Dr. Richard Cunningham shares some important information on preventing knee and other injuries this winter. With over 20 years of experience as a Board Certified Orthopedic Surgeon and Sports Medicine Specialist, and widely recognized as the Vail Knee Doctor at Vail-Summit Orthopedics & Neurosurgery in Vail, Colorado, Dr. Cunningham shares a comprehensive overview of preventing skiing and snowboarding knee injuries this season. Dr. Cunningham’s goal is to empower you with knowledge and strategies to prevent common knee conditions that may limit your winter activities.

How to Avoid ACL tears this Winter

Skiing is especially risky for our anterior cruciate ligament (ACL) tears. When you think about it, we are locking our lower extremities onto two stiff 5’ composite boards and hurtling ourselves down a snowy hill with uneven surfaces and unknown hazards at a high rate of speed. BUT, OH HOW FUN IT IS! There are steps we can take to decrease the risk of tearing our ACL’s this winter according to Dr. Cunningham. Firstly, Dr. Cunningham notes that many patients who he sees after ACL tears manifest certain muscle imbalances that have predisposed them to ACL tears. Most commonly, patients have stronger quadriceps and hip flexor muscles than their opposing muscles, which are their gluteal and hamstrings. Dr. Cunningham notes that these imbalances develop because in our active mountain communities, our main sports are skiing, running, hiking and biking. All of these activities are great to do, but they are quad dominant activities. As such, people get strong in their quads and their hip flexors, but relatively weaker in their glutes and hamstrings. In addition, people’s core muscles may be weak. Core strength is synonymous with spine stability. If one is quad dominant and has a weak core, people often “land in the back seat” when they come off any sort of mogul while rotating on their skis. This causes sudden increased forces in the ACL which can cause it to tear. So if you are falling backward and rotating on your knee, you may want to let yourself fall instead of attempting a heroic save. Furthermore, Dr. Cunningham is a big proponent of working on glute and hamstring strength and IT foam rolling. He says that patients often go from their quad dominant sports to then doing more quad strengthening in the gym such as doing leg press, lunges and squats and they fail to primarily do hamstring and glute strengthening and IT band foam rolling, as the IT band gets tight when hamstrings and glutes are weaker.

As an aside, Dr. Cunningham also finds that these same muscle imbalances lead to kneecap pain particularly in his female athletes. Women tend to be a bit knock- kneed (whereas men tend to be bowlegged). Being knock-kneed causes the knee cap to track toward the outside instead of being centered in the groove at the end of our femur. Dr. Cunningham encourages his female athletes with knee cap pain to also work on hamstring and glute strengthening and to foam rolling their tight IT bands, all of which will help correct patellar maltracking and decrease knee pain.

In summary, Dr. Cunningham, the Vail Knee Doctor, recommends that skiers and snowboarders do their best to strengthen the muscles in the back of their leg so that they are as strong as the muscle in the front of their leg. They should also do spine stabilization exercises for a strong core that then helps you to land over your feet and not land in the back seat. Keeping your body weight under good control is also recommended, thus limiting the shear forces across your ACL if your knee if you sustain a sudden twisting injury.

The effectiveness of knee bracing to prevent ACL tears is debated. Dr. Cunningham does recommend ACL knee braces for patients who have undergone ACL reconstruction surgery just for their first year back to cutting and pivoting sports, as patients often do not have all of their endurance strength back to normal for 2 years from surgery.

How to Avoid Knee Pain This Winter

Dr. Cunningham sees and evaluates a large number of patients who come to see him with knee pain that limits their ability to comfortably ski and snowboard. The most common cause of knee pain is arthritis. Arthritis is a wearing down of the coating cartilage on the ends of the knee bones. The once smooth cap of cartilage wears away with age, overuse, and injury. Patients typically experience pain, swelling, and tightness in the knee. Although there is no cure for arthritis, there are measures that can limit arthritis symptoms and allow patients to be more active and have less pain.

After obtaining a thorough history of one’s symptoms, Dr. Cunningham examines the knee. He determines if there are any ligament laxities that are contributing to the problem. He checks if there is any pain over the meniscus shock absorber cartilages that may indicate a meniscus tear. He also assesses a patient’s alignment. Finally, he obtains knee xrays that will show if there is a narrowing of the spacing between the knee bones which would indicate arthritis.

Arthritis symptoms can be alleviated by various means. Some patients may benefit from physical therapy if there is evidence of muscle weakness or muscle imbalances. If there is malalignment of the lower extremity, a patient may benefit from an unloading knee brace that unweights an overloaded compartment of the knee. Dr. Cunningham is also a proponent of an anti-inflammatory diet comprised primarily of whole plant foods and moving away from processed foods. Other lifestyle changes such as weight loss efforts and smoking cessation are encouraged as both of these factors contribute to premature cartilage damage. Finally, various types of injections can be helpful in alleviating the pain and swelling associated with arthritis. Although Dr. Cunningham will occasionally utilize a steroid injection, he prefers hyaluronic acid (HA) injections. HA injections contain a natural protein found in coating cartilage that is lacking in arthritic knees and injecting HA helps “lubricate” arthritic knees. Finally, platelet rich plasma (PRP) injections and stem cell or bone marrow aspirate (BMAC) injections are also an option. However, PRP and BMAC injections have limited scientific evidence to support their use in the scientific literature, and insurance companies do not cover them in the office setting, so Dr. Cunningham prefers utilizing HA injections, which he finds may be as effective as these biologics and which are covered by most insurance plans.

The Right Gear Matters

Choosing the appropriate outdoor gear is a crucial aspect of preventing knee injuries. Skiers and snowboarders must invest time in ensuring that their equipment fits correctly and is well-maintained. Ill-fitting boots or bindings can lead to improper weight distribution, increasing the strain on the knee joint and elevating the risk of injury. It is especially important for skiers to have the appropriate DIN setting on their ski binding. The DIN setting is set based on your skiing ability, weight, height, and boot size. Be sure to consult your ski technician on your DIN setting before hitting the slopes.

Protective gear such as helmets can help prevent devastating head injuries and are highly recommended.

Choosing your Days Wisely

Although ski racers and snowboarders who participate in various competitions may need to be on the hill training nearly every day, others may wish to avoid days when the light is flat and it is hard to see natural hazards. One may also want to avoid days where the snow is very heavy as Dr. Cunningham notes that these are the days where ligament tears are more likely. Really hard snow days such as in the early season when there is mostly man made snow leads to higher fracture risk as it can be like landing on concrete on those sorts of days. In addition, it may be best to avoid those days or hours on the mountain when the slopes are packed with people. Dr. Cunningham is amazed at how many people he sees in the office who were hit by another snowboarder or by another skier and who, as a result, suffer some terrible injuries and fractures. For Dr. Cunningham’s elderly patients, realize that your risk of fracture is greater as your bone mass slowly decreases with age. Dr. Cunningham has seen some elderly patients go from an active lifestyle to having sustained devastating fractures that may even prevent them from getting back to simple activities such as hiking without having pain. Skiing and snowboarding is very fun, but realize that there is significant risk of injury especially in older individuals.

Preventing Snowboarding Injuries

Although skiers have a higher likelihood of sustaining lower extremity and especially knee injuries, snowboarders have a higher likelihood of sustaining upper extremity injuries. As a knee and shoulder specialist, Dr. Cunningham sees a large number of shoulder dislocations in his snowboarder patients. Snowboarders also sustain a large number of wrist and hand fractures that Dr. Cunningham sends to his hand partners for treatment. When snowboarders fall, they tend to fall on an outstretched arm and hand. This can cause the shoulder to dislocate anteriorly where the ball comes out the front of the shoulder socket. Shoulder dislocations are extremely painful. Most patients have to go to the ER to get their shoulder reduced with the ER doc having to administer strong muscle relaxing and pain medications and employing certain specialized techniques to get the shoulder back in place. Young patients that dislocate their shoulder are at high risk of having future shoulder dislocations and therefore often come to surgery to stabilize their shoulder. Dr. Cunningham does a large number of shoulder stabilization surgical procedures, usually in young males who are the highest risk population. For patients who have suffered a first time shoulder dislocation, Dr. Cunningham may recommend avoiding surgery to start and instead try physical therapy and wearing a shoulder sling for 3 weeks. When a first time shoulder dislocator returns to snowboarding, Dr. Cunningham may recommend that they wear a Sully Brace for the first few months back in order to prevent the patient from getting their shoulder into a “throwing position” where they are most likely to dislocate again. Similarly, snowboarders who wish to prevent a wrist fracture may choose to wear wrist splints. Finally, Dr. Cunningham does see a significant number of snowboarders who “land flat” in the park and subsequently tear their ACL, so watch your landings out there.

Preventing Knee Injury: A Winter Mindset

Preventing knee injuries during winter sports requires a holistic approach that encompasses conditioning, equipment considerations, and technique refinement. Whether you’re an avid skier or a passionate snowboarder, the principles of knee injury prevention remain consistent. As the Vail knee doctor in Eagle and Summit Counties, Dr. Cunningham urges winter sports enthusiasts to prioritize their overall health, knee and shoulder health, and adopt proactive measures, and embrace a mindset of injury prevention.

If you have been injured or have knee or shoulder pain, please feel free to request a consultation with Dr. Cunningham and his team. You can fully enjoy our awesome winter landscapes while safeguarding the longevity and well-being of your knees and shoulders.

Rediscover your inner athlete

Dr. Cunningham specializes in the treatment of knee, shoulder, and sports injuries.