Nordic & Backcountry Skiing Injury Prevention
As most people learned to punt last year, outdoor recreation was one of the activities that people could do to keep busy while social distancing. There was an explosion in Nordic (cross-country) and backcountry skiing. These often get confused as the same thing but they are very different sports requiring quite different equipment and are different altogether than resort skiing. With resort skiing, injuries tend to be more traumatic such as occurs when crashing at a high speed or misjudging a turn. Resort or inbounds skiing was covered in a past blog so we will turn attention to Nordic and backcountry skiing now. In these disciplines, injuries tend to result from repetitive stress. Pole length, pole grip and pole adjustability are very important with Nordic and backcountry skiing to avoid overuse. It can be helpful to understand the benefit of sport-specific training when one has a good grasp of what each sport requires. This is especially important when starting a new sport as it will help to develop appropriate training habits while learning form and ultimately will optimize performance.
Where did Nordic Skiing Begin?
Nordic skiing has its origin in Norway (of course) in the mid-1800s but was used for centuries before that as a mode of transportation in areas as varied as China and New Zealand. It was made into a recreational and competitive sport over the decades. There are two common types of Nordic skiing.
the classic technique and skate technique. With classic Nordic skiing, the skis are gliding forward and many Nordic ski areas have two tracks on their Nordic trails meant for classic skiers.
Skiers shift their weight from ski to ski more and the ski in this sport has a “skate cut” with a different edge than a classic cross-country ski. Nordic centers leave a groomed center lane for skate skiers.
**Pro tip: It’s important that snowshoers who might share such trails don’t walk down the middle of this as it makes skate skiers negotiate potholes.
backcountry skiing’s evolution
Backcountry skiing has evolved greatly over the last few decades. It used to be that people traveled in the backcountry on telemark gear using a “drop the knee” technique. This required a binding with a free heel (or broken heel as non-telemark skiers like to joke). Now bindings are widely available in the “AT” category which means telemarking is more rare (but a very aesthetic looking turn). The AT stands for “alpine touring” as people traveling in the backcountry use the terminology of going on a “backcountry tour”. People ascend a mountain via a technique called skinning. These are strips of material that have adhesive on one side and mohair on the other. They are designed to be taken off at the top of the slope you are skiing and are named after seal skin. The first backcountry skiers in the world utilized actual seal skin to make these in the Arctic but now they are commercially available.
What are the most common Nordic Ski Injuries?
Injuries in Nordic skiing and backcountry skiing (the uphill portion at least) are common in the wrist, thumb, elbow and shoulder. Like most things, it all comes down to the core. Having a strong group of core muscles can ensure you are gliding efficiently and not overloading the joints of the upper extremities during pole plants. Technique is key and classic and skate skiing have slightly different techniques. In both classic and skate skiing, there are different pole plants used for skiing fast on the flats versus attacking a hill. An introductory lesson can teach you the fine art of double pole and single pole plants for classic skiing and V0, V1 and V2 for skate skiing. If you try to V2 up a hill you’ll quickly see the reasoning behind a V1. If you find you like Nordic skiing, it’s worth your time to learn the different techniques to make yourself the most efficient and to spare your shoulder from overload of the biceps tendon (front shoulder) or rotator cuff. If using an improper pole length, the inner elbow and thumb can take unnecessary load. So be sure to find a ski store you trust and spend time before buying a kit to be sure you are sized properly. With alpine touring, the key to reducing stress on the thumb, wrist and elbow is to adjust the poles to the slope angle on the way up. The steeper you go, the shorter the pole needed. You can always lengthen them for the descent.
““All the gear matters, but as a knee surgeon, I’d say definitely be sure your bindings are appropriately adjusted.””
Back Country Ski Injury Considerations
Dr. Wahl’s recent ACL Webinar with LWPT
We asked Dr. Christopher Wahl about the most common issues he sees with his time on the slopes and working with injured skiers. “All the gear matters, but as a knee surgeon, I’d say definitely be sure your bindings are appropriately adjusted. Modern bindings have a lot of adjustability with respect to boot length, boot toe height, forward pressure and the DIN setting. Injuries happen when the binding's DIN settings are too high or too low or even with an appropriate DIN if the rest of the parameters are ignored.” On the topic of a high DIN Dr. Wahl adds, “A lot of skiers think it’s “cool” to ski with a high DIN on the binding, but the fact is that technically good skiers don’t need to overtend their bindings (except in the rare circumstance that they are skiing in an extreme “no fall” environment). However, as you become a better or more aggressive skier (or gain or lose strength or weight), it is good to have your bindings professionally re-adjusted. The same is true if you change boots or even as the soles of your boots wear (which is common in back-country skiers who boot hike a lot). It takes a lot less time to put back on a ski than it does to rehab after an ACL surgery!”
Why do I need shoulder training for skiing?
The shoulder joint needs to be trained to take specific loads including the weight-bearing that is required in Nordic and backcountry skiing. Rotator cuff exercises and strengthening of the muscles around the shoulder blade in addition to the core is key to success. Even Olympic level athletes on the Nordic team, perform dryland training to strengthen the rotator cuff through resisted band exercises, planks and mobility drills. You can’t use the motion if you don’t have the motion so stretching the shoulder, thoracic spine, elbow and wrist is essential. Not all shoulder issues are the same. Some are related to weakness, some due to posture and some due to lack of range of motion. Just like a baseball pitcher needs to have a strong core to avoid overloading their shoulder during a pitch, Nordic skiers can think of the shoulder as an extension of the core. There are four muscles that make up the rotator cuff: supraspinatus, infraspinatus, teres minor and subscapularis. They are key at pole plant and follow-through and, if weak, can load the tendons of the wrist that insert at the elbow. If you have ever had golfer’s elbow (medial epicondylitis) or tennis elbow (lateral epicondylitis) you know how painful that can be and how suddenly it can sometimes present itself.
““Not warming up and not getting in shape for ski season. Especially as we get a little older it is important to prepare for ski season to reduce your risk of injury. It is also important to work your way into it —don’t go up your first day of the season and expect to ski hard runs all day. Start easy, take breaks if you need to and increase the difficulty of runs, speed and amount you are skiing gradually.””
Safety & Performance Considerations
When interviewing different sources and years with the US Ski Team there were several areas that repeatedly came up with our colleagues. Dr. Camille Clinton when asked about the concerns she sees as an orthopedic surgeon echoed Dr. Wahl on bindings but also added, “You should get your skis tuned frequently (edges sharpened and waxed) and make sure you have a good fitting helmet.” Dr. Wahl added further, “Skiing with and studying better skiers or instructors and taking the occasional lesson, trying a new discipline (back-country, racing or nordic), and even spending time on easier runs working hard on carving and technique or trying to ski on one ski all can get you to the next level.” When life long skier and sports medicine physician Dr. Chris Peterson as asked he had some very practical advice as well, “As our opportunities to exercise and work out during COVID have been limited, we tended to lose some of our fitness and may have added a few pounds too. The additional weight will affect the performance of your bindings and may negatively affect how they work. Getting your skis and bindings adjusted for your weight and level of ability will help prevent injuries.” Dr. Peterson echoed what several of the sports med physicians recommended, “ for some of us returning to skiing, can be a great time to start the season off with a lesson or two. This will allow another set of eyes to evaluate your mechanics as well as offer tips to prevent injuries.” This is something that the professional skiers and honestly any athlete wants if they can afford the time and coaching.
Is your heart in it?
Cardiovascular fitness is tested with Nordic and backcountry skiing so that is usually what limits people on any given outing. Typically it’s the next day when people feel the result of overload of tendons or muscles. Normal post-workout soreness is called DOMS (delayed onset muscle soreness) and lasts 24-48 hours after a workout. If discomfort or pain lasts 72 hours or more, that is a sign that the muscle or tendon is not recovering properly. Physical therapy can play a preventive role for Nordic or backcountry skiers as we can do a movement screen that indicates areas of weakness or hypomobility that need to be addressed to avoid injury or we can be consulted after injury. Seeing a PT after injury will still involve a movement screen to target weak and tight areas but it will also involve education about healing time frame of injuries and how to manage injured tissue. Seeing a PT pre or post injury will involve exercise prescription either way. So get ready to work. But it’s fun when you are doing it for a hobby you enjoy.
“After many months of Summer activities that may not strengthen their core and hips, some skiers find themselves “not in skiing shape” at the beginning of the season. Failure to specifically target these muscle groups will place the athlete at risk for a lower extremity injury. ”
What is my pre-season Ski training missing?
Ski conditioning classes tend to emphasize the lower extremity with lunges, box jumps and planks. There is a reason for this as research shows that strength through the lateral hip muscles (primarily gluteus medius) and core will reduce the rotational forces on the knee to minimize inward stress to the knee (valgus). The goal with these programs is to avoid getting hurt in the first place. Injury rates, including ACL tears, are significantly reduced with exercise prescription that includes hip and core strengthening as well as eccentric (lengthening) contractions of the quadriceps. The hamstrings are protective muscles to the ACL and will help skiers avoid getting hurt in the first place. Research has shown that periodization of training (gradual increase in load) can safely optimize performance. I encourage all skiers to start training for ski season about 6-8 weeks prior to your first estimated day out on the slopes. When we asked Dr. Chris Peterson at UW Medicine he added these considerations, “Often, early season snow can be wet or heavy making it difficult to navigate in the deeper snow. This double effect (weak muscles in harder conditions) often leads to ligament issues in the lower extremities.”
Ramping up slowly will allow your first days back on the slopes to feel more effortless. Exercises to address recovery and maintenance are part of a holistic approach to athlete management too. Even the highest level athletes consult the sport science experts to minimize their time on the IR list. When going out, just remember to check out the weather forecast, avalanche forecast, have the proper equipment in the backcountry and know how to use it.
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AUTHOR:
Mandie Majerus, PT, MSPT, OCS, CSCS, SFMAc, CMPT, CFSC
CONTRIBUTORS:
Dr. Christopher Wahl, MD
Orthopedic Surgeon OPA
Dr. Camille Clinton, MD
Orthopedic Surgeon Evergreen
Dr. Christian Peterson, DO
UW Surgeon and Sports Medicine Physician
Ben Wobker, PT, MSPT, CSCS, CFSC, SFMA
About the author:
Mandie is a physical therapist at Lake Washington PT in Kirkland, WA. She is a co-founder of the Alpine Training Project as well as an avid backcountry skier and ski mountaineer. She grew up skiing in Bozeman, Montana and now enjoys every opportunity to ski in the N. Cascades of Washington State and the volcanoes of the west coast. Mandie works in the medical pool with the US Ski Team including covering World Cup races and camps as the on-site PT. She particularly enjoys helping people reach their goals whether they involve the outdoors or not.
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