NORDIC/XC/TELEMARK SKI INJURIES


"Nordic skiing" per se encompasses a wide spectrum of activity from gentle trail skiing in the forest, through ski touring on hills and mountains and, more recently, fast downhill telemark skiing. On this page, I am going to split the sport into XC (cross country or trail skiing) and telemark skiing. Apart from generally narrower skis, the main difference between all forms of nordic and alpine skiing is the "free heel" nature of nordic skiing. Nordic has always had a lower injury rate than alpine - perhaps because of the lower speeds involved - but as downhill telemarking gets faster and continues to attract alpine skiers in search of a new challenge - perhaps this will change. In the 1990's the development of plastic boots and carving telemark skis opened up a whole new dimension to the sport of telemarking. I have to confess that I am a telemark skier, although not the world's best by any means. On this page I am going to examine the (limited) data that exists on nordic and telemark skiing and also the influence - potential and real - that modern equipment may have on injury risk. In the near future I plan to split this information into two pages, but for now its all lumped together on this page so please bear with me.
 

Injury studies in XC skiing

One of the main problems in accurately assessing nordic ski injuries is the relative lack of data specifically relating to them. Very few studies have looked at XC injuries alone compared to the masses of publications on alpine ski injuries. One of the reasons is that, by the sport's very nature, its participants are often spread out far and wide in the hills unlike alpine skiers who are concentrated in a downhill resort. This makes identification and follow-up of injured nordic skiers much more difficult. It also means that studies that do track down injured XC skiers are likely to fall into one of two patterns - firstly - hospital based studies which will be biased towards those who only suffer major injury and thus come to hospital attention with many minor injuries that don't slipping through the net.

[This "by-pass" effect is well described in the literature and affects all ski injury studies. However, its effect is believed to be less where there is a defined ski resort area, as the presence of medical facilities at such areas encourages people to seek medical attention more readily.]

The second kind of study performed - relying on self-reported injuries - has the reverse problem. In these studies there is a tendency to report every single injury no matter how small with a consequent over-exaggeration of the injury rate. Self-reported injuries also rely on honest reporting for their accuracy and are thus open to data abuse.

Nevertheless, the data that does exist consistently shows that the typical nordic ski casualty is on average 5-10 years older than an injured alpine skier, and -perhaps not surprisingly - a much larger percentage are experienced skiers. 

Thankfully, a recent study on XC injuries has come out from the Czech Republic which helps to address some questions about injuries from XC skiing (see the next section).
 

XC (Cross-Country/trail) skiing injuries

This section concentrates on injuries sustained as a result of skiing on track skis, either in the forest or low level hills.

Based on a prospective study from 5 ski-touring areas in the USA between 1979-81, Boyle et al determined an injury rate of 0.72/1000 skier days - well below that of alpine skiing and snowboarding (bear in mind the above comments regarding the bypass effect).

41% of injuries affected the upper limb, 49% the lower limb and 10% the head, face and trunk. The commonest upper limb injury reported is the so-called "skier's thumb" - this occurs when a skier falls onto an outstretched hand with the pole still in their grasp. The pole acts as a lever and damages the ulnar collateral ligament. It's prevention involves skiing with the pole held loosely in the hand rather than in the straps so that, in the event of a fall, this does not occur. The injury is very rarely seen in snowboarders who obviously do not use poles. Most other upper limb injuries involve the shoulder joint - usually as a result of a twisting fall onto the upper limb causing clavicular (collar-bone) fractures, acromio-clavicular joint disruptions or shoulder dislocations.

At the 2011 ISSS meeting, Dr Jan Rokyta presented data on 2295 XC skiing injuries that occurred between 2003 and 2010. The overall injury rate was 0.1/1000 XC skiing days compared to 1.0/1000 for alpine skiing. Males and females were injured in equal proportions although injured males tended to be slightly older (average age 42.5 yrs compared to 35.5yrs). The lower extremity was the commonest area of injury and falls accounted for about 85% of all injuries. About 8% of events were due to skier exhaustion and fractures made up about 25% of all injuries.


The commonest cause of a lower limb injury is the "catching" of a ski edge or tip. Because of the free-heel nature of the boot-binding system, it is much harder to exert torsion via the ski to resist such an occurrence. This mechanism leads to damage to the medial collateral ligament of the knee and, much less commonly, anterior cruciate ligament damage. The ankle is also at risk of injury in this form of nordic skiing, being afforded little protection by trainer-like or leather boots. Ankle sprains and boot top fractures are relatively common - basically the ski stops but the skier doesn't!! Be aware of snow conditions and prepare to hit softer, slower snow in good time.



Some studies have looked at possible differences in injury patterns between "classic" nordic striding and skating techniques. The overall conclusion is that, contrary to what was expected, there is no real difference between the two groups. This has been attributed to advances in ski, boot and binding design.

Remember that this form of skiing is extremely energetic - ensure you are well prepared, equipped and fit. A sobering study by Tough and Butt showed that most backcountry ski fatalities occurred when experienced skiers triggered avalanches in areas where the avalanche risk was known to be moderate or high. Check forecasts and conditions, don't ski alone, carry transceivers and KNOW HOW TO USE THEM!!

 

Telemark skiing


Telemarking has become increasingly popular in the last 15-20 years - rapid advances in both ski and boot designs have brought the speed and agility of telemark skiing up to (if not beyond) the level of alpine skiing. More and more alpine skiers are looking for a new challenge and giving the sport a go. In my own field of ski patrol medicine, the ability to climb and traverse relatively easily on lighter telemark skis makes the sport ideal for ski patrol work.

The injury rate for telemarking has been quoted to be anything between 0.41 and 10 injuries per 1000 skier days. If you've read other pages on my site, you'll know that the current rate for alpine skiing in Scotland is 2.38 injuries per 1000 skier days, whereas it is 1.13 (half as much) for telemark skiing. The higher rates tend to be reported in studies where telemarkers are sent questionnaires asking about the injuries they have sustained compared to those (like my own) that are based on ski patrol/health centre statistics. As I mentioned earlier, questionnaire studies tend to pick up every single little sprain and scrape and so will usually report a higher injury rate.

Overall, most experts would agree that telemark skiing has a lower injury rate than both snowboarding and alpine skiing, perhaps because the free-heel allows falls to occur with less torsional damage on the lower limb. As with alpine skiing though, less experienced skiers and women skiers suffer more injuries. Knees account for the largest % of injuries (40%), then thumbs (17%), shoulders (15%) and ankles (9%). Knee injuries that do occur are usually grade 1 or 2 in nature rather than the more serious grade 3 (complete ligament ruptures) injuries seen in alpine skiers - perhaps in part due to generally slower ski speeds (hence less force on the ligament and less damage).

In recent years, the traditional leather boot has been challenged by the emergence of plastic and hybrid (plastic and leather combination) boots. Its pretty rare now to see leather boots on ski slopes at all, unless a ski tourer is finishing off his/her day with a final blast on the piste! Plastic boots undoubtedly give the ankle joint more support, and also help skiers to turn more easily as the rigid plastic transmits forces up and down the leg so that the ski is more responsive. They also reduce the likelihood of an ankle injury which has always been a risk with leather boots. However, as happened in alpine skiing when alpine boots went through a similar change, the reduction in ankle injuries has been at the price of a rise in knee injuries. Plastic boots help the skier to transmit turning force to the ski (a good thing!), but equally any torsional forces sent back from the ski will affect the knee joint primarily (a bad thing!)
 
 

Telemark ski bindings


As with telemark skis, telemark bindings have undergone a huge change in the last 10-15 years. Initially, telemark skiers made use of the 3 pin nordic binding system, albeit with a more substantial toe binding. These bindings do not have either a release system or an integral ski brake. The former has never really been a problem as the binding allows you to twist in most directions, thus avoiding injury. The lack of a brake is dealt with by the use of a tie connection between the boot and binding unit so that if the ski did detach (rare unless you hadn't got the pins correctly in the boot toe) then the tie would prevent a runaway ski. The problem with these bindings is that, whilst they are lightweight and cheap, they're not very efficient at transmitting turning forces down to the ski. This means you have to be a pretty competent skier to ski well with them.

The next solution to come along was cable bindings. Adding a cable that ran from the toe unit down either side of the ski boot to the heel allowed for more torsional control. The tightness of the cable is adjustable usually by dialling up a small screw unit attached somewhere on the cable. Cable bindings per se do not have either a release system or ski brakes built in. Whilst you can buy a one of several release systems for cable bindings, in reality in the event of a high force fall, the cables usually came away anyway before injury occurred. Ski ties are again used to prevent runaway skis.



Release mechanisms have become more popular in recent years. Notwithstanding what I have just said in the last paragraph, their use would seem to make sense - if you have a fall you don't really want the risk of staying attached to a ski which might act as a force lever causing injury. With the limited data available, release cable bindings do seem to offer some degree of protection against lower limb injury. The problem is that setting the binding release is largely a matter of trial and error. Problematic though the ISO release settings may be for alpine bindings, there is no such benchmark for telemark cable release bindings - basically you just get out there, see how you go and adjust your own binding if it seems too loose or too tight! Not ideal, as shown in one study presented at an ISSS meeting in Cervinia by Dr Carol Federiuk of the University of Portland USA, where in 66 out of 82 injuries sustained whilst using a release plate, the binding did NOT release! However, in the same study, release bindings were used by 28% of all skiers but were in use in only 19% of injuries which does suggest a protective role.

More recently and inevitably, we have now seen the development and introduction of step-in releasable bindings for telemark skiing. One of the first examples was the rather mechanical Linken binding. A more modern development on this is the Hammerhead binding. Other variations on the theme include the Black Diamond O1 and O2 binding ranges. None of these bindings have built in release though and therefore there remains a concern that non-release might be associated with a risk of injury. Modern examples of step in releasable telemark bindings include the 7tm Power and Power Tour bindings. These have DIN settings from 4-11 just like standard alpine ski bindings and, as such, should offer a higher degree of protection in the event of a fall.

The truth of the matter is that, apart from anecdotal individual stories from skiers, there have been no recent scientific studies that have examined the safety (or otherwise) of any of these more modern bindings. All I can say is that we have not seen an increase in the number of telemark injuries on the slopes since they came in, which has to be a good thing. To my mind, although they are more expensive, buying a release system (cable or otherwise) would seem to be a wise investment.
 

 

Testing telemark release bindings


A recommended way to test your release bindings (DIN or not) is a variation on the alpine ski binding self test. This is described with photos elsewhere on this site. For telemark release bindings (not cable!), try the following adaptation:


1. For lateral release - set the ski on its edge with the binding set on a very low setting. Now try to twist your boot out of the binding with the maximum force you can generate - your binding should release. Progressively increase the settings until you are only just able to generate a release - this is where your binding should be set initially. Obviously, everyone varies in their technique - you may need to make minor adjustments up or down to suit your own needs if you are experiencing a lot of unwanted pre-releases or your bindings are not releasing when you feel they should.

2. For toe release - pull back on your boot in a similar manner slowly with the maximum force you can generate. Again, adjust the binding setting up or down as described above.

This technique has been shown to reduce injuries in alpine skiers

For more information on telemark injuries as well as his "on-line" injury study, click here to go to Mike Tuggy's website in the US. Mike has written widely on the subject of telemark injuries.

 



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