It's that time of year when many of us are eagerly checking snow forecasts and looking forward to a week of radical powder action- or perhaps a gentle pootle down a cruisey blue run. We hope this won't apply to you (and we hate to rain on anyone's piste) but there is no denying the presence of a few braces and plaster casts on the way home, and as doctors, we feel honour bound to help you to avoid this. This post focuses in particular on skiing injuries of the knee, which account for a third of all Alpine ski injuries.

Knee injuries are unpleasant for the pain and immobility they cause, and also their rather long and involved road to rehabilitation. That being said, take heart that most knee injuries have a good long term prognosis, with permanent functional loss relatively uncommon.

Know your Enemy
Before we get in to how to avoid getting injured, here's some background knowledge to help you understand exactly what knee injuries involve.

If you know someone who has had a knee injury, or perhaps if you follow sport reasonably closely, chances are you will have heard the terms ACL and MCL in relation to knee problems. The MCL is the medial collateral ligament and is on the inside aspect of the knee, whilst the ACL is the anterior cruciate ligament, which runs diagonally in the middle of the knee.

The MCL is involved in about a quarter of skiing knee injuries, whilst the ACL is involved in 10-15% of cases. And some (even more unfortunate) cases are more complex, involving both ligaments, and also cartilage and some bone (fractures).

MCL risk factors
The MCL is at risk when the foot is forced outwards (laterally, valgus stress), such as when in a deep snowplough or when you catch a ski which takes your leg outwards/away from the other leg. This results in varying degrees of injury classified from 1-3; listed below.

The ligament is partially torn but most fibres remain intact so the knee joint remains stable
The tear is more severe, the knee joint is less well supported (laxity, with definite end point)
The whole ligament is torn and the knee is unstable (laxity with no definite endpoint)

It may take a while to work out which number applies to an injury as examinations are hindered by pain and swelling - more can be seen after about a week when these have subsided a little.

ACL risk factors
The ACL is commonly damaged when another skier/boarder crashes into the back of the leg, with the victim falling backwards whilst the leg is forced forwards, and also when landing an incautious jump/falling backwards.

Cartilage tends to get damaged when the knee is twisted.

Too late was the cry? How to tell if you've hurt more than just your pride...
When it comes to a suspected knee injury, seek a skilled examination and investigation as quickly as possible, as this leads to appropriate management and the best recovery outcomes.

Here are the indicators to see a doctor:

-Obvious deformity of the knee
-Unable to weight bear
-Lots of swelling, particularly if the swelling occurs fast (within 2 hours of the injury)
-A locked knee (inability to fully straighten)
-Severe tenderness

How can we mend it doctor?
In the first instance, think RICE- rest, ice, compression (wool and crepe bandaging) and elevation

Your doctor may consider a cricket pad splint (to keep the knee straight and protect it) and you may also need crutches. (Tip: casual observers may notice these... feel free to reward their razor sharp observation skills with an embroidered version of your heroics... it was a black diamond run, in a white out, etc. etc.)

You will certainly be wanting anti-inflammatories, initially for the pain, but advice is to continue a regular dose for the first week, even if not in pain.

During the rehabilitation period, you will be given quad (thigh) exercises to help strengthen the muscles around the knee and stabilise it.

And lastly, in the case of severe and complex injuries, you may require surgery.

By now you probably don't need much convincing that prevention is better than cure... so here are a few tips for avoiding skiing knee injuries.

Ditch the retro skis
Whilst we heartily applaud any skier proudly sporting their 80s fluoro all in one, complete with head band, we cannot extend this enthusiasm to retro (i.e. straight edged) skis. After an initial teething period, as skiers got used to the modified technique, the arrival of carving skis heralded a clear improvement in the rate of knee injuries. This is because they are easier to control, and therefore result in fewer falls and reduced risk of injury.

Prepare your body for skiing
Pre-season quads exercises will strengthen the muscles which support your knee. Exercises will also improve fitness, reducing poor technique due to fatigue.

Check your bindings
Make sure they are appropriately set for your level of experience and the type of skiing you're doing. Of course, nobody enjoys trudging down the piste to retrieve a lost ski, or worse, digging it out of a deep powder field, BUT it's still a whole lot less hassle than six weeks of hobbling around (and no more skiing for this holiday).

Other things to think about as you ski (apart from 'BEND ZEEE KNEEZZ')

Avoid wide snowplough (which stresses the MCL a lot)
Avoid fully straightening your legs when falling
Don't try to get up after falling until you've stopped sliding (regain control)
Try not to land on your hands - keep arms up and forwards
Don't jump - unless you know how to and where to
Watch out for boarders (and sometimes skiers) crashing into you from behind.
And it's a good idea to wear a helmet.

Bon Voyage, et Bon Ski Tout le Monde!!