The most common types of skiing knee injuries typically involve the lower extremity. Newer technologies such as breakaway bindings have cut down on fractures and decreased the chance of injury, but the biomechanics of the sport still lead a number of knee injuries.
In a ski boot, the foot and ankle are fairly locked into place, but the knee is unprotected and often bears greater pressure and is at a higher risk for injury. The most common skiing knee injuries for are sprains or tears of the MCL (medial collateral ligament) or the ACL (anterior cruciate ligament).
Biomechanics of the knee ligaments
The knee is a complex joint that supports the vast majority of the body’s weight. In a sport such as skiing, this joint is vulnerable do to the compression and rotation of the joint.
Image source: knee injuries to ACL and MCL
The knee joint is made up of three separate compartments: the medial, lateral, and patellofemoral. The bones that make up the joint are the femur (the superior portion), the tibia (the inferior portion) and the patella (anterior portion), also known as the knee cap, which is held in place by a tendon passing over the joint and connecting to the tibia.
There is no boney component that provides stability to the joint; the stability comes from a series of ligaments running through the knee joint capsule. There are also two menisci between the femur and tibia that provide stability and act as a shock absorber. Although there are many components that make up the joint, most knee injuries involve either the MCL or ACL, so this article will focus on those two ligaments.
The MCL is the ligament that runs on the inside of the knee from the femur to the to the tibia, and is the most commonly injured area in the knee. The ligament tightens during knee flexion and also prevents increased valgus stress to the knee. Imagine you have fallen on the ski hill and are sitting down with your planted skis shoulder width apart. When standing up, you bring your knees together. This places a valgus stress on the inside of the knee. Another common way to injure the MCL is to receive a blow to the outside of the knee forcing increased movement and stress to the medial portion of the knee.
The ACL is the ligament that attaches from the posterior medial portion of the lateral femoral condyle to the anterior lateral portion of the medial tibial eminence. In other words, the ACL attaches from the back of the inside portion of the outside femoral condyle and goes to the front of the tibia. The purpose of this ligament is to provide stability and prevent anterior translation, or forward slippage, of the tibia in relation to the femur. Whenever you see a football player go down on the field, the trainer will come out and grasp the knee to see if it slides forward. This tests the stability of the ACL.
Mechanism of knee injury
Skiing knee injuries to MCL
The most common cause of injury to the MCL is an inward blow to the outside of the knee. This forces increased movement and stress to the medial portion of the knee, and when this occurs, the medial joint or most inside portion of the tibia and femur become slightly separated, stretching or possibly tearing the MCL. There are a number of scenarios in which skiers can stretch or tear an MCL.
First, beginner skiers generally learn to control their downhill motion with the “snowplow” technique, where they bend their knees inward making a triangle with their skis facing down the hill. This places a stress on the inside of the knee. While this alone will not cause a tear of the MCL, it can cause a stress and some discomfort for a few days after skiing, depending on the condition of the skier and the hill.
However, if the skier picks up any speed or simply has a fall with the knees bent in, then the risk for a sprain or strain of the MCL is greater. Injuries to the MCL are generally isolated and have no further damage to the rest of the knee.
Injuries to this area are classified in 3 grades
- Grade 1- A slight sprain or stretching of the medial collateral ligament causing mild pain and tenderness over the area. This is a mild injury in many cases this will not necessarily keep the athlete out of competition. If the athlete is held out it is usually for less than 2 weeks.
- Grade 2- An incomplete tear of the MCL, there is more pain and some slight instability. After a grade 2 injury the time away from sport will be around 2-4 weeks to allow proper healing.
- Grade 3- A complete tear within the MCL causing pain and instability on the inside of the knee. The healing process for a complete tear can take up to 6 weeks or longer.
Skiing knee injuries to ACL
The ACL injury is the second most common injury to the knee for skiers, and is usually more serious.
The danger for skiers is the boot is locked into the ski and the ankle is also fairly motionless in the boot, which requires the knee to provide most of the motion for the legs. For beginning skiers, the bindings are set more loosely and the risk of damage to the ACL is decreased; however, the more advanced skiers have tighter bindings to allow for more aggressive skiing, which puts the knee at greater risk.
The ACL is at highest risk during a hyperextension or an accident with the foot pointed inward. This might happen on skis if the tips of the skis get caught in the snow or a tree root, forcing the forward tip of the ski to rotate inward. Even if the ski pops off, the motion of your body will continue forward and the knee could be hyper extended. This can also happen when turning hard and catching an edge. The ACL becomes tight with an inward rotation so a quick jolt and rotation can often cause an injury.
Unfortunately, many ACL injuries are the result of a collision between two skiers. If any of these things happen to you and if you hear or feel a pop in the knee during a hyperextension there is a good chance you have damaged your ACL.
Signs and Symptoms of Skiing Knee Injury to ACL & MCL
After the initial injury the most common signs and symptoms are pain, swelling, and tenderness on the inside of the knee joint right over the area where the MCL runs. It is also common to see slight bruising in the area. In some cases it is also likely to have slight instability, locking, or catching of the knee.
If the injury is a minor or grade one sprain, the athlete will still be able to walk with only mild discomfort in the knee in weight bearing situations. If there is a complete tear and a lot of swelling the athlete may have difficulty walking, and should be removed from sports until the injury has healed.
In many cases of an ACL tear or injury, the athlete will recall hearing or feeling a pop. With an ACL injury, there is usually immediate swelling and pain. The ACL is embedded deep in the knee joint, so an injury to this area will cause swelling of the entire knee instead of just the inside portion as an injury to the MCL would. It is also very unlikely to have an ACL injury without pain.
In most cases, especially that of a complete tear, the pain is moderate to severe. If after the initial injury the skier has a lot of swelling and feel as if the knee is giving out or unstable, that means you probably have an ACL injury.
Treatment for Skiing Knee Injury to ACL & MCL
The treatments of these two skiing injuries are fairly similar.
The beginning step is to immediately apply ice to the area. If you cannot get yourself to a doctor, continue to ice the knee as much as possible until you see one. It is best to use gel ice pack and apply it to the skin with a thin covering. It is usually not preferable to apply ice directly to the skin.
You should ice for about 20 minutes per hour, and no longer than 20 minutes at a time, as it is possible to over ice. If you keep the ice on the area for an extended period of time, then that portion of the body will think it is going into hypothermia, will pull more blood to the area, and will make the swelling worse. For the same reason, do not use heat at all. Even though the heat will feel good, you will cause further swelling to the area and will cause more pain later.
MCL Injury Treatment
Fortunately, most cases of MCL injuries can be treated without surgery. Only after conservative care has proven ineffective, or if there are multiple ligaments involved, is surgery recommended for MCL injuries. If you have a knee injury, go see your sports doctor. If you have a medical doctor or orthopedist you prefer, you can go to him or her for a diagnosis, however the treatment will more than likely come from a chiropractor or physical therapist, so you could save yourself a trip.
It is important to describe exactly how the injury happened to your doctor, as the history of the injury is one of the most helpful portions of the diagnosis. Your doctor will first perform an X-ray to rule out any underlying fracture or dislocation. A series of orthopedic tests will also be performed to assist in the diagnosis.
One specific test is to lock out the knee in full extension, and provide a slight valgus force (pushing from the outside of the knee inward). If this provides laxity or pain on the medial portion of the knee joint, then it is a very good indicator of an MCL injury. If your doctor believes there may be further instability or possible damage to the ACL, then an MRI will also be ordered, as x-rays do not reveal any soft tissue injuries.
Once the severity of the MCL sprain is determined, the length of treatment and time away from sports will be determined. It is possible not to miss more than a week, but a good rule of thumb is to expect about two weeks off after a grade 1 sprain. If you follow through with the treatment plan and give adequate rest you should be back to full strength within two weeks.
The most important step here is resting and icing. If you want to be back on the ski hill then take two weeks off and don’t push it, or else this could become a chronic issue.
Step two is dealing with the pain. During your therapy your doctor should apply some electrotherapy to not only diminish pain, but also remove swelling from the area. As the swelling goes down, the range of motion will increase and the stiffness and difficulty walking should improve.
At our office, Mountain View Pain Center, we prefer the use of interferential therapy as this provides both pain relief and removes edema (swelling). After the initial treatment, we also apply kinesio tape to the area. This tape is applied in a spider web fashion around the medial portion of the knee to assist in the removal of swelling. The tape can be worn for several days and will speed up the healing process.
The next step is to strengthen the area, and provide soft tissue release to regain the full range of motion. As with any ligament injury, there is scar tissue and restriction to the ligament after the healing process begins. To counteract the buildup of scar tissue we will strip out the ligament with soft tissue massage and other release techniques to free the ligament.
After this, micro-current therapy is used to allow the ligament and tissue to heal faster. Knee braces can be worn, but we often keep patients away from braces for long-term use, because some will use them as a crutch and not proceed with the proper treatment, and can even end up re-injuring the area. However after the injury it is advised to use a brace for around 2-4 weeks while in treatment and building up the area.
ACL Injury Treatment
If you suspect an ACL injury, immediately go to your doctor. They will perform specific tests to see if there is any ligament laxity or instability to the knee.
The two tests that are considered the gold standard for this type of injury are Lachman’s test and the anterior drawer test. The concept is to stabilize the femur or keep the foot planted with the knee bent and try to slide the tibia forward in relation to the femur. If the tibia slides then it is a great indicator of an ACL injury. (If you are trying to do this test at home to yourself, which is not recommended, then test both sides and compare your good leg to your injured leg, just as your doctor would.)
If your doctor thinks there is damage to the ACL he or she will order an MRI to determine the severity of the injury. If the ACL is torn completely through, you are more than likely headed to surgery. If you undergo ACL reconstruction, do not plan on getting back on the ski hill again until next year, as this is usually a season ending injury for any sport.
In minor cases of ACL sprains or non-complete tears, the treatment is very similar to the MCL; however, a different electric current, called Interferential, will be used to encompass the entire knee joint. The reason we use Interferential for the ACL is the pads are crossed around the knee to push the current deep inside the knee joint to treat pain and swelling.
ACL injuries usually have more pronounced swelling than that of an MCL and swelling abatement will generally take longer. If you have injured the ACL, it is highly recommended you do not compete in any sport unless cleared by your doctor, as the joint is too unstable. The most important thing in conservative treatment of the area is to ensure stability of the ACL so there is no reoccurrence of the injury. If you are a high level athlete or a more advanced skier, then it is important not to delay on treatment, or you will reinjure the area.
Exercises to Rehab from Skiing Knee Injury to MCL, ACL
These exercises can be performed for basic rehab or post surgical rehab. First step before your rehab of these injuries is to properly stretch to loosen up any tight musculature. Make sure to stretch the quads and the hamstrings, as well as the adductors and abductors.
The adductors run on the inside of the leg and can be stretched by spreading the legs far apart with your feet planted. Reach to one foot, hold for ten seconds, and then reach to the other foot. The abductors are on the outside of the leg and you can stretch these by crossing your feet and leaning over to one side. To stretch the right side, place the right foot behind the left and lean over to the left. It is important to note when stretching to not bounce to go further. This can cause further muscle injury. Just go to the point where you feel a good stretch and hold. As you progress over time you will be able to go further and further.
The important part of performing these exercises for the knee is full range of motion. We are not trying to bulk up these muscles right away, so start with low weight and high repetitions. If at any point the knee is in pain, then stop that exercise, drop weight, or don’t move the leg that far yet. If you cannot bend the leg all the way at the beginning, do not force it. Go to the full range of motion that your body allows without pain, and try to improve on that the next week.
For the first week we will contract the muscles without movement, these are called isometric exercises. You will start with leg extensions and leg curls. You can perform an isometric contraction of the hamstrings by bringing one leg up and placing the foot on a chair in front of you. Contract the leg as you would in a normal leg curl. Another simple way to do this is to sit on the floor with the leg flat in front of you and contract the hamstring by pressing the heel into the ground. For the quadriceps, place the foot under the couch or another object that will not move on contraction.
Perform three sets of 15 contractions holding for about five seconds each time. As we progress we will add weight, but make sure you are doing the exercises one leg at a time. Take your time, go slow, and perform the exercise correctly. If you do not have access to the gym then a simple method is to buy an exercise band and perform these in a chair. You can also take the band with you to work and do a few sets during the day.
As we advance in our rehab and the knee becomes more stable, the exercises will become more advanced, but be careful not to progress too quickly. If it hurts, don’t do it.
The next exercise can be performed daily. Sit in your chair and slowly stand without any assistance of the arms. This is a simulation of a squat or deep knee bend, but takes out the tension at bottom of the squat. As we progress, the next step is body weight squats, again slow and steady movements. Once these can completed without any discomfort and there is no residual pain the next day, begin single leg squats. These are performed by standing on one leg and then doing a deep knee bend.
It is always important, especially after the first few weeks of exercise, to ice the knee after the workouts, to prevent swelling and discomfort. If you have had an ACL injury, you should begin with a brace. The best type of brace you can get for an ACL will have hinges on the side. If it does not have hinges on the side then it is basically pointless to wear.
Another important note when getting a brace is to see if your insurance company will cover braces or DME products. If you are already paying for the insurance then you may as well use it. Most people are unaware that this is a covered service. If you decide to get one from your doctor, be sure to double check the product on line so you are not over paying for a product you can get on your own.
Supplements for ligament injuries:
- Glucosamine with MSM 100mg a day
- Vitamin C -1000mg a day
- Fish oils -as recommended
- Ligaplex and Cataplex ACP are herbal supplements we use at our office which promotes healing and helps strengthen the ligaments. These are brand specific; if you wish to look into them just email and I will point you in the right direction.
- Flavanoids -as directed on bottle. These are great for pain and swelling.
If you would like further information on supplements or vitamins for similar types of injuries, contact us or we can direct you to www.maxmusclehighlandsranch.com.
This article contains the opinions and examples of treatment plans for plantar fasciitis from Mountain View Pain Center in Centennial, CO, and is not intended as a substitute for specific medical advice from a doctor regarding your individual injury or condition. If you have any further questions or concerns feel free to contact our office or leave a comment below.
The Trainer’s Room is written exclusively for Midwest Sports Fans by Denver chiropractors Dr. Niall McNally and Dr. Ihsan Erhuy of the Mountain View Pain Center in Denver, CO. If you would like more information about skiing knee injuries, especially if you live in the Highlands Ranch or Centennial areas and would like to schedule an appointment, you can contact them by leaving a comment below, calling their office at 303-221-1569, or sending an email to firstname.lastname@example.org.
Dr. Niall McNally is certified in chiropractic neurology and has a strong background in sports injuries and in the rehabilitation of common nagging athletic problems. Dr. McNally also is trained in pediatrics, orthopedics, and nutrition.
He graduated from the University of Central Oklahoma and successfully completed his Doctor of Chiropractic degree at the Parker College of Chiropractic in Dallas, TX. A very active athlete, Dr. McNally played hockey up into the junior level. In fact, it was his love for hockey, and the Colorado Avalanche, that originally gave him the idea to one day practice sports medicine and chiropractics in the area.
Dr. Ihsan Erhuy specializes in motor vehicle accident injures, back, neck, and extremity problems, as well as treating pregnant patients and children. He is certified in the Diversified, Gonstead, Thompson, Upper Cervical, Activator, Sacral Occipital, Applied Kinesiology, Soft Tissue techniques.
Originally from Adana, Turkey, Dr. Erhuy graduated from the University of Arizona and also susuccessfully completed his Doctor of Chiropractic degree, along with his bachelor of science in health and wellness, at the Parker College of Chiropractic in Dallas, TX.
* – B&W skier image credit: Skiing knee injuries
* – ACL image credit: Ski knee injuries to ACL
* – Valgus street test photo credt: Ski knee injury treatment
* – Lachman’s text photo credit: Treatment and rehab for skiing knee injury to ACL