Sideline Consult

Help Your Patients Ski Safely This Winter

Bert R. Mandelbaum, MD, DHL (Hon)


November 30, 2016

Reducing Skiing Injuries

On a winter day at the Snowbird ski resort in Utah a dozen years ago, I paused on my skis to watch my 6-year-old taking a lesson. I didn't notice the snowboarder hurdling out of control on the hill above me.

By then, I had already taken a keen interest in injury prevention in skiing. And I was already coaching others in proper technique, fitness, acclimatization, and equipment.

In fact, concepts that I later helped integrate into the Fédération Internationale de Football Association 11+ (FIFA 11+) soccer injury program started with a skiing program.

In the 1970s, orthopedic surgeons Robert Johnson, MD, and Carl Ettinger, MD, at the University of Vermont, and engineering professor Jasper Shealy, PhD, at the Rochester Institute of Technology, started researching anterior cruciate ligament (ACL) injuries in snow sports.[1]

They realized that a large proportion of ACL tears occurred when the tail of the downhill ski, in combination with the stiff back of the ski boot, act as a lever to apply both twisting and bending loads to the knee—a phenomenon known as the "phantom foot." This is particularly likely to happen when the skier was off-balance to the rear, with hips below knees, the uphill ski unweighted, weight on the inside edge of the downhill ski, and the upper body facing downhill.[1]

They discovered that they could significantly reduce this type of injury if they coached skiers to keep their hips above their knees, feet together, and arms forward. The researchers' phantom-foot videos explaining these principles proved highly successful.[1]

Innovations such as this, as well as better bindings, have decreased the rate of injury in skiing and snowboarding. The rate of serious injury is now about 1 per million skier/snowboarder visits, a decline of 50% since the 1970s, according to the National Ski Areas Association (NSAA).[2]

Preparing to Ski Safely

The success of the phantom-foot program inspired me to carefully study patterns of injury in other sports and develop injury prevention techniques based on them. But it also taught me how to be a more careful skier.

Thirty inches of snow had fallen the day before I stood watching my daughter on the bunny slopes. I'd been skiing steep and deep but keeping these principles in mind to avoid a knee injury.

I was in good shape as well. I teach skiers and snowboarders to prepare for the slopes with a series of neuromuscular exercises.

Such a routine might include:

  • A running mash-up—run forward, backward, left, and right for 15 seconds each;

  • Standing hip rotations—raise your knee and rotate to the side and back again;

  • Planks—hold 15 seconds on facing down, then on each side and finally facing up;

  • Good mornings—hold a small kettlebell behind your head and bend forward at the waist;

  • One-legged dead lift to row—standing on one leg, bend at the waist until your torso is parallel to the ground, then slowly raise a kettlebell to one side and then the other;

  • Kettlebell overhead clock lunges—hold a lightweight kettlebell overhead in your left hand, elbow locked; then lunge forward on your right leg; press through your heel to return to standing; then lunge to the right, gradually working your way around the clock from 12 o'clock down to 9 o'clock, with backward lunges for 8, 7, and 6 o'clock; rest and repeat with the right arm holding the kettle bell;

  • Goblet squats—holding a kettlebell at the chest, squat down, pushing your hips back and as low as possible with your chest up and back flat; push through your heels to stand, rise onto your toes, hold for three beats, then lower back down, holding for three full beats, and repeat; and

  • Moving tuck jumps—stand with your knees soft, arms at your sides; jump up and forward as high as possible, bringing your knees toward your chest, to land a couple of feet in front of where you started; then jump and tuck backward to the right and to the left.

Twelve repetitions is a good goal for these exercises, but depending on their fitness level, your patients might want to start with fewer repetitions and work their way up.


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