Common Injuries in Elite Junior Figure Skaters

Figure skating may not attract a lot of attention except for the winter Olympics. However, it is a quit unique sport with plenty of technical skills and artistic aspect in it. As this figure skating season is coming close to an end this year, we thought to discuss common injuries in figure skating. According to a study published in 2003, which looked at singles, pairs, and ice dancing, about 70% of injuries in singles figure skating were chronic injuries. 60% of injuries in pairs were acute injuries. Of all the acute injuries suffered by elite junior figure skaters, ankle sprain was the most common. Common chronic injuries among those figure skaters were stress fracture, jumper's knee, Osgood-Schlatter disease, etc. Common injury sites for stress fracture were located in the foot and lower leg. Over all, more than 44% of all the injuries suffered was chronic in nature. This means that it is very possible to prevent such injuries.

 

It is very important to know that figure skaters wear rigid type boots which prevent them from moving their ankle. The importance of this is that......when athletes jump and land, they will bend the ankles, knees, and hips to absorb a force placed on the joints. The muscles around each joint play an important role in absorbing the force so that stress placed on the joints will be minimized. However, figure skaters do not have ankles and muscles around to dissipate the ground reaction force due to the boots that they wear. From a recent study, it is known that knee and hip angle on landing correlates with the amount of pressure felt by knee and hip joints. When figure skaters do not have the ankle and the muscles around it to absorb the ground reaction force, it is a disadvantage to them. They may need to work on the knee and hip muscle strength to 1) cancel out this disadvantage and 2) relieve a compensatory stress placed on those joints.  

Literature Update: Preventing ACL Injuries after Reconstruction

Anterior cruciate ligament (ACL) injuries are a hot topic again after RG III underwent reconstruction. And this is his 2nd reconstruction in the last 4 years. While some researchers suggest that a primary ACL reconstruction will not increase a risk of second injury, studies have suggested that there may be an increased risk of re-injuring the same knee or injuring the other knee  in up to 20% of those who have undergone a first reconstruction. This means that it is very important for athletes and health care providers to not only rehabilitate the reconstructed knee but also to minimize a risk of another ACL injury after returning to sports. We know from past studies that there are predisposing risk factors including muscle imbalance, poor biomechanics of high risk movement patterns, decreased neuromuscular control, etc. The same approach can be used to prevent a secondary ACL injury. However, a recent study suggests that asymmetries between a reconstructed knee and healthy knee are the key factors to prevent an ACL injury after reconstruction. Especially after a surgery, it is not rare that the athlete presents decreased muscle strength compared to the other healthy knee mostly in quads. Some athletes may have decreased range of motion. When returning to sports, it is very important that the athlete has optimal symmetries in muscle strength and balance, neuromuscular control, biomechanics of trunk and lower extremities, in addition to minimizing other risk factors.

Literature Undate: Preventing ACL Injuries

Anterior cruciate ligament injuries are a huge concern for athletes involved in high risk sports such as women's soccer and basketball, women's gymnastics, football, etc. Studies have shown that female athletes are 4-6 times more prone to an ACL injury. Researchers have done extensive studies on ACL injury risk factors and we now know more about the injury than in the past, even though there are still things that are not clear to health care providers and sports medicine personnel. One of the possible factors that make female athletes more prone to an ACL injury is a neuromuscular deficit that female athletes demonstrate. This neuromuscular deficit is shown to be developed after puberty in females. Also, it is shown that neuromuscular training can reduce the risk of ACL injuries in female athletes. A recent meta-analysis study shows that there may be a window where the neuromuscular training to prevent ACL injuries should be done. It collected study data from the literature published in the past and showed that preventative neuromuscular training may need to be done before female athletes develop the deficit. 

 

It may be difficult for parents and athletes to understand why. However, it is important to utilize injury prevention training/program earlier, especially if athletes are already demonstrating injury risk factors.   

Rehabilitation after UCLR: 12 Week Post-Op to Return to Play

During this phase of rehabilitation after Tommy John surgery, isokinetic exercise can be initiated if available and interval throwing program (ITP) can be initiated. In most protocols, isokinetic shoulder internal and external rotation, wrist flexion and extension, and forearm pronation and supination exercises can be initiated after 12 weeks after surgery. Shoulder internal and external rotation exercise may be initiated even earlier. However, these exercises should be done pain free or any ulnar nerve symptoms. Shoulder and wrist plyometric exercises after 12 weeks. Strengthening exercises should be advanced including shoulder exercises with shoulder in 90 degrees of abduction (closer to throwing motion). The athlete will start swinging a bat and start a batting program. Fielding the ball can also the initiated without throwing.  

 ITP is usually initiated after 16 weeks post-operatively. There are several ITP's available, each of which starts with short distance and gradually increases in distance and the number of throws (an example of ITP is listed below). Again, ITP must be done symptom free throughout. If any symptoms exist, it should be stopped until it resolves. After completion of ITP, the athlete will gradually return to play. For baseball pitchers, it usually takes about 10-12 months before they will start pitching in a game.

The goals of this phase are 1) to maintain full ROM, 2) to advance in strengthening program, 3) to initiate plyometric exercise for shoulder and wrist, 4) to start sport specific training such as ITP, swinging a bat, and fielding, and 5) to gradually return to play. 

Interval Throwing Program (ITP) (Phase 1: Soft Toss) 

Distance (ft)                   Warm-Up                  # of Throws

30                                                                      20 - 20
45                                    30                              20 - 20
60                                  30 - 45                         20 - 20
75                                  30-45-60                      20 - 20
90                                  45-60-75                      20 - 20
120                                45-60-90                      20 - 20
150                                45-60-90-120               20 - 20
180                                45-60-90-120-150        20 - 20

This is an example of ITP. The athlete will soft-toss 2-3 times at each distance before advancing to next and may throw 10-15 times at each distance for warm-ups. And ITP should be done every other day. The distance can go farther than 180 feet if athletes want to. 

Interval Throwing Program (ITP) Phase 2

In this phase of ITP, the athlete will start throwing with intensity gradually increasing. They will start at a shorter distance (around 60 feet) and less intensity (50%) and gradually increase in intensity and distance as needed.

Rehabilitation after UCLR: 6-12 Week Post-Op

After 6 weeks post-operatively, strengthening exercises of forearm, wrist, and shoulder should be advanced while maintaining/regaining full ROM of the elbow. Isometric and isotonic exercises can be used for forearm, wrist, and shoulder muscles. The goals of this phase is 1) to maintain or regain full ROM, 2) to control pain/inflammation, and 3) to progress in strengthening program. Some examples of shoulder (posterior cuff and scapular) exercises can be seen in our website (Please note that NOT ALL of these exercises are appropriate for this phase of rehabilitation after UCLR). Wrist curls using free weights and tubing, radial and ulnar deviations, pronation and supination, grip exercises are some of examples.

If full ROM is not achieved by this phase, it is critical to regain full ROM, especially in extension. ROM (active and passive) exercise to regain full ROM should be emphasized. Exericises that cause any pain on the surgical site or any ulnar nerve symptoms should be avoided. Note that ulnar nerve may or may not be transpositioned.

Use of elbow brace is usually discontinued at week 6 (may vary depending on the surgeon's protocol).

Rehabilitation after UCLR: 2-6 Weeks Post-Op

During this phase of rehabilitation after UCLR, elbow range of motion (ROM) is increased gradually (i.e.5 degrees/week). The goal of this phase is to regain full ROM by the week 6, especially extension, control pain/inflammation, and retard muscle atrophy. Shoulder and scapula strengthening exercises can be initiated in this phase as well as some forearm exercises such as grip exercises and wrist exercises. It is more common to use the muscle splitting technique than cutting the forearm muscles to reconstruct UCL, however, aggressive forearm strengthening targeting the wrist flexors/forearm pronators using heavy weights should be avoided in this phase. If the forearm muscles are cut, any forearm flexor strengthening should be avoided at least 6 weeks after surgery. Some of the shoulder and scapular exercises can be found on our website (Note that some of these exercises may not be allowed in some protocols). Also note that any strengthening exercise should be done pain-free. All of the rehabilitation exercises (ROM and strengthening) are to be progressed based on tissue healing and athletes' tolerance.    

Rehabilitation after UCLR: Immediate Post-Op

Ulnar collateral ligament injuries are very common in baseball pitchers and some other over head athletes such as javelin throwers. When athletes tear their UCL, surgical reconstruction of the injured ligament is often needed to restore stability of the medial elbow. There are several approaches to surgical methods including fixation method. Also, post-surgical rehabilitation protocol may vary depending on the surgeon. We will discuss general rehabilitation process for UCLR, however, please note that protocols may vary depending on who the surgeon is.

Immediate Post-Op (Week 1-2)

The goals of this phase are to protect reconstructed graft and graft site, to decrease inflammation, and to retard muscle atrophy. The athlete's elbow will be put in a splint right after surgery for about a week. Then, he/she will be fitted to an elbow brace with range of motion (ROM) usually limited from 30 degrees of extension to 100 degrees of flexion. The athlete may start doing wrist flexion/extension active range of motion (AROM) exercises and grip exercise.

Schematic view of reconstructed graft using end button