"Kids are making 50 to 60 jumps per day and landing on a razor blade." With that description from Brian FitzGerald, BSN, ATC, Children's Hospital Boston, Division of Sports Medicine, it's easy to understand why figure skating can be a dangerous sport. Even though the end product is beautiful, the intense training, often on growing bodies, puts skaters at risk for a variety of overuse injuries.
"Hands down the most common injury I see is lumbar spine stress fractures," said Allison Stringer, PT, MS, with Colonial Figure Skating Club in Boxborough, MA. Stringer, a figure skater herself, works with skaters both on and off the ice and has lectured extensively on injury treatment and prevention. She notes that two opposite body types, hyper- and hypo-mobile, tend to be more prone to spinal injuries.
Injuries are more likely to happen when young skaters have a growth spurt, around age 13 or 14, because, as Stringer explained, "they train at a level far greater than their own strength." She also sees more injuries during the summer when skaters can triple the amount of time they spend on the ice. This dramatic increase in training leads to overuse injuries.
Other physical therapists and certified athletic trainers agree with Stringer's assessment about the prevalence of spinal stress fractures among this population. According to Louise Terciak Donlon, PT, MS, SCS, CSCS, Boston University Physical Therapy Center, a figure skater herself who works with skaters both on and off the ice, there's a lot of jumping and rotation and extension through the spine. "The combination of those three things on an adolescent body can cause problems," she added.
Moving further down the body to the hips and legs, skaters are prone to hip labral tears from repetitive stress on the hips. Some also develop patellar tendinopathy, colloquially known as "jumpers' knee," which results when skaters land a jump on one leg and don't have the hip strength to control the landing.
Young skaters, especially boys, are prone to developing Osgood-Schlatter disease, a painful swelling of the bump on the upper part of the shinbone that's caused by repeated minor overuse injuries before the area has finished growing. Jumping, in particular, sets it off.1
Dislocation of the patella and shin splints are other lower-extremity injuries that FitzGerald has seen at Children's Hospital Boston, where they've been treating figure skaters for more than 30 years. Among the acute leg injuries therapists deal with include tibia-fibula fractures and knee sprains from bad landings on jumps. FitzGerald also acknowledged that ruts or divots on the surface of the rink can cause acute sprains or fractures.
Eric Greenberg, PT, DPT, SCS, CSCS, Children's Hospital of Philadelphia Sports Medicine and Performance, tends to focus his treatment on foot and ankle injuries in a variety of athletes, including figure skaters. Ankle sprains and fractures caused by falls are a common occurrence among this population. Achilles tendonitis and plantar fasciitis are also two common overuse ailments. Since a lack of strength and flexibility along the foot, ankle and up the chain can contribute to lower-extremity ailments, Greenberg will examine his patients for those issues.
Foot and ankle issues can also be caused by poor equipment, such as ill-fitting skating boots. The design of skating boots hasn't evolved to keep up with the sport's increased demands on the body. The boots have a hard time absorbing the impact of jumps and protecting the feet and ankles. No matter the body part, Greenberg sees overuse injuries when patients repetitively practice a new skill they've not mastered.
More Risk Involved
The therapists ADVANCE spoke with all mentioned jumping and landing as main culprits for injury. "The sport has evolved into more of a jumping sport, so inherently now it's more risky," observed Donlon. Repetitive landings from jumps can bother skaters' knees. "If a skater lands on his/her right leg and has weakness in core and/or right hip musculature or poor motor planning, the left hip can drop, causing misalignment in the right lower extremity and potentially cause pain," she said.
"As you get up to working more advanced with the double and triple jumps, that's where injuries are more likely to occur," Donlon explained. The acceleration and twisting involved in jumps is transmitted through the lower extremities, often leading to injury. The danger lies not necessarily with the act of jumping itself, but rather with moving into jumps, propelling, turning and sticking landings.
Other than jumps, moves that hyperextend the spine, such as layback spins and stroking, gliding on one foot, can cause injury. One move in particular, the Biellmann spin-where a skater spins upright with one leg extended over the head as they grab the skate blade-"really takes a toll on their spines," said Stringer. In fact, the International Skating Union, the governing body for international competitions, passed a resolution limiting the number of times a skater can perform a Biellmann spin in a routine.2
When a figure skater seeks out the help of a physical therapist or certified athletic trainer for injuries, there are several avenues to pursue. Clinicians should get an idea of which positions aggravate the injury. Often, the treatment protocol depends on whether the skater is in or off season. The earlier the skater is treated, the better the chance of healing.
If an athlete presents with back pain, for example, a health care professional might refer for a CT scan or MRI to rule out spondylolisthesis, where a vertebra slips out of alignment onto the vertebra below.3 If that is the diagnosis, the skater could be put into a back brace. Rest is often the first line of defense when dealing with skating overuse injuries.
With figure skaters, the role of the PT or ATC is not to just get them back to activities of daily living, but also to get them back to a competitive level. Stabilization exercises train the muscles against too much extension or rotation. The thoracic spine and hips need to have enough mobility so movement comes from those areas and not the lumbar spine.
Another area to focus on is the core, because it is the source of power for all the complicated jumps. According to Stringer, exercises such as lower-abdominal exercises, squats, bridges on exercise balls and sit-ups work to stabilize the core. In addition to exercises, Donlon will sometimes use taping at the knee. While therapists focus mainly on exercises and soft-tissue mobilization, some will use modalities when indicated. Regarding modalities use, Greenberg said, "I use them sparingly, mainly for pain control." He will use electrical stimulation when warranted.
Off The Ice
Treating injuries is only part of the battle. The other part is trying to prevent injuries in the first place. Off-ice conditioning focuses on injury prevention and performance enhancement. There's an inherent risk in the sport and off-ice programs can help mitigate it. The U.S. Figure Skating Association's goals for an off-ice conditioning program include enhanced posture; increased jump height; increased rotation speed; better upper-body strength, and enhanced cardio conditioning.4
More physical therapists and certified athletic trainers now work in figure skating clubs, adding what FitzGerald called "a world of help." While it's not necessary for clinicians to be skaters themselves, like Donlon and Stringer, "it is important to have someone who can understand skating," Stringer said. Because of how hard they train on the ice, off-ice programs are important for skaters' balance. Conditioning gives athletes a baseline of strength and flexibility and helps to build power and range of motion. Ideally, skaters should do an off-ice program two or three times per week, focusing on different exercises depending on where they are in a particular competition season.
For example, in January, they lay the foundation with endurance-building exercises. Throughout the year, skaters add weights to their workout. In the summer, they focus on agility and plyometrics, with activities like jumping on boxes. Stringer will also work with patients on cardio training exercises, such as running and intervals that get them to 95 percent of their maximum heart rate. The better conditioned figure skaters are, the less likely they are to break down during their programs.
Off-ice conditioning works to develop skaters in an age-appropriate manner. FitzGerald recommended athletes avoid learning new moves during a growth spurt. "A lot of what I do is education especially when they're incorporating a new skill," Greenberg acknowledged. Educating skaters, parents and coaches so everyone is on the same page is critical. Skaters start training younger and younger before they've developed a baseline of strength.
Figure skating is a tricky sport to treat because athletes compete at elite levels at young ages. There's a very short window to be at the top of the sport and the biggest problems arise when the youngest skaters compete at the highest levels. The experts ADVANCE spoke with acknowledged the need for balance between skaters doing enough to master a technique and doing so much that they injure themselves.
1. "Osgood-Schlatter Disease." Medline Plus. www.nlm.nih.gov/medlineplus/ency/article/001258.htm
2. "Biellmann Spin." Wikipedia. http://en.wikipedia.org/wiki/Biellmann_spin
3. "Spondylolisthesis." Medline Plus. www.nlm.nih.gov/medlineplus/ency/article/001260.htm
4. "Off-Ice Strength & Conditioning for Figure Skating: What the Parent Should Know." United States Figure Skakting Association. www.usfsa.org/content/office-training.pdf
Danielle Bullen is an associate editor at ADVANCE and can be reached at firstname.lastname@example.org