Preventing Sports Injuries

Making sports safer for competitors is a laudable goal for athletes, parents, coaches, and administrators, especially at the amateur level, where the benefits of sports participation are plentiful for children, adolescents, and teenagers. Unfortunately, some of these athletes will suffer consequences of musculoskeletal injury and pay the price, which can last for days, weeks, months, years, or possibly, a lifetime. While the benefits of sports participation still outweigh the risks for most, even in contact sports, the price that the injured will pay is a factor that should be considered before participation begins. Consequently, realistic efforts to make athletic competition and recreational sports safer should always be encouraged and supported by those in authority, especially at the amateur level. Current efforts to minimize head trauma and subsequent concussions are progressing and have hopefully made the gridiron game safer. These efforts are relatively new but have changed contact sports for the better.

There are many organized efforts to improve sports safety, including those by the American Orthopaedic Society for Sports Medicine and their Stop Sports Injuries campaign,¹ which became a major focus under the leadership of Dr James Andrews. This campaign has targeted public awareness, hopefully bringing sports injury prevention to the level of conscious awareness. However, few efforts to increase sports safety have been more consistent and enduring than those by the University of Vermont and their research into alpine skiing. These efforts took root when a farm boy from Iowa was stationed at an Air Force base in Maine after his orthopaedic surgery residency at the University of Iowa. Dr Robert Johnson learned to ski during his military career before accepting a faculty position at the University of Vermont in 1971. Even though he was much more familiar with the game of football, he accepted the challenge of improving ski safety after experiencing the outdoor exhilaration enjoyed by those descending the slopes along the East Coast. Thus began 47 consecutive years of ski epidemiology at Sugarbush Mountain in Vermont. Dr Johnson’s interests in ski safety grew more focused in 1972, when he sustained an anterior cruciate ligament/medial collateral ligament (ACL/MCL) injury to his own knee while skiing, heightening his awareness of ski injury pathology. It became evident that expertise beyond that of orthopaedics was needed to strengthen the research team. Shortly after the clinical evaluation of ski injuries and research began at the base of Sugarbush Mountain, Carl Ettlinger, MS, joined the research team in 1972, and later, Jasper Shealy, PhD, from the Rochester Institute of Technology, followed by a young PhD researcher named Bruce Beynnon in the early 1980s. Together, this gifted, dedicated research group has contributed tremendously to ski safety by documenting the effects of ski boot height, ski binding settings, and ski technique on a number of ski injuries, especially at the knee joint.

It is quite instructive for today’s musculoskeletal researchers to examine the Vermont Group’s course of research over the years to gain perspective on how to build a successful, world-class program. Their work began with a retrospective analysis of injuries collected at Sugarbush Mountain. These injury data led to prospective studies complete with matched experimental controls of uninjured skiers at the same resort. As those studies progressed, videos of ski injuries were collected, and common mechanisms of ACL injuries surfaced. The “phantom foot” and the “boot-induced ACL” phenomenon^6,7 were identified and described in detail. The recognition of these injury mechanisms led to the development of a ski injury prevention program. This instructive program was prospectively introduced to ski instructors at resorts nationwide and is arguably the most successful ACL injury prevention effort to date.² During the 1993 and 1994 ski seasons, ski instructors from 26 ski areas participated in a training session designed to prevent maneuvers prone to ski injury. Serious knee sprains declined by 62% among trained instructors, with no decline in injuries among the control group. The phenomenal success of the Vermont ACL injury prevention program was built on a sound research paradigm: retrospective epidemiology studies that built the foundation for prospective studies. A meticulous review of thousands of ACL injury videos identified the common injury mechanisms. These works led to an intervention that could be tested and was eventually proven to be correct. The Vermont ACL injury prevention program could prevent ACL tears even among experienced ski instructors. No doubt the time commitment and monumental effort were difficult, but the results have been impressive.

As with many outdoor recreational activities, many falsehoods are popularized by commercial interests. Equipment manufacturers, resort operators, and expert instructors can all be found guilty of perpetuating false claims of safety and performance. Separating fact from fiction can be arduous for committed researchers. In 2009, the Vermont Group published a review article³ on the myths concerning alpine skiing injuries. Quite surprisingly, they were able to dispel 10 common falsehoods about skiing and demonstrated that skiing was no more dangerous than riding in a car or on a bicycle. Additionally, they found that standard formal ski instruction did not make you a safer skier. Their work was practical and advanced ski knowledge in many ways. Their “Tips for Knee-Friendly Skiing”^6,7 is a must read for all skiers—beginners and experts, young and old. These publications heightened public interest in their research, which is featured in many reprints and summaries in the lay press.^4,5,8

Thankfully, this research effort continues in 2019 at Sugarbush Mountain. Some highlights of the status of alpine skiing research are found in this issue of Sports Health by a current orthopaedic faculty member at the University of Vermont, Dr Nathan Endres. The Vermont Group, led by Dr Robert Johnson, Professor Emeritus, has provided a great example of research dedication. Hopefully this effort can continue with more improvements in ski safety to come.

—Edward M. Wojtys, MD
Editor-in-Chief