Undoubtedly, the sport of figure skating has changed dramatically over the past decade, let alone the past 20 years. Two major changes include the dissolution of the traditional compulsory figures of figure skating and then the complete overhaul of the judging system. The emergence of complete programs being virtually void of anything but triple jumps has brought renewed emphasis on technical difficulty and power, but also is causing physicians to see increasing numbers of injuries to skaters, including an expansion in the number of hip, abdominal, and back injuries (1).
In addition, the competitive sport of figure skating has evolved and now includes two new branches, the synchronized skating team and the adult skaters. As the number of participants increases in both of these separate events, physicians are bound to see new and differing injury patterns. Consistent with other skaters, the most common area of injury remains the lower extremity (2,3).
These increases in ice skating participation have opened the doors for sports medicine physicians to become involved with caring for skaters at many levels. By embarking on the adventure of providing sports medicine care and rinkside coverage of ice skating events, one must realize it is vitally important to not only understand the basic injury patterns but also the distinct factors that predispose different types of skaters to the injuries that they sustain. Additionally, physicians must be aware of the role equipment plays, how to care for an athlete on the ice, and the rules governing coverage of the sport.
FIGURE SKATING 101
As with caring for any athlete, knowing the basics of figure skating is essential in establishing trust with skaters. As previously alluded to, nowadays, figure skaters come in a variety of forms. Competitive figure skating now includes singles, pairs, ice dancing, synchronized skating, and adult skaters. Becoming familiar with the intensity and level of a figure skater will help a physician understand the unique needs of that particular athlete.
After acquiring knowledge on the type of skater one is caring for, the basics to understanding the majority of figure skating injuries are centered around the skate itself. The skate is made of a boot and blade. The boot is made of stiff leather, which binds the ankle tightly, and may be stock or custom. Attached to the boot is the steel blade, which has a rocker bottom and extends to a toe pick at the end. Although seemingly simple, the construction of the "perfect boot and blade" is a unique and precise science. An improperly fitted boot can cause many of the foot deformities commonly seen in a skater's feet as well as contribute to the issues that extend up the kinetic chain.
Here, it also bears mentioning that perhaps the most important thing to remember regarding the prevention and identification of injuries in figure skaters is the way skaters and their coaches train on a day-to-day basis. Throughout the years, skaters have been trained to continually repeat move after move, which usually means jump after jump. This repetitive training greatly contributes to the chronic overuse injuries, which are so prevalent in the sport. Thus it is not surprising that in study after study, singles skating injuries are predominantly overuse injuries (4). This, however, is in contrast to data obtained for both pairs and ice dancers, where acute injuries are more common than overuse (5-8). In these two disciplines, the close proximity of the two skaters during their feats of athleticism can lead to conditions such as concussions, fractures, and lacerations. These injuries can result from falls during a lift, collisions between the skaters, or merely tripping over one's partner.
At similar risk are the synchronized skating teams that consist of 8-20 skaters all on the ice at one time, moving and competing together as one. The injuries incurred in "synchro" also involve acute injuries that occur while on the ice with their teammates. This was demonstrated in a recent study of over 500 skaters, which showed an increasing number of acute injuries instead of the predominance of the overuse injuries commonly seen in singles skating (2). Of the acute injuries reported, the majority of injuries were in the lower extremities, followed by upper extremities, head, and trunk.
One teaching point for the physician is to realize that the "synchro" skater may have transitioned into synchronized skating, carrying previous singles skating injuries with them. In the previously mentioned study, of those "synchro" skaters with overuse injuries, 65.8% of the injuries occurred during their figure skating careers versus the 34.2% of injuries that occurred after they began a synchronized skating career or in those who had done only synchronized skating (2).
For adult skaters, whether they are experienced or new to skating, they require a different approach in their treatment as well. Often with differing body structures and lifestyles confounded by work schedules, compared with the younger skaters, adult skaters have vastly different needs in regards to rehabilitation and return to skating issues. They also have increased educational needs for prevention of injury. Although the research is lacking, preliminary studies and observations do demonstrate that adults may carry increased risk of injury mainly because their different training and exercise patterns (3).
Even with injury studies such as those mentioned above, there still is a significant lack of knowledge pertaining to competitive figure skaters. Interestingly, figure skating does not require the pre-participation physical we are all so accustomed to performing. As a consequence, the only time the majority of figure skaters are seen is once they are already injured. Most studies in peer-reviewed literature pertain to elite skaters on either a junior or senior national or world level (4,5,8). This, unfortunately, fails to account for the majority of skaters who make up the competitive skating world. Currently, the U.S. Figure Skating committee on Sports Science and Sports Medicine is attempting to address these very issues by forming a regional level injury registry (9). Through further research and education, all types of skaters will benefit from better training and injury prevention.
For the sports medicine physician who wishes to become involved in the coverage of ice skating events, it is paramount to fully understand the nature and complexities of ice skating event coverage. In addition to covering competitions, physicians are expected to also provide coverage for the practices leading up to the event. Having covered multiple skating events, this translates into many long hours rinkside as practices begin in the early morning and can extend into the late evening. Despite the long hours, the time is well spent as it allows the physician an opportunity to get to know the skaters and provide many facets of medical assistance.
An excellent resource to refer to is the International Skating Union's (ISU) Medical Care Manual, which can be found online (10). This manual outlines the requirements of medical providers at ISU-sanctioned events. Regardless if the event you are covering is ISU-sponsored or not, the materials are well worth adhering to for the good of all skaters.
Similar to preparing for most other types of event coverage, a physician needs to arrange for provision of medical supplies, devise an emergency action plan (EAP), and secure a strong support network of local healthcare providers such as physical therapists, certified athletic trainers, massage therapists, paramedics, and various subspecialists.
Numerous lists of medical supplies exist in the literature and can be used as a starting point for covering an ice skating competition (11). Essential items should include wound care equipment and suture kits, resuscitation equipment for airway emergencies and major lacerations, and spine boards/cervical collars. These emergency items should be kept rinkside, in addition to a wheelchair and stretcher. The medical team also should be prepared to handle neurologic emergencies, such as concussions and seizures, as well as any musculoskeletal or gastrointestinal issues that may arise.
The designated medical areas rinkside must allow for unobstructed visualization of the skaters at all times. ISU guidelines recommend two teams of emergency medical providers positioned at diagonal corners of the rink to allow for greatest visibility. Additionally, ambulance access must be secure and unobstructed (10).
A separate examination room with signage and a clear path from the rink also is required. This room will ideally have a medical provider stationed there at all times to provide needed assistance during practices and competition. In addition to the necessary medical supplies, the room should be equipped with a television feed of the rinks to allow for monitoring of medical situations that may develop on the ice. All medical team members should be able to communicate with each other via radio or phone (10).
In preparing for an emergency, it is essential that the medical team coordinate practice sessions on the ice to become accustomed to the stabilization and transport of an injured skater off the ice. Not only will the treating physician have to contend with an injury, but also with the slipperiness of the ice and the sharp blades on the athlete's feet. Many ice rinks will not allow street shoes on the ice, so the use of disposable surgical booties can provide minimal traction for the treating physician as he or she steps onto the ice.
When working at international and high-level competitions, assistance with drug and asthma testing may be an added feature of the medical care for the event. Becoming familiar with the protocols and how they may impact you during your care of an athlete is yet another necessary step in preparing to cover an event.
Aside from the risk of injury, a physician also needs to be prepared to treat a variety of illnesses and medical conditions during skating events. Frequently, skaters are traveling from distant locations and may have neglected a nagging cough or an unusual rash in order to get to their next competition. Establishing guidelines with the medical staff with regards to what types of treatment will be provided should be clearly established before the start of the event.
INJURY PATTERNS SEEN AT EVENTS
Foot and Ankle Issues
It is well documented that the most common area of injury in a figure skater is the foot and ankle (1,12,13). Skaters are known to have significant foot deformities, some of which they refer to as "double ankle bones," "lace bites," and "pump bumps." This translates medically into malleollar bursitis, midline anterior tibialis callus formation, and Haglund's deformity of the calcaneal tuberosity, respectively. An exhaustive list of further foot deformities can include hammertoes, corns, hallux valgus, bunions, warts, and "beat-up" great toenails (6,14). However, the mere presence of these deformities does not necessarily guarantee pain and problems for the skater.
If these deformities become symptomatic and painful, the covering physician may be called upon to treat these conditions. During one's examination of the foot, it is essential to extend your examination to the skate: looking for areas of friction, increased contact and pressure. There are multiple options in the form of skate modification to get a skater through the day's events by measures as simple as "bumping out" necessary areas with a special hole punch carried by most skating shops, or the use of sheepskin, padding, silicone sleeves, doughnuts, and a host of other special padding techniques.
Malleolar bursitis is frequently related to boot pressure on the malleoli, while "pump bumps" or Haglund's deformities are a result of a boot heel that is too wide, resulting in repetitive friction as the skater's heel moves up and down. In both these situations, it is usually the skate that needs correction, not the skater (1,7).
Tenosynovitis of the anterior tibialis and toe extensor tendons is seen anteriorly and is referred to as "lace bite." This injury relates to the compression caused by the tongue and lace crease of the boot as a skater dorsiflexes in the stiff boot. Maintaining the tongue in a neutral or medial position can help to prevent this injury. Treatment can be as simple as changing the type of tongue padding or the use of alternative lacing techniques. If this fails, harder materials such as orthoplast can be molded over the foot to protect the area from compression (7).
In addition, skaters may experience Achilles tendonitis or Achilles tenosynovitis from either overtraining with repetitive off-ice jumping or more commonly from the pressures exerted from the top of the boot. Routine use of heel lifts and standard rehabilitation protocols may work for the former, but if the injury is secondary to the latter, modifications including cutouts or padding the posterior portion of the boot can help to relieve the pressures associated with the boot (1,7,13).
Surprising to most, but well documented in the literature, is the prevalence of ankle weakness and injury in figure skaters. Once again, there is a direct link back to the boot. In 2003, a study was done with 208 figure skaters at U.S. national competitions showing the number one area of injury to be the ankle (27.7%), followed by the knee (18.6%) and the low back (15.4%) (4). Several theories on why skaters have weak ankles exist, the most recognized is the theory that weak peroneal muscles are created by the stiff support of the skates, which puts the ankle at higher risk for sprain (7). To help prevent and rehabilitate weak ankles, it is important to emphasize off-ice, out-of-boot training that focuses on peroneal strengthening (7) increased proprioception, inversion/eversion strengthening, and core stabilization.
Skaters may initially continue to skate with and on a problem area until a stress fracture surfaces. This, of course, is very difficult in a sport where training is year-round and there are few breaks built into the schedule. Emphasis on a gradual return to the ice and full activity will be paramount to address with all people involved in the care of the athlete. This includes the athlete, their trainers, parents, and coaches.
Most commonly, one can expect to see the usual suspects when it comes to knee injuries. Patellofemoral syndrome, along with Osgood-Schlatter's in the younger skater, are the most common complaints. Trauma from falling on the knees is another potential injury that can be seen while covering skating events. Of note, ligamentous knee injuries such as anterior cruciate ligament tears and meniscal injuries have a low prevalence in figure skating (15).
Hip, Back, and Abdominal Issues
Specifically targeting new areas of concern and attention, one must look to the escalating rates of hip, back, and abdominal pathology. The abrupt addition of these newer injuries may be secondary to the increasing rotation asked of our skaters. Anterior iliac crest avulsions, internal and external oblique strains, and hip flexor issues are becoming commonplace in this group (7,15).
Current theories about low back pain in skaters once again focus on the boot. We know based upon the architecture of the skating boot combined with the biomechanics of landing, force is transmitted cephalad (1). Forces placed upon the landing foot are based on the limited flexion that occurs at the ankle and knee secondary to boot constraints, which results in excessive hip flexion to absorb the force of landing. Subsequently, the skater has to hyperextend the lumbar spine in an attempt to land the jump successfully (1,7,10). This forced hyperextension loads all the posterior elements of the spine and puts a skater at risk for a multitude of back issues, including spondylolysis and spondylolisthesis. Further analysis also demonstrates tight lumbar fascia and hip flexors related to low back pain (4). Addressing muscle imbalances and increasing core strength early on can hopefully assist a skater in avoiding these debilitating types of back injuries.
Due to the aesthetic nature of the sport, ice skaters have their fair share of disordered eating habits. While the available literature does not reveal a significant number of true anorexics or bulimics, many skaters try to exist on considerably low caloric intakes. Historical studies demonstrate findings such as the fact that female skaters only consume 59% of their estimated caloric needs and 55% of female skaters are dieting, while over half are already below the 25th percentile for weight, demonstrating that these athletes are at risk (16,17). More recent research reveals that female figure skaters exhibit a preoccupation with weight and body dissatisfaction, which are known risk factors for an eating disorder (18).
The complex nature of eating disorders does not lend itself well to treatment by an event physician. An awareness and sensitivity to these types of issues and an ability to respond to potential acute situations, such as the collapse of an athlete or dehydration arising in an undernourished skater, is an area to consider when preparing for events. Further education of young skaters on the detriments of living and competing with a negative energy balance requires ongoing participation of all involved with the sport.
Despite the trend of disordered eating in skaters, the rising incidence of stress fractures in skaters does not appear to be associated with the osteoporosis often seen in athletes with the female athlete triad. Even if a skater is amenorrheic, osteoporosis in skaters is extremely rare. The theory is that the high-impact forces generated with landing jumps has a protective effect upon the skater's skeleton (7). A frequently cited study showed increased bone mineral density in skaters without stress fractures compared with age-matched subjects and those with stress fractures. In addition, greater bone mineral density was found in the landing foot compared with the take-off foot (19).
Various reports demonstrate between a third to half of all figure skaters suffer from exercise-induced bronchospasm or asthma (15). Symptoms are exacerbated by the cold, dry air found in ice rinks, and some skaters are further provoked by the chemicals associated with the maintenance of the ice. Skaters may present with a chronic cough, decreased aerobic capacity, or wheezing. Physicians covering skating events should have a high index of suspicion when it comes to this diagnosis.
The physical and psychological demands placed on many of today's ice skaters is often unfathomable. At a very young age, talented skaters are spending long hours at the rink and often are forced to move away from their families to train with highly sought after coaches. Keeping this in mind while caring for an ice skater is essential to understanding the dynamics that can impact their ability to rebound from an injury.
Now as we witness the continued evolution of figure skating, we also witness the ever-expanding list of injuries. The sport as a whole still lacks significant research on the majority of its competitive athletes. In addition, the new judging system has not been out long enough to truly collect the needed numbers and time to say whether it is having a positive or detrimental effect upon the prevalence of injury in our skaters. Currently, U.S. Figure Skating's Sports Science and Sports Medicine Committee is actively addressing many of the above-mentioned issues. In addition to the establishment of an injury registry and tracking tool, efforts are being put into place to focus upon aspects of high performance, research, and education (14).
It is an exciting time to be involved in the sport of figure skating. The hard work of the sport's governing body to use science to improve figure skating is ever present. Research also is ongoing to potentially improve the skate itself through the development of the articulated skate (20). As many of these great changes occur in the skating world, sports medicine physicians are poised to contribute considerably to the advancement of the sport through our commitment to become even more adept at recognizing and treating the competitive figure skater both on and off the ice.