Knee injuries

Knee injuries are quite frequent in skiers because of the simple mechanics of the sport: the body is propelled at high speed. Your feet and ankles are relatively locked into your skis. In a situation where your ski is torqued, but does not release, the joint that sustains the most force is the knee.

Knee injuries can range from simple meniscus tears, to more severe injuries such as ACL tears or even complete dislocations.

By far, knee injury is the most common disabling injury for skiers and boarders. It accounts for 25% of all ski injuries and occurs in approximately 1.33 per 1,000 skier days. The two most common knee injuries are to the medial collateral ligament (MCL) and the anterior cruciate ligament (ACL).

Medial collateral ligament (MCL) injuries occur most frequently in beginning and intermediate skiers. This is due to the fact that beginning skiers use a snowplow type of stance to stop and turn which places a tremendous amount of stress on the inside portion of the knee. This stress or force is multiplied by the mass of the skier and the acceleration of gravity and results in a physics disaster (F= M * A). Fortunately, a majority of these injuries can be treated without surgery. A brace, physical therapy and the tincture of time usually takes care of these injuries. In rare cases, surgical reconstruction is undertaken to treat these injuries.

Anterior Cruciate Ligament (ACL) injuries tend to occur in more advanced skiers and can be attributed to specific falling patterns. Despite wonderful engineering advances in skiing and snowboarding equipment which have reduced the rate of lower extremity fractures, these advances have failed to reduce the incidence of ACL injuries. In fact, there is an alarming increase in ACL injuries (almost a 240% increase) with some interesting theories for this increase. Specific suggestions to prevent knee injuries include:

* Keep your knees flexed, and don't try to straighten them during a fall since a straight leg provides a longer lever force against the knee.
* When you're down, stay down; don't try to stop the fall. You can not predict which way your leg is going to twist.
* Fall forward. Don't land on your hands backward. Keep your arms up and forward. Falling backwards places abnormal forces across the ACL.
* Don't jump unless you know where and how to land. Land on both skis and keep your knees flexed.



(reference: Ettlinger CF, Johnson RJ and Shealy JE, American Journal of Sports Medicine 1995; 23(5): 531-537)

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Piriformis syndrome

Piriformis syndrome is a neuromuscular disorder that occurs when the sciatic nerve is compressed or otherwise irritated by the piriformis muscle. This causes pain, tingling and numbness in the buttocks and along the course of the sciatic nerve. The syndrome may result from anatomical variations in the muscle-nerve relationship, or from overuse or strain. Although the existence of this syndrome is disputed by some, two recent uncontrolled studies support the possibility. The need for controlled studies is supported by studies of spinal disk disease that show a high frequency of abnormal disks in asymptomatic patients.

Pathophysiology

In 15% of the population the sciatic nerve passes through the piriformis muscle, rather than underneath it. These people have been reported by some studies to have a greater incidence of piriformis syndrome than does the general population. Some researchers discount the importance of this relationship in the etiology of the syndrome. Inactive gluteal muscles also facilitate development of the syndrome. These are important in both hip extension and in aiding the piriformis in external rotation of the femur. A major cause for inactive gluteals is unwanted reciprocal inhibition from overactive hip flexors (psoas major, iliacus, and rectus femorus). This imbalance usually occurs where the hip flexors have been trained to be too short and tight, such as when someone sits with hips flexed, as in sitting all day at work. This deprives the gluteals of activation, and the synergists to the gluteals (hamstrings, adductor magnus, and piriformis) then have to perform extra roles they were not designed to do. Resulting hypertrophy of the piriformis then produces the typical symptoms. Another purported cause for piriformis syndrome is stiffness, or hypomobility, of the sacroiliac joints. The resulting compensatory changes in gait would then result in shearing of one of the origins of the piriformis, and possibly some of the gluteal muscles as well, resulting not only in piriformis malfunction but in other low back pain syndromes as well.

Other presentations

In addition to causing gluteal pain that may radiate down the leg, the syndrome may present with pain that is relieved by walking with the foot on the involved side pointing outward. This position externally rotates the hip, lessening the stretch on the piriformis and relieving the pain slightly. Piriformis syndrome is also known as "wallet sciatica" or "fat wallet syndrome," as the condition can be caused or aggravated by sitting with a large wallet in the rear pocket.

Treatment

Treatment usually begins with stretching exercises and massage, and the avoidance of contributary activities such as running and bicycling. Some clinicians recommend formal physical therapy, including the teaching of stretching techniques, manual massage, and strengthening of the core muscles (abs, back, etc.) to reduce strain on the piriformis muscle. Recommended stretching exercises will usually target the piriformis muscle, but may also include the hamstrings and hip muscles, in order to adequately reduce pain and increase range of motion. Patients with piriformis syndrome may also find some pain relief from ice and heat. Ice can be helpful right when the pain starts or immediately after an activity that usually causes pain (e.g., going up stairs). The ice may be in the form of an ice pack held to the area or an individual ice cube used in combination with a massaging motion. A heating pad may be alternated with the ice for relief from the pain. Natural substance call Bromelain (pineapple enzyme) in pineapple juice has the function of anti-inflammatory. The prognosis with treatment is generally good. Ultrasound is another option for treatment.

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What we can help on Piriformis syndrome patient:

Chiropractic care with deep tissue therapy, stretching technique, therapeutic exercise, ultrasound and manupulation technique.