THE KNEE DOCTOR
with Jonathan Bell
Our expert is on hand to help you set up your ski gear for maximum pleasure in the mountains – and minimum pain
Follow our expert’s tips to help you stay injury free
Last issue, we looked at how we can reduce injury risk through being mindful of our behaviours, such as building strength and fitness. This month we’ll consider how our choices of kit can make a difference, and why simple changes to the equipment we use can reduce the risk of having to see someone like me!
YOUR BINDING SET UP
The risk of a ski injury is roughly 3-4 per 1,000 skier days. Boarders are much less likely to sustain a knee injury than a skier; soft boots do mean we see ankle injuries, which incidentally need very careful imaging to diagnose, but for snowboarders it’s the wrist and shoulder that are the main areas of concern.
It’s knee injuries that spook skiers. With skiers, the knee is certainly the area most likely to be injured, with minor injuries to the inner ligament known as the medial collateral being among the most common. These are generally very sore but heal well, though they will stop you skiing for the rest of your week.
It is the dreaded ACL rupture that we want to avoid. The difficulty in designing ACL-friendly bindings is that most ACL injuries occur during slow twisting falls. So getting a binding to release in a slow-speed fall that holds you tight at high speed has been an unresolved challenge. I think modern pin bindings have become more knee-friendly, and I chose one of the best-known names for my touring set-up for this reason.
I’m not convinced that traditional downhill bindings have made much progress, but there is something you can do. Do not have your DIN set too high! I’m 80kg and ski almost exclusively off-piste. My ski doesn’t come off unless I mess up. Yes, I have lost a ski in powder that I may not have done with my DIN set higher, but my knee survived the wipeout. I can insure my ski for a new one, but can’t do the same for my knee. I believe I’d see less ACL ruptures if there was less bravado when setting DIN.
BRACES AND BOOTS
I don’t see any convincing evidence that those with an intact ACL should wear a brace, but I will sometimes put post ACL-reconstructed knees into a brace. This is more for the improvement in confidence than the physical restraint. Fear increases injury risk so anything that reduces fear is a good thing in my book.
One area that has changed enormously is boot technology. The lace-up boot of old wasn’t very rigid and so it was possible to fracture the ankle. Modern boots protect the ankle very well. The injuries have moved to the knee for this reason, as the energy from a bad fall has to exit somewhere.
Modern female-specific boots are worth a look especially if you have a short lower leg. A cuff that is very high on the calf will more effectively push your shin forwards, putting your ACL at risk.
SKIS FOR KNEES?
How about skis? Aggressive carving skis can put a great deal of torque on the legs, so if you aren’t used to them use a ski that has a less aggressive turn radius.
Fat skis come up for criticism for causing knee pain. Perhaps if a very wide ski is being skied on the edge on a hard piste there will be some increased load on the inside of the knee, but that’s not what they are designed for. I don’t think fat skis are a problem for the knee when used correctly. Injuries are therefore more likely due to a ski that is not matched to your skill, the terrain you are skiing and the conditions. If you’re not sure which ski to go for, go into your local ski store and talk to an expert.
POLE PROBLEMS
Poles, on the other hand, can be a problem. I've seen a few instances of really nasty injuries from carbon fibre poles when they snapped. They can store a colossal amount of energy before they snap, which is of course released into whatever the fragment connects with. I’ve seen a few quite nasty calf injuries from the direct blow. I prefer the old-fashioned hollow aluminium pole, but putting your hand through the straps of the pole when skiing in trees is, in my opinion, an injury waiting to happen.
If your pole gets caught in a tree and you continue you may sustain a dislocated shoulder, or a nasty wrist or elbow injury. For that reason I almost always ski without the straps and, once in a while, have to tramp back uphill for my pole.
Choice of kit does influence injury risk, so choose wisely and get it set up correctly. There is one final take-home message: if you borrow kit and it isn’t set up or matched for your capability expect a huge increase in risk of injury. If you aren’t sure, take it into a ski shop and get it checked over by an expert.
FACTFILE
Jonathan Bell is a keen skier and consultant orthopaedic knee surgeon at Wimbledon Clinics. His areas of expertise include treating sports injuries, ligament reconstruction, knee replacement and non-operative management of arthritis. Jonathan founded Wimbledon Clinics where he runs a team of orthopaedic specialists and sports injury experts offering a multidisciplinary approach to keeping the active active.