Cross-country skiing: very safe, until the fall

Feb 15, 2002

As one might assume, cross-country skiers generally sustain fewer traumatic injuries than downhill skiers. And when Nordic skiers get hurt, it’s usually when they're going downhill, using navigational moves that may come more naturally to Alpine skiers.

So said Dr. Robert Johnson, an orthopedic surgeon at the University of Vermont College of Medicine in Burlington. Over years of work with the university’s McClure Musculoskeletal Research Center, Johnson has helped define the epidemiology of skiing. Alpine enthusiasts, with their far greater numbers and their downhill speed, represented the majority of Johnson’s subjects. But cross-country skiers weren't immune to injury.

"In the studies we did, we saw pretty much the same array of injuries among cross-country skiers as we saw in downhillers," Johnson said. "And almost all of the cross-country skiers got hurt trying to go downhill." Failing to negotiate a steep slope caused most of the falls, and hence most of the injuries, among recreational cross-country skiers.

Anecdotally, the fall -- as in autumn -- also seems to be critical for elite skiers, Johnson said. That’s when he’s seen the most injuries among members of the University of Vermont’s championship cross-country teams, typically running injuries such as shin splints from conditioning in preparation for the ski season.

But even if running is more injurious, cross-country skiing provides a range of potential pitfalls, including a traumatic injury called "skier’s thumb" and an overuse injury known as "skier’s toe."

Skier’s thumb is an ulnar collateral ligament injury to the metacarpophalangeal joint. Research has shown it to be the most common upper-limb injury in cross-country skiing, and once again falls are to blame. As the skier falls, the pole she grasps may lever her thumb into abduction and extension, stressing the ulnar collateral ligament.

X-rays may show a fracture with the thumb injury; Grade 3 sprains may warrant MRI to detect Stener’s lesions. The lesion occurs when the adductor aponeurosis becomes interposed in the ruptured ligament distally at its attachment at the base of the phalanx. The torn ligament ends are unable to reapproximate, causing residual instability.

According to Johnson’s research, the more common traumatic injuries among cross-country skiers are ankle ligament sprains and fractures, muscle ruptures, and knee ligament sprains. Shoulder dislocation, acromioclavicular separation, and rotator-cuff tears are not infrequent (Sports Medicine, December 1989, Vol.8:6, pp. 346-370).

The most common overuse injuries Johnson and his colleagues found among cross-country skiers were medial-tibial stress syndrome, Achilles tendon problems, and lower back pain. Then there is skier’s toe, or hallux rigidus, a painful arthritic change in the big toe at the first metatarsophalangeal joint, a condition caused by repeated dorsiflexion stress. On radiographs they appear as osteoarthritic changes with dorsal osteophytes visible on lateral views.

Most of Johnson’s research focused on classical cross-country skiing, in which long, skinny skis are moved in parallel. Nowadays many cross-country enthusiasts are so-called freestyle skiers, using shorter "skate" skis in a skating-like stride. In 1988, freestyle events were added to the Olympic Winter Games, along with the classical cross-country competition.

Because of the different stride and greater speed achieved on skate skis, researchers have surmised that freestyle skiers might sustain more injuries than classical cross-country skiers. However, at least one study of mid-level competitors found no statistically significant difference between the two groups in the location of injuries or the frequency (Clinical Journal of Sports Medicine, April 1998, Vol.8:2, pp.88-91).

Another study found that using a skating ski rather than a classic ski didn’t increase anterior leg pressure leading to chronic compartment syndrome (American Journal of Sports Medicine, November-December 1992, Vol.20:6, pp.750-753).

But if a researcher is particularly interested in Nordic ski injuries, then Nordic countries are the place to be. "In Scandinavia," said Johnson, "30% of the skiers on the trails are on skinny skis."

By Tracie L. Thompson
AuntMinnie.com contributing writer
February 16, 2002