A Look at Ski Injuries With Jeff Padalecki, MD

Texas orthopaedic surgeons are busy treating numerous ski injuries. TOA recently sat down with Jeff Padalecki, MD – an Austin orthopaedic surgeon – to take a look at ski injuries.

TOA: What are the most common ski injuries that you see in your clinic?

I treat ski and snowboard injuries frequently during the winter months in my clinic. In my experience, ligament sprains of the knee are the most common joint injury in skiers. This high frequency of knee injury in skiers may seem intuitive considering the way that ski boots stabilize the foot and ankle thus leaving the knee to experience rotational stress. Ligament injuries to the knee can often occur as a result of a quick low-energy abnormal knee rotation. Some evidence has suggested that MCL injuries are the most common ligament injury amongst skiers but obviously anterior cruciate ligament injuries receive more press because of the low propensity to heal without surgical intervention. ACL tears can also frequently occur while reapplying skis after a fall or when exiting the lift.

Skiers also often sustain fractures of the lower extremity which can include fractures to the tibial plateau or long bones. With lower extremity fractures, it is not uncommon to note a high energy mechanism which results in very significant trauma to the limb. These fractures are sometimes temporarily stabilized on the mountain and then patients travel back home for definitive fixation.

Skiers also sustain their share of upper extremity trauma including shoulder/wrist injuries and of course the so-called gamekeeper’s thumb. In inexperienced skiers, female injury rate is much higher than the injury rate in their male counterparts but this seems to equalize in the elite skier group.

Snowboarders seem to have a higher incidence of upper extremity trauma with wrist and shoulders being the most commonly affected joints. I have frequently seen AC joint trauma and clavicle fractures related to snowboard accidents which is somewhat intuitive with the frequency of falls in snowboarders and the propensity to “catch an edge.”

TOA: You completed your fellowship at the Steadman Clinic in Vail. What kind of an experience was that for you from a ski-related injury standpoint?

Jeff Padalecki, MD speaking at a TOA conference

Jeff Padalecki: I was very fortunate to be a fellow at the Steadman clinic. If you accept some historically published numbers, ski injuries may occur as frequently as three injuries per 1,000 skiers per day. It is not uncommon for the Vail area to experience 20,000 skiers on any given day. If you do the math, there are a lot of injuries that need medical attention throughout the ski season. That makes for a very extensive experience with treating upper and lower extremity injuries. It also leaves very fertile ground for award-winning research that has applications locally and internationally.

The patient population did not just provide ski and snowboard injuries however, there was also a pipeline of tertiary referrals from other institutions. Many international athletes would travel to the clinic for surgical treatment of sports injuries. In addition to this dynamic, we were also responsible for covering events such as the X games and the Dew Tour to provide on-site medical care. In much the same way, we traveled with the US Ski and Snowboard team to assist with the medical coverage.

TOA: What type of evolution have you witnessed in treating sports injuries during your time in practice?

Jeff Padalecki: Orthopedic sports medicine is always evolving with new surgical tools and knowledge creating a constantly changing environment. Perhaps the biggest contributor to that evolution in the last 10 years is that of the use of biologics. Stem cells and platelet rich plasma are becoming household names where patients now enter the clinic and ask about these modalities by name.  PRP has become a frequently offered treatment modality for tendinopathies and also an injection option to treat the symptoms of arthritis.

I think the single most significant evolution in shoulder treatment involves a new option for patients who suffer from pain and weakness related to rotator cuff tear arthropathy. Arthroscopic superior capsular reconstruction has emerged as a very promising new treatment option in the last 10 years. This treatment, which involves fixation of a patch between the glenoid and humerus, allows for recentering of the humeral head to reduce pain and allow for active elevation. This has the potential to allow patients to avoid the risk and finality of reverse shoulder replacement.

TOA: What advice do you have for Texans who plan to go skiing?

Jeff Padalecki: It is important to remember that ski injury risk can increase in poor conditions. Flat lighting, a paucity of snowfall in the recent 24 hours, and limited grooming all contribute to increased risk for skiers. There are factors that most skiers and snowboarders can control, including appropriate rest and hydration, as well as choosing runs that are within one’s own abilities.

There is some research suggesting that skiing or snowboarding more than three hours without the appropriate break or hydration may result in higher risk of injury. There is also research that has suggested an extreme decrease in injury rate by simply providing education based on diet and hydration for a group of employees at a ski resort.

Risk can become fairly extreme when disregarding warning signs and choosing to enter areas that have been roped off or listed as dangerous. Avalanche risk is carefully studied daily at most major resorts, and often there is available information and signage to help limit the chance of experiencing avalanche related injury. There has recently been some research and interest in specialized bindings with two distinct pivot points that would “sense” a twisting load applied to the ski.

There is current research looking into the efficacy of these so called “knee bindings” to help reduce the risk of knee injuries in skiers. There have been no proven reports that these bindings can reduce injury to date but certainly it is an attractive thought to think that you can reduce the risk of injury simply by choosing the appropriate gear. It makes intuitive sense that improving fitness, strength and flexibility prior to skiing has the potential to reduce risk of injury. For skiers who don’t live near snow and only ski infrequently, we typically recommend a six to eight week focus on high intensity interval conditioning. This should also include a focus on quad strength and core strength. We also recommend focusing on aggressive hamstring and hip flexor stretching.