Knee-hab: Skiers can take steps to protect against leg injuries on the slopes |

Knee-hab: Skiers can take steps to protect against leg injuries on the slopes

Christine Stanley

Ryan Salm / Sierra Sun / In his office at Sierra-Tahoe Orthopaedics and Sports Medicine, Dr. Anthony Zissimos explains the inner workings of the knee.

TRUCKEE – With ski season here, the dedicated powder-hounds and fair-weather weekenders are gearing up to hit the slopes. But as Alpine skiers are readying themselves, it’s likely that few are thinking of – and preparing for – the possibility of a season-ending injury.

Ahmed Gomaa certainly wasn’t. It was an enjoyable afternoon on a powder day last January when Gomaa’s tips clipped and sent him rolling like a rag doll down a backcountry run at Alpine Meadows.

“I took an angled line off a steep pitch, took 10 turns, and tumbled,” he said. “One ski didn’t release, and I could hear my knee popping over the sound of my head phones.”

It took some swallowed pride, hundreds of miles on a bike and reconstructive knee surgery to get Gomaa back on top of his game. But come this season’s first snow, Gomaa said he intends to be back at it.

To avoid sharing Gomaa’s experience, understanding the physiology and events that can result in knee ligament sprains and tears – the most common type of ski-related injuries – is important, according to local experts Dr. Anthony Zissimos and Dr. Nina Winans.

Gnarly knee injuries

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Thanks to improvements in ski boots, bindings and mountain grooming, major resorts across the county from the 1970s through the 1990s reported a 50 percent decrease in the number of ankle and lower-leg injuries sustained while Alpine skiing.

However, the same data also showed that during those years the number of knee injuries increased by a staggering 240 percent, equating to one-third of all ski injuries.

Tears of the medial collateral ligament (MCL) are most common and account for 20 to 25 percent of those injuries, according to Zissimos, an orthopedic surgeon at Sierra-Tahoe Orthopaedics and Sports Medicine in Truckee. In 90 percent of cases, MCLs will heal on their own.

Anterior cruciate ligament (ACL) tears, on the other hand, are a more difficult and painful matter. They account for 10 to 15 percent of all skiing injuries, can be extremely painful, and often require reconstructive surgery.

How the ‘ouch’ happens

A comprehensive study of Alpine skiing-induced knee sprains, published in 1995 in the American Journal of Sports Medicine, found that ACL sprains usually occur on the slopes in one of two ways.

The first way has been dubbed “boot induced,” and occurs when the impact of a hard landing applies forces to the back of a ski boot to drive the tibia out from under the femur.

The second and most common scenario is called “phantom foot.” This occurrence involves the tail of a ski moving in an opposite direction of the foot, thus twisting the ACL to its tearing point.

“From what I have seen and read, it’s not necessarily a person who falls, but a person who falls and tries to recover themselves,” said Pam Hosier, Alpine Meadows’ risk manager.

A skier who accepts a fall and allows the body to relax has a much better chance of avoiding a serious injury.

“You also need to be physically ready for your sport, with maximized core strength, balance and flexibility,” said Winans, also of Sierra-Tahoe Orthopaedics. “If you still think you can ski like you did when you were 18, but you haven’t done anything to prepare for it, then you are going to get yourself into trouble.”

Assessing the damage

If trouble does find you and the ACL is damaged, the affected knee will swell almost immediately.

“Anyone who has sustained a knee injury needs to first reduce effusion – the inflammatory fluid inside the knee capsule – with rest, ice, compression, and elevation (RICE),” Winans said.

There is a period after injury when weight should not be placed on the knee, according to Winans. But after swelling has subsided, range-of-motion exercises, such as bicycling or walking in a pool, should begin. A focus should also be placed on strengthening the hamstring and quadricep muscles that support the knee.

This “pre-habilitation” process will need to occur before ACL reconstructive surgery becomes an option.

ACL reconstructive surgery is never immediate, and is almost always optional, said Zissimos. Knee instability, which results in the leg buckling under the body’s weight, is often the determining factor.

For some, surgery can be avoided if the quadriceps and hamstrings are strong enough to support the body’s weight, or if the level of activity is lessened.

“I knew that I was going to need surgery because I still wanted to do everything possible,” said Gomaa, who underwent surgery five months after being injured.

To ready himself for the procedure and the rehabilitation to follow, Gomaa focused on cycling in order to keep his muscles active and engaged, including a 16-mile ride on the day of his surgery.

“ACLs will not heal themselves, but most people can live a relatively active life without one – just not many people that live here,” Winans said, commenting on Truckee’s high demand for active and aggressive lifestyles. “The people here who have not had to have ACL reconstruction have done an amazing job with their rehab and have very strong hamstrings and quadriceps.”

Ready for rehab?

With or without surgery, anyone who has sustained an ACL injury will need some rehabilitation – usually four to six weeks without surgery and up to 16 weeks with.

After surgery, a patient should be back to active in about eight weeks, though the knee will still not be strong enough for twisting and cutting move-ments, such as those sustained in tennis, soccer, skiing, and snowboarding.

“If you tear your ACL during the ski season, you are probably done for the year,” Winans said. “If you have surgery in the spring, you might be able to ski with a brace the following season, but taking one off might not be a bad idea either.”

Quick bites:

The ACL is located in the center of the knee joint and runs at an angle from the femur (thigh bone) to the tibia (shin bone). It is the major stabilizing ligament of the knee, and provides rotational stability, prevents buckling, and keeps the tibia from sliding out from under the femur.

The boot-induced ACL injury:

If a skier lands a fall with their weight back, the muscles in the legs contract to their maximum capacity, and the stiff back of a ski boot is often able to drive the tibia out from under the femur, thereby tearing or severing the ACL in one quick snap.

The Phantom-Foot ACL injury:

For this type of injury to happen, six things must occur simultaneously:

1.The skier falls off-balance to the rear

2. All weight is pushed to the inside edge of the downhill ski tail

3. The uphill ski is un-weighted

4. Hips fall below the knees

5. The upper body faces toward the downhill ski

6. The uphill arm is back

If a skier can react quickly and correct one or more of those elements, an injury can be avoided.

Avoiding damage

It is important to avoid high risk behavior and know how to respond when falling is likely.

“ACL injuries occur because people resist the fall. The best way to fall is just to fall,” said Jason Dobbs, Squaw Valley Freestyle Team coach.

Once your arms and body weight begin to fall backwards you should

— Try to get your hand out in front and down to your boots

— Bring your skis together

— Keep your shoulders forward and your hands over your skis

— If you cant save yourself immediately, don’t.

If you are falling:

— Keep your legs partially flexed, and do not fully straighten your legs

— Don’t try to get up until you stop sliding

— Keep your arms up and forward


Women experience ACL injuries at a ratio of four to one over men, and there are a number of reasons why according to Dr. Anthony Zissimos, an orthopedic surgeon at Sierra-Tahoe Orthopaedics and Sports Medicine.

One is that women are more ligament dominant, meaning that they rely less on their muscles for strength and control, and more on their ligaments, said Dr. Nina Winans, also of Sierra-Tahoe Orthopaedics. They are also more quadriceps dominant over hamstrings, which is a large factor in boot-related injuries.

When landing from a jump, hamstrings serve to pull the tibia back and hold the bone in place. Without that antagonism against the ACL, it is easier for the back of a ski boot to force the tibia out of place and tear knee ligaments.

Hormonal factors can change the laxity of ligaments and tendons during different stages of the menstrual cycle, said Winans.

Women can counterbalance these issues by increasing hamstring strength, as well as hip adductor and abductor strength, and working on stretching and flexibility.

What is ACL reconstructive surgery?

If ACL reconstruction is necessary, there are three primary techniques for surgeons to consider.

The first is called an allograft, and uses tendons gathered from a cadaver.

“It’s not my first choice, because it’s not fresh and it’s expensive,” Zissimos said. “You can get great results, but would you rather eat frozen vegetables or fresh vegetables?”

The second option is called a hamstring tendon graft. It is a technique that is increasing in popularity, and uses two of a patient’s own four hamstring tendons.

“For me, the ham harvest was the way to go,” said Gomaa. “I wanted to have a knee that would allow me to do anything, and while rehab (after a hamstring graft) is a bit longer, the tendon is stronger.”

The third method is called patellar tendon graft. In this commonly used technique, the middle half of the patient’s patellar tendon is removed along with a small block of bone at each end.

An ACL reconstruction works like this:

The harvested tendon graft, which will serve to replace the damaged ACL, is fitted on each end with a small plug. The damaged ACL is removed and aligned tunnels are then drilled at an angle in both the tibia and the femur. The graphed plugs are then fitted into either tunnel and tightened into place.

Check it out:

Want to know more about the latest and greatest treatments for knee and other injuries? Check out the Winter Injury Sports Medicine Symposium on Dec. 5 from 4 p.m. to 9 p.m. at the Resort at Squaw Creek.

Topics will include case presentation, injury prevention, chest and abdominal trauma, non-avalanche related snow immersion death, mountain rescue, evaluation and care of wilderness orthopedic injuries, and mountainrescue.

Registration is complimentary to pre-hospital providers such as EMT’s, paramedics, ski patrol, fire fighters and law enforcement. For all other participants registration is $20 and includes CE’s, dinner, exhibits, raffle, and no host bar.

For more information or to register contact Loretta Shields at (530) 582-3543.