Review of the medical research on cross-country skiing related overuse injuries reveals a “Catch-22”:
- 60% of overuse injuries in competitive cross-country skiers are caused by preseason fitness training.
- Experts advise that cross-country skiers engage in preseason fitness training to prevent injuries.
This paradox bedevils elite athletes of all sports and raises high-level competition to an art form with endless debate concerning optimal training regimens. But, for the recreational skier it is fairly easy to resolve the conflict.
In spite of the potential for overuse injuries, cross-country skiing is one of the safest and most efficient fitness enhancing sports in the world. However, for a recreational skier contemplating embarking on a long excursion on the Catamount Trail, a weekend at a touring center, or skiing a marathon the very real potential for sustaining an overuse injury can be minimized by sensibly training ahead of time, learning about common injuries, and knowing how to prevent them.
There are many overuse injuries which can afflict cross-country skiers. Below are a few which are more common to cross-country skiers in general.
Patellofemoral Syndrome (also called chondromalacia or runner’s knee)
This most common of all running injuries can be a problem for skiers too. It is an overuse syndrome that involves various degrees of degeneration of the cartilage of the patella (knee cap) or the knee joint surface of the femur. There are numerous anatomical factors which can predispose one to this injury. These include (a) faulty tracking of the patella on the knee due to asymmetric development of the quadriceps muscles, and (b) increased angle between the femur and the lower leg, more commonly seen in women. Often, patellofemoral syndrome will be precipitated by skiing, running, or cycling too far, too soon, too fast.
The symptoms of patellofemoral syndrome are:
- Gradually progressive aching or grating pain under the knee cap.
- Stiffness
- Giving-way sensation
- Grinding, popping, or clicking sound on knee flexion
- Crunchy sensation felt when holding fingers on the patella through knee range of motion
Provocative factors
- Going up or down stairs, or down hills
- Running
- Squatting
- Prolonged sitting with knee bent (Theater sign)
If there is locking or catching, a meniscal cartilage tear should be considered instead.
Management of patellofemoral syndrome:
- Relative rest
- Avoid squats and lunges
- Reduce mileage to painless distance
- Cross-train with biking, swimming, or elliptical trainer
- Pain relief
- Tylenol or ibuprofen – sparingly
- Ice Therapy
- Patellofemoral knee exercise instruction with a physical therapist
- Footwear modifications
- Replace when excessively worn
- Consider custom Orthotics
- Avoid provocative factors
- Limit weight on a flexed knee
- Reduce mileage and pace
- Avoid uphill and downhill running
Exercise Induced Bronchospasm (EIB)
This is a condition which, while not an injury in the usual sense, seems to be the result of repetitive exposure to cold air while vigorously exercising. EIB is the constriction of the small airways (bronchi) in lungs making breathing difficult during exertion. Sufferers often will have a hacking cough after skiing hard in the cold. EIB is pronounced in winter sports because of the irritative effect of cold, dry air. It is prevalent in several winter sports affecting nearly one of every four winter Olympians. In fact, studies show that 50% of Olympic cross-country skiers have the condition. Obviously, those with EIB can perform at a high level but they need to know how to manage the condition:
- Warm up slowly in the cold.
- Avoid exercise in very cold weather and, if you must ski, use a face mask.
- Don’t smoke and ensure that indoor air is of high quality and smoke-free.
- Avoid viral upper respiratory infections such as colds and influenza by assiduously washing hands.
- Consider using asthma inhalers before skiing if your doctor believes it is indicated.
- If you have asthma, follow you doctor’s recommendations.
Sesamoiditis
The sesamoids are small bones (sesame seed-shaped) associated with tendons around some joints. These bones are prone to overuse inflammation. This condition is called sesamoiditis and is common in the first metatarsophalangeal (MTP) joint which is located in the ball of the foot just behind the great toe. Cross-country skiers using classic technique are especially prone to this. Treatment is focused on removing pressure on the sesamoids and reducing inflammation.
Sesamoiditis ranges from a mild, occasional ache to a debilitating, intense throbbing with swelling. One of the major causes of sesamoiditis is suddenly increased activity. Speed work, hill work, or increased distance can cause this. Also, a high arched foot will put more pressure on the ball of the foot.
Treatment for sesamoiditis is almost always conservative; surgery is rarely necessary.
- Be sure to have properly fitting footwear for training, walking, and, most importantly, for skiing.
- Consider buying new ski boots if your old ones are worn and overly flexible at the ball of the foot.
- Consider using Combi boots (can be used for both classic and skating technique and have a relatively stiff sole) when classic skiing.
- Cross-train by ski skating. Skating boots are much less likely to aggravate the condition due to their stiff soles reducing flexion at the MTP joint.
- Get arch supports or custom orthotics to reduce pressure on the sesamoid bones by distributing pressure more evenly on the foot.
- Use ice treatments and anti-inflammatory medications such as ibuprofen or naproxen to reduce pain.
- Deep massage in the hands of a massage professional who understands sports medicine.
- Cut down on duration of skiing or even stop skiing for a time.
Exertional Compartment Syndrome
While not as common as the above conditions, exertional compartment syndrome, a cause of leg or arm pain, can be very serious if not identified and treated early. Extremity muscles are encased by compartments formed from connective tissue. If the muscles swell due to rapid muscle growth or injury-associated inflammation, pressures in the compartment increase. This rise in pressure can constrict nerves and blood vessels running through the compartment. Constriction of veins causes a vicious cycle of increasing swelling and pain resulting in more venous constriction. This occurs most commonly in the lower legs and presents with exercise-induced pain and swelling relieved with rest. There is a sensation of fullness over the involved compartment. Pain begins predictably after exercise for a fixed time interval or at a specific intensity level. Pain is relieved with 20 minutes of rest and resumes on exercising again.
Blood clots, stress fractures, clogged arteries or other serious disorders can mimic this condition. Definitive diagnosis is made by having a doctor measure pressures within the involved compartments. Severe cases can involve a cold, pale, numb, or painful foot and require immediate medical attention and surgical treatment to prevent tissue damage and permanent disability.
Conservative treatment, when begun early, is often effective and involves rest, activity alteration, rehabilitation exercises, and stretching.
Listen to Your Body
The bottom-line: be aware of signals from your body. Pain can be your friend. When you are having persistent discomfort pay attention. Do not merely treat the symptoms with pain pills and ice. Educate yourself about sports medicine and take action to prevent and treat problems. Seek help from physicians or other qualified practitioners when appropriate. Proper preparation and attention to symptoms will improve your enjoyment of the outdoors.
This article was originally printed in the Catamount Trail Newsletter and was authored by Dr. George Terwilliger, an ER physician who lives in Brattleboro and is a lifelong Vermont resident. He is an avid backcountry skier and has skied many sections of the Catamount Trail.
