13 COVID-19 UPDATE 17 FROM THE LITERATURE 37 SLEEP & INJURIES 45 WOUND CARE UPDATE 48 NO-NONSENSE SEMINAR: 25 CMES
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13 COVID-19 UPDATE
17 FROM THE LITERATURE
37 SLEEP & INJURIES
45 WOUND CARE UPDATE
48 NO-NONSENSE SEMINAR: 25 CMES
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January 2021
VOLUME 13 NUMBER 1 L ERM A G A ZIN E .C O M
contents
PUBLISHER’S MEMO COVER STORY FEATURED ARTICLE
9 CARPE DIEM! LET’S SEIZE 37 LEEP SERIES PART I: BASICS
S
THE HECK OUT OF 2021! OF SLEEP AND ITS ROLE WITH
Now that 2020 is finally over… INJURY
we can reflect on all that we
Sleep is an important part of our
have learned: Who and what is ability to function optimally as
important, how to work on our humans, yet we know very little
business and not in it, how to slow about it. This series explores what
down, look for opportunities, stay positive, be kind to 21 SKIING-RELATED INJURIES: we do know and the role it plays
others always, stay focused, and keep our eyes and WHO, WHAT, HOW, WHEN, in health, injury, and athletic
ears open. AND A BIT OF PREVENTION performance.
S kiing, a complex athletic endeavor, is growing By Jeremy R. Hawkins, PhD, LAT, ATC; Michael
By Rich Dubin, Publisher as a winter pastime. It remains a high-risk sport, Reeder, DO; and Alli Powell, DAT, LAT, ATC
particularly for the anterior cruciate ligament.
COVID-19 UPDATE By Janice T. Radak
WOUND CARE UPDATE
13 A RTIFICIAL INTELLIGENCE PATIENT GUIDANCE 45 CASE OF A MISDIAGNOSED
A
AND COVID-19 NEOPLASTIC WOUND OF THE
33 ONE THING YOU CAN DO TO FOOT
AI is playing a critical role in the battle against COVID- SKI BETTER
19. One study identified 7 different applications
Improving the connection
With the ongoing rise in skin
already in play; another pegged melatonin as a cancer incidence, the possibility of
between your feet and your
potential treatment, and still others have been used to malignancy should be considered
skis is critical to improving your
develop “smell” tests. when ulcers fail to improve with
skiing.
2-3 months of appropriate wound
AD INDEX By Mark Paigen care or develop atypical signs.
By Windy Cole, DPM, CWSP
57 G ET CONTACT INFO FOR ALL OF FROM THE LITERATURE
OUR ADVERTISERS 17 • Snowblower Injuries From PATIENT GUIDANCE
2003–2018
N
EW & NOTEWORTHY • Corrective Insoles Improve Leg 51 STAY ACTIVE TO REDUCE THE
Muscle Activation RISK OF FALLING: 5 EXERCISES
58 P RODUCTS, ASSOCIATION • Disparities Persist in Amputations TO KEEP YOU FIT
NEWS & MARKET UPDATES for Critical Limb Ischemia Aging brings not only a greater risk
of falls, but a greater fear of falls.
CROSSWORD PUZZLE LEREXPO.COM These exercises can help older
patients safely stay physically
62 T EST YOUR KNOWLEDGE OF 48 THIRTY-FIFTH ANNUAL NO- active.
NONSENSE SEMINAR XXXV
INFORMATION FROM THIS
ISSUE Since 1985, the No-Nonsense seminar has provided a By Detric Smith
world-class program with scientific presentations and
workshops presented by leading clinicians and experts
in podiatric medicine and related disciplines.
The views and opinions expressed in this issue are those of the authors and do not necessarily reflect the official policy or position of Lower Extremity Review.
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Lower Extremity Review Mission
Showcasing evidence and expertise across multiple medical disciplines to build,
preserve, and restore function of the lower extremity from pediatrics to geriatrics.
EDITORIAL PILL ARS
• Biomechanics matter • Injury prevention is possible
• Diabetic foot ulcers can be prevented • Collaborative care leads to better outcomes
Richard Dubin
Publisher and Chief Executive Officer
rich@lermagazine.com | 518.221.4042
EDITORIAL ADVISORY BOARD
STAFF David G. Armstrong, DPM, MD, PhD Stefania Fatone, PhD, BPO Bijan Najafi, PhD
Professor of Surgery and Director, Professor, Physical Medicine & Professor of Surgery
Editor Southwestern Academic Limb Salvage Rehabilitation Director, interdisciplinary Consortium on
Alliance (SALSA), Keck School of Northwestern University Advanced Motion Performance (iCAMP)
Janice T. Radak | janice@lermagazine.com Medicine of the University of Southern
California, Los Angeles, California Chicago, Illinois Director, Clinical Research in Vascular
Surgery
Associate Editor Windy Cole, DPM Timothy E. Hewett, PhD
Baylor College of Medicine
Laura Fonda Hochnadel | laura@lermagazine.com Medical Director, Wound Care Center, Director, Biomechanics Laboratories &
Houston, Texas
University Hospitals Ahuja Medical Sports Medicine Research Center
Consulting Editor Center Mayo Clinic Antonio Robustelli, MSc, SCS
Adjunct Professor/Director Wound Care Minneapolis, Minnesota Sports Performance Consultant
John Baranowski | john@lermagazine.com Research Applied Sport Scientist/Technologist
Geza Kogler, PhD, CO
Kent State University College of Podiatric
Graphic Design/Production and Medicine Program Director
Strength & Conditioning Specialist
Website Development Cleveland, Ohio MS Prosthetics and Orthotics
Salerno, Italy
Anthony Palmeri | PopStart Web Dev Kennesaw State Unversity, Clinical Jarrod Shapiro, DPM
Robert Conenello, DPM Biomechanics Laboratory
webmaster@lermagazine.com Vice Chair, Department of Podiatric
Orangetown Podiatry Kennesaw, Georgia Medicine, Surgery & Biomechanics
Clinical Director, NJ Special Olympics
Operations Coordinator Robert S. Lin, CPO
Associate Professor of Podiatric
NYPD Honorary Surgeon Medicine, Surgery & Biomechanics
Melissa Rosenthal-Dubin | melissa@lermagazine.com Managing Partner, Adaptive Prosthetics
Greater New York City Area, New York Western University of Health Sciences
& Orthotics
Liaison, American College of Podiatric
Sarah Curran, PhD, FCPodMed Residency Coordinator, New England
Medicine
Lower Extremity Review Professor, Podiatric Medicine &
Rehabilitation
Orthotic and Prosthetic Systems, LLC
Wethersfield, Connecticut
Pomona, California
Cardiff Metropolitan University Bruce E. Williams, DPM
Lower Extremity Review informs healthcare practitioners
on current developments in the diagnosis, treatment, and Cardiff, United Kingdom Medical Director
prevention of lower extremity injuries. LER encourages a Go4-D
Paul DeVita, PhD
collaborative multidisciplinary clinical approach with an Chicago, Illinois
Director, Biomechanics Laboratory
emphasis on functional outcomes and evidence-based Leroy T. Walker Distinguished Professor
medicine. LER is published monthly, except for a combined of Kinesiology
November/December issue and an additional special issue in East Carolina University
December, by Lower Extremity Review, LLC. Greenville, North Carolina
Subscriptions may be obtained for $38 domestic and $72
international by writing to: LER, PO Box 390418, Minneapolis,
MN, 55439-0418. Copyright ©2018 Lower Extremity Review,
INFORMATION FOR AUTHORS
LLC. All rights reserved. The publication may not be reproduced LER encourages a collaborative multidisciplinary clinical approach to the
in any fashion, including electronically, in part or whole, care of the lower extremity with an emphasis on functional outcomes
without written consent. LER is a registered trademark of Lower using evidence-based medicine. We welcome manuscripts (1000-
2000 words) that cross the clinical spectrum, including podiatry,
Extremity Review, LLC. POSTMASTER: Please send address
orthopedics and sports medicine, physical medicine and
changes to LER, PO Box 390418, Minneapolis, MN, 55439- rehabilitation, biomechanics, obesity, wound management,
0418. physical and occupational therapy, athletic training, orthotics
and prosthetics, and pedorthics.
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Please attach manuscript as an MS Word file or plain text. Tables may be
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lermagazine.com 1.21 7
Publishers Memo
Carpe Diem! Let’s Seize the
Heck Out of 2021!
By Rich Dubin, Publisher
iStockphoto.com #1272601076
Now that 2020 is finally over…we can reflect on all that we have relevant clinical information in line with our 4 pillars (see page 6) and
learned: represent our broad audience of multidisciplinary clinicians in their
Who and what is important, how to work on our business and not quest for providing collaborative care. You can see that already in this
in it, how to slow down, look for opportunities, stay positive, be kind issue with topics ranging from the “Basics of Sleep” (page 37) and “A
to others always, stay focused, and keep our eyes and ears open. Case of a Misdiagnosed Neoplastic Wound of the Foot” (page 45) to
“One Thing You Can Do to Ski Better” (page 33) and our recently added
These are a few of the lessons that I have learned. What about
Patient Guidance offering, "Stay Active to Reduce the Risk of Falling:
you?
5 Exercises to Keep You Fit" (page 51). And we'll continue with the
I want to acknowledge our readers for always being there, our Edi-
COVID-19 Update to keep you up-to-date on relevant information about
torial Advisory Board Members who offer expert guidance, our multidis-
ciplinary authors who give of their time and clinical expertise, our staff SARS-CoV-2 until this pandemic is in the rearview mirror. If you have
for their willingness to be flexible during these trying times, and our a topic you want to see covered, reach out to our Editor Janice T. Radak
loyal and steadfast advertisers and sponsors for their continued support. (janice@lermagazine.com), she’s always happy to engage around story
And a special shout-out to 2 of our content partners, the American ideas with would-be authors.
College of Podiatric Medicine (formerly the American College of Foot & I am pleased to report that we have officially partnered with the
Ankle Orthopedics & Medicine) and the MedFit Network. Without all of Pedorthic Footcare Association (PFA) to manage all their marketing,
you, none of what we do would be possible. sales, and strategy efforts. This will be exciting as there are many
Stepping into 2021, our editorial content will continue to provide synergies and the relationship plays into our strengths at LER and
Continued on page 10
lermagazine.com 1.21 9
Continued from page 9
print product, it’s a winning combination. We have created lerEXPO to
deliver engaging events and have facilitated over 10 events thus far with
another 20 already on the calendar for this year. These range from a few
hour-long manufacturers’ CEU and non-CEU events to a several day-
long association CME events. The power and reach of Lower Extremity
Review provides a solution that offers more marketing and coverage to
make a successful event before, during, and after. Check out the website
at lerEXPO.com to see what events are coming up.
lerEXPERT is our practice consulting division where clinicians can
leverage everything that LER offers including, creative, production, and
design capabilities as well as content development, SEO, and social me-
dia management to grow your presence in print and online to establish
your brand, grow your practice, and further position you as the EXPERT
you are.
2020 was a hard year for all of us, and certainly some more than
iStockphoto.com #691666666 others, but we’ve made it this far, and we’ll keep moving forward. Life
will get back to “normal”…and while that normal will be new, LER will
provides a lot of value for the PFA, its members, and vendors.
still be here, but we’ll be joined by lerEXPERT and lerEXPO to further
2021 will be a great year (always think positively!). It will be the
your educational and business needs.
year we tame COVID (again, think positively). But more importantly, it
will be the year we begin to implement the key lessons of 2020’s various
virtual tryouts: namely the power of non-live events and their ability to
spread messages in non-traditional ways. When coupled with the right
10 1.21 lermagazine.comLightweight, Durable, Responsive
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Artificial Intelligence and patient management systems through better treatment algorithms
COVID-19 (figure).
2. Monitoring the treatment—AI helps in monitoring and predicting
the virus’ spread in large and small areas.
2. Contact tracing—AI can help analyze the level of viral infection
through identification of clusters and hot spots, as well as manag-
ing the necessary contact tracing.
4. P
rojection of cases and mortality—Using various tracking mea-
sures (eg, social media), AI can forecast risk of infection, likely
spread, and potential deaths by region.
5. D
evelopment of drugs and vaccines.
6. Workload reduction for healthcare workers—AI is being used to
develop better training and CME programs to spread the knowl-
edge about how best to treat COVID-19.
7. P
revention of disease—Because AI can identify traits, causes and
reasons for spread, AI can be used in the future to fight against
emerging pandemics.
Source: Vaishya R, Javaid M, Khan IH, Haleem A. Artificial Intelligence
(AI) applications for COVID-19. Diabetes Metab Syn Clin Res Reviews.
2020;14:337-339.
Melatonin to Treat COVID-19?
The COVID-19 pandemic has disrupted healthcare around the world.
The need for solutions today—for better predictive models, better diag-
nostics, more and better treatments—is driving the adoption of artificial
intelligence (AI) as a necessary—yet still experimental—methodology.
While some are concerned about the quality of the studies being per-
formed, or the need for better datasets, potential solutions are unfolding,
and their development will play a much-needed role in reducing the
workplace burden today’s healthcare workers are facing.
iStockphoto.com #612625720
A recent rapid literature review, published for Diabetes India, found
7 applications for how AI is already making headway in the fight against
the virus. According to an AI platform developed by researchers at the Cleveland
1. Early detection and diagnosis of the infection—AI is being used Clinic’s Lerner Research Institute, the hormone that helps regulate
to identify irregular symptoms and ‘red flags’ that allow for faster sleep—melatonin—may be a novel treatment for COVID-19.
decision-making. It is also being used to develop diagnostic and The finding that the OTC sleep aid might be of help came as the
Continued on page 14
lermagazine.com 1.21 13Continued from page 13
experience researchers were seeking to identify previously approved drugs for repur-
posing in the fight against the rapidly spreading SARS-CoV-2, the virus
that causes COVID-19.
Using network medicine methodologies and data from the electronic
health records of Cleveland Clinic patients, the researchers were able
to identify common clinical manifestations and pathologies between
SARS-CoV-2 host genes/proteins and those well-associated with 64
other diseases (eg, cancer and autoimmune, cardiovascular, metabolic,
neurological and pulmonary diseases), where closer proximity indicates a
higher likelihood of pathological associations between the diseases.
Among their findings: the proteins linked with respiratory distress
PREMIUM CUSTOM ORTHOTICS syndrome and sepsis (2 causes of death in COVID-19 patients) were
highly connected with several SARS-CoV-2 proteins. Translation: drugs
already approved to treat such conditions may be viable candidates for
COVID-19 because they share biological targets.
All-in-all they identified 34 drugs as potentials for repurposing in-
cluding some of those used to treat autoimmune (eg, inflammatory bowel
disease), pulmonary (eg, COPD and pulmonary fibrosis) and neurological
(eg, depression and ADHD) diseases.
“Recent studies suggest that COVID-19 is a systematic disease
impacting multiple cell types, tissues and organs, so knowledge of the
complex interplays between the virus and other diseases is key to under-
standing COVID-19-related complications and identifying repurposable
drugs,” Feixiong Cheng, PhD, assistant staff in Cleveland Clinic’s Ge-
nomic Medicine Institute and lead author on the study told Consult QD.
OTC ORTHOTICS “Our study provides a powerful, integrative network medicine strategy to
predict disease manifestations associated with COVID-19 and facilitate
the search for an effective treatment.”
Source: Cleveland Clinic Foundation. Melatonin a Promising Candidate
for Prevention and Treatment of COVID-19. Consult QD. Nov. 13, 2020.
Available at https://consultqd.clevelandclinic.org/melatonin-a-promis-
ing-candidate-for-prevention-and-treatment-of-covid-19/. Accessed Jan.
5, 2021.
“Smelling” COVID-19
A simple test—akin to the well-known breathalyser to detect blood
alcohol—may be able to “smell” COVID-19 according to Indonesian
researchers. Using AI in the form of an electronic nose, the GeNose C-19
device is able to identify elements that are unique to COVID-19. This test
is expected to be in use in India by February to increase mass testing of
THE RICHIE BRACE® people for coronavirus at hospitals, airports, seaports, and other public
places in the world’s fourth most populous country.
A similar test is under development at Indiana University’s School
800.444.3632 of Engineering and Technology. In response to a call from the US Na-
www.alliedosilabs.com tional Institutes of Health and Department of Defense, a team lead by
Mangilal Agarwal, PhD, is developing a sensor that would identify the
14 1.21 lermagazine.comiStockphoto.com #1131975205
scent in breath altered by COVID-19. “We have the unique perspective
of identifying a signature. We’re looking at the metabolic pathways the
virus causes, which can be identified,” Agarwal said, adding that they are
collecting breath samples from people who have tested positive, including
asymptomatically, and negative for COVID-19.
A third such test is under development at Texas A&M University.
This test uses a kiosk where a person uses a disposable straw to blow
into a copper inlet. In less than a minute, test results can be sent to the
person’s smartphone. The beauty of this approach is that it’s noninvasive,
there’s no touching or the need to get within 6 feet of another person,
and it’s fast—the results are immediate, or at least as fast as your phone’s
service provider can muster. Using AI, the team is improving results
every day.
Sources: Barker A. Could a breathalyser help detect COVID-19? Indo-
nesian scientists say they’ve developed one. ABC News. Available at abc.
net.au/news/2021-01-02/indonesia-to-use-breathalysers-to-help-detect-
covid-19/13019744. Accessed Jan. 5, 2021.
Schwarb J. Breath test to detect COVID-19 in development
by IUPUI researchers. Available at news.iu.edu/stories/2020/12/
iupui/16-breathalyzer-breath-test-device-covid-19-coronavirus.html
Accessed Jan. 5, 2021.
Reilly M. Texas A&M System, Worlds Inc. Collaborate on COVID-19
Breathalyzer. Available at today.tamu.edu/2020/11/19/texas-am-system-
worlds-inc-collaborate-on-covid-19-breathalyzer/. Accessed Jan. 5, 2021.
lermagazine.com 1.21 15With PolyMem, finger and toe injuries ® don’t have to slow you down. 6DYHWLPHZLWK3RO\0HP)LQJHU7RHGUHVVLQJVZKLFKDUHHDV\ WRDSSO\ĘHYHQIRUSDWLHQWVWKHPVHOYHVĘDQGRIWHQUHTXLUH IHZHUGUHVVLQJFKDQJHVWKDQNVWRWKHLUXQLTXHGHVLJQ6LPSO\ UROOWKHGUHVVLQJRQWRWKHLQMXUHGGLJLWDQGOHW3RO\0HPGRWKH ZRUN3RO\0HPGUHVVLQJVKHOSUHGXFHHGHPDEUXLVLQJSDLQ DQGLQûDPPDWLRQZKHQDSSOLHGWRRSHQRUFORVHGLQMXULHV THE IDEAL CHOICE FOR MANAGING: ĚSprains Ě/DFHUDWLRQV ĚStrains ĚBurns ĚContusions Ě8OFHUV ĚAbrasions Ě0DWULFHFWRPLHV NEW, BIGGER sizes available – ideal for large toes! Ferris Mfg. Corp. 5133 Northeast Parkway, Fort Worth, TX 76106 USAĚ1 817-900-1301Ěwww.polymem.eu Unless otherwise indicated, all trademarks are owned by or licensed to Ferris. © 2013, Ferris Mfg. Corp., Fort Worth, TX 76106 USA MKL-619, REV-1, 0913
Snowblower Injuries From incidence of ED snowblower visits was 1.845 per 100,000 US population
2003 – 2018 with no change over time. There was a general correlation between the
number of visits and the annual snow cover.
Ample opportunity for injury prevention exists, as there was no
change in the incidence over time. Cardiac events accounted for essentially
all of the deaths.
Source: Loder RT, Solanki D. Events due to snowblower use seen in US
Emergency Departments from 2003 through 2018. Cureus. 2020;12(12):
e11836.
Corrective Insoles Improve Leg
Muscle Activation
Figure: Injuries sustained from snow blowers
Rice farming is conducted in slippery and viscous muddy soil, which leads
to a high prevalence of musculoskeletal disorders and malalignments. Over
half of Thailand’s farm labor force is engaged in rice farming, making these
occupational challenges a public health burden. Thai researchers from
Power snow blowers allow for easier, quicker snow removal at homes and Khon Kaen University hypothesized that interventions originally designed
businesses. However, they are potentially dangerous and can result in sig- for congenitally disabled individuals, such as corrective wedges to reduce
nificant injury. Most studies of snowblower injuries discuss those sustained foot eversion, might be applicable to rice farmers. In a study published
when placing the hand into the chute, resulting in lacerations, fractures, in the journal Foot, these researchers sought to investigate the effects of
and, frequently, amputations. However, other injuries can also occur such corrective wedges on lower extremity muscle activity and alignment when
as being hit by a missile ejected from the chute, slipping/falling while study participants stood on flat rigid ground or muddy terrain, simulating
using the snow blower, and medical issues such as shortness of breath and the work conditions of rice farmers.
cardiac events (myocardial infarction/cardiac arrest). The study recruited 9 healthy farmers with pronated feet and cus-
There is very little literature reviewing the whole scope of injury tom-fabricated wedges for each farmer based on physical therapy assess-
associated with snow blowers. It was the purpose of this study to analyze ment and use of rapid prototyping techniques. Participants then stood
all types of injuries and medical events associated with snowblower use barefoot or with wedges on the two surface types.
presenting to emergency departments (EDs) in the United States. Foot pronation and knee valgus improved (ranging, on average
Data on National Electronic Injury Surveillance System ED visits due between 5.5 and 16.1 degrees) when participants were equipped with cor-
to snow blowers from 2003 through 2018 were analyzed by age, sex, diag- rective wedges. The muscle activity of the peroneus longus and the tibialis
nosis, anatomic location of the injury, and year, month, or weekday. The anterior increased for muddy terrain, as compared with the rigid surface.
mechanism of injury and alcohol use were noted. Statistical analyses were In general, the wedges induced less tibialis anterior activity and greater
performed, accounting for the weighted, stratified nature of the data. peroneus longus activity, compared to when participants were standing
There were an estimated 91,451 patients with an average age of 51 barefoot. An elevation in evertor muscle activity may reflect stretching of
years; 91.2% were male. Amputation, fracture, or laceration accounted for the shortened muscle as a result of the reduced degree of foot pronation.
43,524 (47.6%) of the ED visits. The mechanism of injury was placing the The researchers concluded that there are potential benefits of correc-
hand into the chute (44.5%), a fall/slip (13.3%), medical events (6.1%), tive insole usage for farmers with pronated feet, including improved lower
and miscellaneous (33.8%). Most (68.9%) occurred at home. Alcohol was extremity alignment and invertor muscle activity reduction for both rigid
rarely involved (0.4%). There were 648 deaths; 647 were due to cardiac and muddy terrains.
events. The five major injury diagnoses were fracture (25.9%), laceration
Source: Kristanto A, Neubert MS, Gross MT, Puntumetakul R, Kaber
(20.2%), strain/sprain (15.0%), amputation (11.2%), and contusion/
DB, Sessomboon W. Effects of corrective insole on leg muscle activation
abrasion (10.2%); 99.8% of the amputations involved fingers (Figure). The
Continued on page 18
lermagazine.com 1.21 17Continued from page 17
and lower extremity alignment in rice farmers with pronated foot: a low-knee or above-knee amputation (BKA and AKA, respectively) for CLI
preliminary report. Foot (Edinb). 2020 Dec 25;46:101771. doi: 10.1016/j. secondary to type 2 diabetes mellitus, atherosclerosis, peripheral vascular
foot.2020.101771. disease, chronic osteomyelitis, and deep soft-tissue infections.
For all diagnoses, blacks were 93.3%, and Hispanics were 61.9%
more likely to undergo a BKA than white patients (P < 0.001). In addition,
Disparities Persist in Amputations
black patients had a 133.0% higher risk of an AKA than white patients
(P < 0.001). Disparities were greatest with blacks undergoing surgery for
for Critical Limb Ischemia CLI secondary to atherosclerosis (BKA odds ratio 2.093; AKA: odds ratio
Critical limb ischemia (or chronic limb threatening ischemia, CLI) is a state 2.625). Black patients also had an elevated risk of amputation secondary to
of arterial insufficiency manifested by chronic inadequate tissue perfusion diabetes, peripheral vascular disease, and deep soft-tissue infections
at rest, reducing patients’ quality of life and increasing the risk for amputa- (P < 0.001).
tion and death. Prevalence for PAD ranges from 3% – 10% but increases The researchers concluded that their findings from this nationally
representative, cohort-based study demonstrate that notable racial and
to 15% – 20% in persons age ≥70 years and is increasing worldwide.
ethnic disparities for lower extremity amputations persist, with a higher
Common risk factors include age, smoking, diabetes, body mass, seden-
proportion of black and Hispanic patients undergoing amputation com-
tary lifestyle, high cholesterol, high blood pressure and family history. But
pared with limb salvage procedures for atraumatic CLI and infection. Data
previous studies have identified disparities in amputation rates, namely
from other studies advocate for an endovascular-first approach to revascu-
demonstrating that blacks were 2 times more likely to undergo amputation
larization in treating patients with CLI.
than whites.
In a new study published in the Journal of the American Academy of Source: Traven SA, Synovec JD, Walton ZJ, et al. Notable Racial and
Orthopaedic Surgeons, researchers used data from the National Surgical Ethnic Disparities Persist in Lower Extremity Amputations for Criti-
Quality Improvement Program’s database for the years 2011 – 2017. They cal Limb Ischemia and Infection. J Am Acad Orthop Surg. 2020 Nov
sought to isolate the effect of race and ethnicity on the likelihood of a be- 1;28(21):885-892.
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18 1.21 lermagazine.comSKIING-RELATED
INJURIES
Who, What, How,
When, And a Bit of
Prevention
More popular than ever, skiing remains a
complex sport with a high risk of injury. Here
we detail some of the pertinent data.
By Janice T. Radak
Skiing, a sport that has been around since Cro-Magnon man, is
among the most popular winter sports in the United States. There
were nearly 15 million skiers in the US in 2017 alone. During the
2017/18 ski season, there were 472 ski resorts in operation in the
US, with more than 53 million visitors. And the numbers continue
to grow, even during a pandemic.
In one of those wonky pandemic upside-downisms, skiing
is tagged as a low-risk activity because the skier is outdoors and
gliding down the mountain is typically a solitary adventure. But
in reality, it remains the same high-risk sport it has always been
when it comes to injuries. As the table shows, knees remain the
most injury-prone body part for skiiers.1
While snowboarding is akin to skiing, the 2 sports are differ-
ent when it comes to injuries; here, we will focus on skiing-related
injuries of the lower extremity only.
Continued on page 22
lermagazine.com 1.21 21Continued from page 21
TABLE. MOST COMMON SKIING INJURIES 1
PEDIATRICS RECREATIONAL ELITE
1. Lower extremity 1. Lower extremity 1. Lower extremity
• Knee (contusion, sprain) • Knee (ACL injury) • Knee (ACL injury)
2. Upper extremity 2. Upper extremity 2. Lower back and hip
• Hand • Shoulder
3. Head/neck/face
• Wrist • Hand
• Concussion
3. Head/neck/face 3. Head/neck/face
• Concussion • Concussion
Who’s at Risk? affecting the anterior cruciate ligament (ACL) Three major mechanisms have been iden-
and/or the medial collateral ligament (MCL). tified as the cause of most skiing-related ACL
In a recent clinical study, the mean age of
These ligaments are at highest risk due to the injuries:1,2,5
injured skiers was 30.3 years (range, 24 to 35.4
torsional forces placed on skiers’ knees. These
1,2
• Valgus-external rotation associated with
years), and the populations at greatest risk
of injury are children/adolescents and adults 2 ligaments account for nearly one third of all a forward fall where the inner edge of the
over age 50. However, another study found no
2 skiing-related injuries. Fractures of the tibial front ski catches in the snow: this causes
difference in risk in the older age group, with plateau and tibial plafond do occur, though they tibial abduction with external rotation,
the exception of tibial plateau fractures. An3 account for less than 10% of injuries. causing a valgus force about the knee
important note: As the Baby Boomers—the The incidence of grade III ACL injuries has with the ski acting as a lever to maximize
generation that popularized skiing in the US— fluctuated since the early 1990s, but most recent torque; this may also produce an MCL
retire, the general age of recreational skiers is estimates place the incidence at 0.23 per 1,000 sprain as well (Figure 1, page 29).6
rising, which could mean a trend toward more skier days.2 This compares to the calculated rate
• “Phantom foot” effect of a backward fall (so
injuries in older adults in the future. of 0.2 ACL tears per 1,000 athlete-exposures
called because the downhill ski produces a
Numerous risk factors for skiing injuries (AEs) in female soccer players but is higher
force as if an imaginary foot were pushing
have been identified and include: age, sex, than the rate for male soccer players, which is
on its tail), causing internal rotation of the
skiing experience level, self-assessed skill level, 0.09 tears per 1,000 AEs. Female sex, lower
downhill knee (Figure 1, page 29).6
body mass index, and trail difficulty. 2 core strength, and non-dominant leg have been
• Boot-induced mechanism where an
identified as risk factors for this specific injury.
What Kind of Injuries In a study aptly titled, “Why do we suffer more
anterior force is applied to the tibia by the
ACL injuries in the cold?,” Csapo et al4 conclud- boot top while landing on the tail of a ski
Ligamentous: Studies report 43% to 77% of
ed that “the reduced capacity of cold knee flexor from a jump with a fully extended knee,
all skiing-related injuries occur in the lower
muscles to explosively generate force may limit resulting in anterior translation of the tibia
extremity, making it the most common body
region for injury in the sport.2 The knee, with the hamstrings’ capability to counter strong and relative to the femur, rupturing the ACL.
27% to 41% of injuries, remains the most com- fast contractions of the knee extensor muscles In a patient survey seeking to understand
mon site for skiing-related injury. And the most that cause anterior shear force on the tibia and, mechanism of knee injury, Shea et al7 found
common injuries are ligamentous, namely those thus, strain the anterior cruciate ligament.” that 33% identified valgus-external rotation as
Continued on page 25
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the cause of their injury, followed by phantom foot at 22%, hyperexten-
sion at 19%, boot-induced at 8%, collision at 2%, and all other causes
at 16%. Interestingly, while valgus-external rotation was most common
in their study, the authors noted that individuals age 30 to 40 years had
an increased risk for the phantom foot mechanism. They also reported
that bindings released during injury in nearly 20% of adults and 54% of
youth.
Fractures: Since the adoption of International Organization for
Standardization (ISO) and ASTM International standard shop practices,
ACL INJURY PREVENTION VIDEO14
the incidence of tibial fracture has fallen, though it remains a common A recently released video from the Stockholm Sports Trauma
cause of skiing-related injuries. Beginners, children, and adolescents are Research Center, Karolinska Institutet, in collaboration
at increased risk, with children under age 10 at 9 times greater risk than with the Vermont Skiing Safety Research Group and the
skiers over age 20.
Swedish Ski Association Alpine Education, reviews critical
In a 6-year study from Finland, Stenroos et al8 reported that fracture
strengthening exercises for the prevention of injury to the
of the tibial shaft was the most common fracture in adult skiers (63%),
followed by fracture of the proximal tibia (27%), and fracture of the distal anterior cruciate ligament in teenage alpine skiers. The video
tibia (10%). In their review of the data, a fall on the snow surface was the provides step-by-step and ski-by-ski instructions for 3 indoor
most common cause of injury. exercises (single leg hop, square hop, squat) and 3 outdoor
The evolution of shaped skis as well as better boots and bindings,
on-snow exercises (The Shuffle, back and forth, turns with
including standards for equipment and boots and for ski-boot-binding
lifted inner ski).
compatibility, has led to a significant decrease in tibial shaft fractures.
However, these remain a common injury for skiers, with boot bindings
Video: Prevention of serious knee injuries. Karolinska Insti-
failing to release properly as the major cause.
tutet. Jan. 19, 2020. Available at https://www.youtube.com/
Contrary to the decline in tibial shaft fractures, fractures of the tibial
plateau are on the rise. Age is the culprit here, as several studies point to watch?v=l-9CrG7lmAg&t=10s. Accessed Jan. 5, 2021.
the increasing age of the skiing population as the risk factor. Indeed, one
prospective study looked at 18,692 injuries sustained by 17,197 skiers in Print Source: Westin M, Harringe ML, Engstrom B, Alricsson
a moderate-size Vermont ski area and found that skiers over age 55 were M, Werner S. Prevention of anterior cruciate ligament injuries
at greater risk for tibial plateau fractures—5.7 times greater risk than the in competitive adolescent alpine skiers. Front. Sports Act.
general skiing population.3 Living. 2020: doi.org/10.3389/fspor.2020.00011
While many attribute the overall decrease in fractures to improved
ski boot-binding systems, it is important to note that the revised de-
signs were in response to fractures and as such these systems are NOT
designed to protect the knee from serious sprains.5 Most researchers and
• Mental errors: This covers a host of issues—eg, poor judgement due
ski pros advised making sure equipment is checked daily by the local pro
to age (too young or too old) or lack of skill or expertise (choosing a
shop before hitting the slopes.
trail too far above ability), losing focus, fatigue.
How Injuries Happen • Obesity, as it hampers flexibility and increases forces.
Most injuries are fall-related, and while most occurred on groomed • Poorly fitting equipment
intermediate (blue) runs, the quick-change line between groomed and - Boots too snug.
ungroomed snow has claimed plenty of skiers. - Bindings release set too tight.
Other causes include:9 • Skis not tuned: Generally, skis should be tuned every 5 to 7 days of
• Poor physical preparation: Knee movement is key to skiing and skiing, not just once a season. Imperfections in ski surfaces result
quadricep support is essential to long-lasting knee flexion/extension from everyday use on changing ground conditions and prevent skis
for shock absorption. Squats are essential to building fitness for this from performing as they should. Tuning regularly fixes these and
particular sport—they draw on trunk and leg muscles in the same keeps skis in proper working condition.
manner as the sport maneuver itself.
Continued on page 26
lermagazine.com 1.21 25Continued from page 25
• Incorrect equipment (wrong type of skis): population are nonemergent (eg, ACL rupture, The high-risk frame of mind occurs during
Modern skis come in different lengths, nondisplaced clavicle fracture, acromioclavicular that last run—no matter what time of day it is.
widths, weights, flex patterns, and sidecuts. joint sprain) and require initial immobilization, “Let your body be your guide,” Maack said. “At
Skis should be fitted based on the skier’s pain management with oral medications, and the end of the day there’s always one last run.
ability and what type of skiing will be done. follow up within 2 to 5 days. 11 That’s unavoidable. So the message that we
A key challenge in treating injured skiers is try to get out is to make that one last run a fun
their location. Most ski resorts are in the moun-
When Do Injuries Occur one… Don’t go hit the double-black as the last
tains, far from advanced medical centers with In a 2016 video interview with University of run, maybe take a groomer. Take a nice, little,
all the needed technology to assess and evaluate Utah Health Sciences Radio, Travis Maack, MD, smooth one down. Enjoy yourself. You don’t
injuries. The ski patrol typically is first to assess a sports medicine expert and Head Orthopedic have to be a hero at the end of the day. At the
and manage injured skiers on the slope at the Team Physician for the Utah Jazz, noted that end of the day, if you do it that way, you’ll be
accident site. Ski patrollers are specially trained in his experience, injuries occurred more often able to come back the day after.”
in outdoor emergency care (and typically basic during 2 different times—the first, a timeframe, Maack’s observations are backed up by the
and advanced life support) and how to trans- the second a frame of mind.12 American Orthopaedic Society for Sports Med-
port injured skiers in a toboggan. (See “A Word The high-risk time tends to occur between icine,13 which notes that skiing-related injuries
About Ski Patrol,” below.) Getting skiers off the 3:30 and 5:00 pm, toward the end of the day. are most likely to occur on:
mountain and to appropriate treatment before Maack identified this timeframe for 2 reasons: • the first day of ski week
hypothermia sets in is key. While some larger First, the sun is beginning to set, and the tem- • in the early morning when the skier is not
resorts have their own clinics with basic imaging perature is cooling down, so the snow is getting warmed up
technology, many of the smaller venues do a bit harder. “During the afternoon, it starts to • in the late morning and late in the day
not, meaning more transport time to reach the cool down, so [the snow] gets a little bit rockier, when fatigue sets in
appropriate level of medical care. The advent a little bit skied out. So, the terrain itself is more
• at the end of the week when the
of hand-held ultrasound technology is helping, difficult.” Second, is muscle fatigue—the decline
cumulative effects of the vacation make the
but cost remains a factor for smaller locales.10 in a muscle’s ability to generate force, which
skier tired.
Thankfully, most injuries seen in this active happens after repeated use.12
Continued on page 29
A WORD ABOUT SKI PATROL
The National Ski Patrol (nspserves.org) is the The course focuses on 3 skills:
leading authority of on-mountain safety. It boasts a • performing safe and effective stabilization and
membership of 31,000 trained emergency medical extrication of injured persons in the outdoor
technicians (EMTs), advanced EMTs, and paramedics, environment
as well as affiliated physicians. There are 650 patrols
• scene safety (identifying hazards to both
across the United States, Canada, Europe, and Asia.
responders and visitors)
Members work on behalf of local ski/snowboard ar-
• safe and efficient use of outdoor emergency
eas and bike parks to improve the overall experience
care skills to prevent further injury to visitors.
for outdoor recreationalists.
Members must pass the Outdoor Emergency Care There is an additional course specifically for Outdoor
(OEC) course for emergency medical responders, Emergency Transportation, which teaches how to
which is tailored to the non-urban rescuer. safely transport injured skiers in a toboggan.
26 1.21 lermagazine.comResearch
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Footmaxx.com/get-startedContinued from page 26
Injury Prevention Works References Grimm NL, Jacobs JC Jr, Willick S, Van
1. Weinstein S, Khodaee M, VanBaak K. Com- Houten H. Knee Injuries in Downhill Skiers:
Skiing is an equilateral sport, where athletes
mon Skiing and Snowboarding Injuries. Curr A 6-Year Survey Study. Orthop J Sports Med.
need good neuromuscular balance between
Sports Med Rep. 2019;18(1):394-400. 2014 Jan 22;2(1):2325967113519741.
the quadriceps and hamstring muscles and
between the dominant and non-dominant leg, 2. Davey A, Endres NK, Johnson RJ, and Shealy 8. Stenroos A, Handolin L. Incidence of rec-
as well as good postural control. ACL injuries
14
JE. Alpine skiing injuries. Sports Health. reational alpine skiing and snowboarding
are known to impair neuromuscular function, injuries: Six years experience in the largest ski
2018;11(1):18-26.
making primary prevention ideal, and secondary resort in Finland. Scand J Surg. 2014;104:127-
3. Shealy J, Ettlinger J, Johnson R. Aging Trends
prevention mandatory for when such injuries do 131.
in Alpine Skiing, J ASTM Int. 2010;7(4):1-6.
occur. 15
9. Stone KR. How to avoid ski injuries. The
Beginners are at the highest risk of 4. Csapo R, Folie R, Hosp S, Hasler M, Nach-
Stone Clinic. Available at https://www.stone-
injury, and so proper education, sport-specific bauer W. Why do we suffer more ACL inju-
clinic.com/how-to-avoid-ski-injuries. Accessed
instruction, and education on risk awareness ries in the cold? A pilot study into potential
Jan. 5, 2021.
is important for novices. Education should risk factors. Phys Ther Sport. 2017;23:14-21.
10. Gammons M, BoyntonM, Russell J, Wilkens
include use of protective equipment and proper 5. Ettlinger C, Johnson R, Shealy J. Functional
K. On-mountain coverage of competitive
chairlift technique. Helmet use has been shown and Release Characteristics of Alpine Ski
skiing and snowboarding events. Curr. Sports
to decrease risk and severity of head injuries Equipment. In Johnson R, Shealy J, Yam-
Med. Rep. 2011;10:140–6.
without increasing risk of cervical spine injury agishi T, eds. Skiing Trauma and Safety. Vol.
11. Ellerton J, Tomazin I, Brugger H, Paal P,
or risk-taking. Other prevention techniques that 16.West Conshohocken, PA: ASTM Interna-
International Commission for Mountain
show possible benefit include neuromuscular tional; 2006:65–74.
Emergency Medicine. Immobilization and
training and improving core strength.1,14 (See
6. Apps M. Causes of ACL Injuries. Ski-Knee. splinting in mountain rescue. Official Recom-
“ACL Injury Prevention Video,” page 25).
com. Available at http://www.ski-knee.com/ mendations of the International Commission
Janice T. Radak, not an avid skier, is Editor of causes Accessed Jan. 5, 2021. for Mountain Emergency Medicine, ICAR
Lower Extremity Review. 7. Shea KG, Archibald-Seiffer N, Murdock E, MEDCOM, intended for mountain rescue first
Figure 1. Valgus external rotation. Image courtesy of Ski-Knee.Com; all rights reserved. Figure 2. Phantom foot. Image courtesy of Ski-Knee.Com; all rights reserved.
Continued on page 30
lermagazine.com 1.21 29Continued from page 29
responders, physicians, and rescue organiza- at file:///C:/Users/jrada/OneDrive/Desk- 15. Jordan MJ, Morris N, Lane M. Monitoring
tions. High Alt. Med. Biol. 2009;10:337–42. top/LOWER%20EXTREMITY%20Feb%20 the return to sport transition after ACL in-
12. TheScopeRadio.com. Why Most Ski Injuries 17%202020%208am/01%20Jan%202021/ jury: an alpine ski racing case study. Front.
Happen After 3:30 PM. University of Utah Skiing_Snowboarding/Skiing%20Inju- Sports Act Living. 2020;2:12. doi: 10.3389/
Health. Feb. 17, 2016. Available at https:// ries%20ASSOM.pdf. Accessed Jan. 5, 2021. fspor.2020.00012.
healthcare.utah.edu/the-scope/shows.php?- 14. Westin M, Harringe ML, Engstrom B, Al-
shows=0_7m18zo0t. Accessed Jan. 5, 2021. ricsson M, Werner S. Prevention of anterior
13. AOSSM Sport Tips. Alpine Skiing and Snow- cruciate ligament injuries in competitive ado-
boarding Injuries. American Orthopaedic lescent alpine skiers. Front. Sports Act. Living.
Society for Sports Medicine. 2008. Available 2020: doi.org/10.3389/fspor.2020.00011.
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PATIENT GUIDANCE:
One Thing You Can Do to Ski Better
By Mark Paigen
Many would argue that the key to great skiing is
understanding how to properly apply pressure
to the edge of your skis. Since your feet are
connected to those skis, this task falls to them.
• Ski boots have the critical job of
communicating your thoughts to your skis,
keeping your feet warm and comfortable,
and helping you perform better on the
slopes. But even the best ski boots don’t
work unless they fit perfectly.
• Most ski boots feature heat-moldable liners
to fine tune the fit; however, these liners
don’t improve contact underfoot. To get
better contact, you need ski boot insoles.
• When you ski, the forces on your feet are
substantial. Insoles for ski boots need to be
just as substantial and do not easily deflect
in the arch area.
• Effective ski boot inserts prevent arch
collapse helping you carve turns, and
minimize buckle pressure. They also keep
your feet warm and comfortable. Shutterstock.com #1178312516
What You Need to Know How Ski Boots Work • Tightening the buckles over your instep to
Whether you’re carving groomers under the You ask a lot of your ski boots. You expect try to prevent foot movement only creates
lift or earning your turns in the backcountry, them to do the difficult job of holding your feet more discomfort. The best-fitting ski boots
one of your biggest skiing challenges is getting completely still while allowing your toes room do not need extreme pressure to keep your
commands to flow from brain to foot to ski to to move. They must allow your ankles to flex feet in place.
snow. The weakest link is often the connection forward, but not side to side. Finally, they have
between your foot and your ski. Ski boots often to keep your feet warm and comfortable in cold Strong Arch Support
don’t fit as well as they should. weather. Minimizes Pronation
Ski boots should be chosen for the combi- They do this with a hard, molded shell and
Strong ski boot arch support lets you reduce
nation of flex, fit, and comfort. But how much a firm, foam liner. The hard shell closes with
does that combination help if the contours buckle pressure without losing performance. In
high-leverage buckles that clamp your feet in
of your feet don’t match the contours of your addition, arch support in your ski boots reduces
place. Here’s the rub:
boots? • As your foot overpronates in a turn, the foot fatigue. The muscles in your foot do not
As board-certified pedorthist and master arch flattens and your foot gets longer. have to try to hold your arches up during each
bootfitter Bob Egeland says, “You marry your With a lower arch, your foot can now slide turn.
boots, you date your skis. You have to get your forward, reducing the great fit that you had Spreading the pressure over a greater area
boots dialed in.” in the ski boot shop. on the bottom of your feet also adds to your
Continued on page 34
lermagazine.com 1.21 33You can also read
