Gavin Jennings, Consultant Shoulder Surgeon, gives advice on how to prepare and what to avoid when skiing and snowboarding in the mountains.
"I have recently returned from a week’s skiing tuition with the Warren Smith Ski Academy in Cervinia, Italy. One aspect of the course which struck me, particularly as a Surgeon, was the importance placed on the performance of a daily warm up prior to any skiing. This was designed not only to "wake up" and activate certain muscles to benefit technique but also to reduce the risk of injury.
As a shoulder specialist, I’ve noticed there seems to be very little information out there on preventing injuries to the shoulder specifically, during alpine sports. Most articles on snow sports injury prevention focus primarily on avoidance of lower limb injuries. This is understandable as most ‘get fit for skiing’ information has a bias towards lower limb strengthening and there is substantial crossover between conditioning and injury prevention.
What are the common skiing and snowboarding injuries?
Upper limb injuries represent one-third of all alpine skiing injuries and the percentage is higher still in snowboarding. Snowboarding injuries are more common in beginners, whereas skiing injuries occur more (but not completely) independently of experience. Upper limb fractures, particularly of the wrists, are both more common and more severe in snowboarders.
Shoulder girdle injuries constitute about 40% of the upper limb injuries seen in alpine sports. In decreasing order of frequency these include; rotator cuff tendon injuries, shoulder dislocations, acromioclavicular joint injuries, clavicle fractures and proximal humeral fractures.
90% of these injuries are caused by falling. Collisions with other skiers and pole planting injuries being the next most common causes. Not surprisingly, similar injury patterns to shoulder trauma are seen in contact sports such as rugby and in sports where falling from a height is common such as cycling.
How can we prevent these injuries?
Injury prevention strategies can be divided into the following categories; training, behaviour, equipment and conditioning.
There is some evidence that technical training can reduce the risk of injury, particularly during higher risk maneuvers such as jumping. It stands to reason that good snow sports technique should facilitate better control on the snow and therefore reduce the risk of falls or collisions.
Training in correct pole planting may help reduce shoulder injury by encouraging the avoidance of heavy and prolonged pole planting which may result in forced rotation of the shoulder as the relatively fixed arm is ‘left behind’ as the body continues to move downhill.
There is some evidence that video training on injury prevention, focusing on injury mechanism, in particular, can lead to a significant reduction in knee injuries, but it is not clear whether this would be transferable to shoulder injury prevention.
It would seem obvious to say that if the risk of falling and collision is reduced, the risk of injury will follow suit. Good technique will only go so far in mitigating these risks. If the participant is skiing or boarding inappropriately for the slope, conditions and/or crowding, injuries are more likely to occur.
Adolescents, particularly when on school trips with peers, are the highest risk group for ski and snowboarding injuries. It has been postulated that this is due to a correlation with higher risk-taking behaviour in a competitive environment.
There would seem to be little doubt that improvements in equipment have been a significant factor in reducing total injury rates, from 5 to 8 per 1000 skier days before the 1970’s to 2-3 per 1000 skier days today. However, the main reduction has been in lower limb injuries, which have been mainly due to improved binding and boot design. Conversely, upper limb injuries have decreased little and as such are proportionately greater now.
One development which may potentially reduce the risk of shoulder injury is that of wrist strap releases on poles. As tension increases on the strap, they become detached from the poles before potentially dangerous forces can be transmitted to the upper limb and shoulder girdle.
When preventing fractures to the bones, there is not a lot which can be done in terms of conditioning when considering the average healthy and active person.
If there is evidence of osteoporosis (reduced bone density) which can sometimes be seen in predominantly female athletes and in the older population, this could be addressed with specific medical treatment.
Core stability and balance training may have a role in reducing shoulder injuries by reducing the risk of falls and by potentially improving shoulder stability. Shoulder stability can also be improved by a number of other strategies including postural correction and by improving muscle coordination and strength of the muscles around the shoulder joint and scapula (shoulder blade).
In simple terms, focus should be placed on pulling exercises (such as in the rowing action) in preference to pushing exercises (such as bench press). More specific exercises related to strengthening the deep tendons around the back of the shoulder (the posterior rotator cuff) are also of use in trying to optimise stability and prevent shoulder dislocation.
It has been postulated that training in tucking and rolling during a fall can help prevent some of the injuries caused by falling on the outstretched arm. This may result in a reduction of injuries to the thumb, wrist and elbow at the expense of more shoulder girdle damage.
A good warm-up immediately prior to skiing or snowboarding is very important. It is well known that warm muscles and tendons are less prone to damage as a result of abnormal tensile forces. In terms of shoulder warm-up specifically, the simple exercises we performed at the Warren Smith Academy are as good as anything. This involves rolling the arms around (circumduction) with increasing rapidity for a number of repetitions, firstly forwards and then backward.
Finally, we know that skiers and boarders are more prone to injury when tired. If you are coming towards the end of the day, are tired and thinking about one more run, you may be better off stopping, having a hot chocolate and looking forward to the next (injury free) day!
I’m certainly looking forward to another week with the Warren Smith Ski Academy next year when I hope to build on what I have learnt this time around. In the meantime I also have a family ski trip to look forward to and, with my improved knowledge, can hopefully pass on one or two tips to help my young children to also enjoy the mountains even more!"