During the early part of the ski season, spend the first few ski days working on your technique. Perhaps some pointers from your friends or a ski instructor would be helpful? As you scroll up and review the possible injury mechanisms, remember that strength and, more importantly, technique are to blame for most ski injuries.
Now is the time to make a game plan. If you are excited for ski season, let this fuel your training!
Any level of commitment to pre-season strengthening is better than nothing! The ideal goal would be to get into the gym 3 times a week for strength training, but start with whatever you can commit to.
If you currently have pain, and aren't sure where to start, make an appointment with a physiotherapist or sports medicine physician.
See you out there!
1) Bere, T., Flørenes, T. W., Krosshaug, T., Nordsletten, L., & Bahr, R. (2011). Events leading to anterior cruciate ligament injury in World Cup Alpine Skiing: a systematic video analysis of 20 cases. Br J Sports Med, bjsports-2011.
2) Bere, T., Mok, K. M., Koga, H., Krosshaug, T., Nordsletten, L., & Bahr, R. (2013). Kinematics of anterior cruciate ligament ruptures in World Cup alpine skiing: 2 case reports of the slip-catch mechanism. The American journal of sports medicine, 41(5), 1067-1073.
The Great Outdoors. It is there for you to enjoy, to push your limits, and develop fortitude. For some people, going outdoors can be synonymous with developing injuries, but there are steps you can take to mitigate future injuries from taking place.
The Right Fitness Level
Greater fitness leads to a better understanding of your limits, as well as the ability to achieve greater feats. A physical assessment by a good therapist or strength and conditioning coach can help you sort through the thousands of exercises out there to know which ones are relevant to your needs.
- Slow, gradual increases in exercise and specific training are necessary (months and/or years). Our bodies adapt well to gradual stresses, but if too much load is placed on it at once, expect failure and injuries. It takes great dedication to yield great results. Most outdoor athletes peak in their 30s and 40s as they build cardiovascular endurance, muscular endurance, and a resistance to injury.
- Outdoor athletes often suffer overuse / over-training. It is important to consider whether you have proper body mechanics during training and outdoor pursuits. Have knowledgeable therapists, coaches and other athletes watch your form and provide suggestions. It is also important to include adequate cross-training, regular body maintenance (physiotherapy, massage, rolling), proper nutrition, and adequate rest.
- As a general rule there are certain joints which must be stable (strong ligamentous and muscular support around the joint, which prevents excess joint motion) and others which must have good mobility (the joint is built to be very flexible, however the muscular support around the joint must be able to control this increased range). As pertaining to lower body exercise, the core must be stable, hips must be mobile, knees must be stable, and the ankles must be mobile (Cook, Burton & Kiesel, 2010).
Try adding the following 20-minute routine into your regular workouts, three days a week. It is a small corrective exercise program built to help the user become more aware of hip / knee / ankle positioning during single leg stance. It is not meant to replace regular strength training. Rather, it should enforce the principles of joint alignment, feeling posterior chain engagement and will allow good transfer to outdoor pursuits.
A) Dynamic stretching. Perform dynamic stretching prior to exercise for 30 seconds per muscle group. A few lower body ideas include front/back and side-to-side leg swings, quick quadriceps stretches, quick piriformis/glute stretches, and hopping.
B) Airplane. At first you may need to hold onto something for balance, but eventually you should be able to progress to no hands. Goal = 10 reps per side.
C) Step-ups. Face a mirror and line up the hips and knees on the working leg to be approximately 90 degrees. Ensure that during the exercise, your knee tracks straight (not allowing it to collapse inwards or outwards). Lean forward, try to feel your glutes and hamstring fire on the upper leg then push through the heel on the working leg as you step up (this will help you to activate the posterior chain). Goal = 10 reps per side, with 2 times the expected weight of your backpack and gear.
D) Single leg star balance. Reach as far in each of the four directions as possible, while bending the stance leg at the hip and knee during the reaching phase (this leg should remain straight in line from the hip to the foot). Goal = 10 reps for each leg. 1 rep = a full cycle of the four directions.
Side note: Work to create symmetry in this test, as evidence suggests that a difference of more than 4 cm between left and right legs in ‘the forward reach’ component can help predict whether an athlete is at risk of injuring the leg (Smith, Chimera & Warren, 2014). Tip: Place masking tape on the ground and mark the distance in centimeters.
E) Piriformis rolling and pigeon stretch. 1 minute rolling, 1 minute stretch per side.
F) Lateral Quadriceps rolling and stretch. 1 minute rolling (focus on the outside of the leg), 1 minute stretch per side.
Start With The Right Intel
- Create specific training goals: How many days/hours, what gear do I need to use, am I familiar with the terrain?
- Become efficient and effective in your skill-set by learning the best decision making skills and techniques via free resources (friends, books, videos), and progressing to courses or hiring a guide.
The Right Gear
- Hiking poles take up to 25% of stress off your knees during descent (Schwameder, et al., 1999) help your legs save energy, and improve your balance on technical terrain.
- Boots that fit well can prevent crushed toes, and rolled ankles.
- Bring microspikes, mountaineering gear and/or avalanche gear if you expect snowy conditions.
Jacob Carter lives and works in Canmore, Alberta. He combines research evidence with clinical expertise to educate other healthcare professionals, athletes, and the general public on a variety of health topics.
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