Skating as a mode of transportation for hunting is documented in the oldest Nordic myths (1). In the 17th century, figure skating began as a recreational pursuit for gentlemen intrigued by executing tracings on the ice (1). More artistic styles evolved in Europe and North America creating competition, making it necessary to form a governing body in 1892, the International Skating Union (ISU) (1). Present day figure skaters combine athletics and artistry in an ever-increasing demand of the sport while still governed by the ISU. Figure skating demonstrates continued growth and popularity as reported by United States Figure Skating (USFS) with the fifth consecutive year of increase in membership during the 2017 to 2018 cycle and the second highest total membership in the organization’s history with 192,110 members (2). Thus, adequate preparation for rink side coverage is a necessity.
Figure Skating Governance
Worldwide, modern day figure and speed skating are governed by the ISU as recognized by the International Olympic Committee (3). National associations who administer an ISU sport such as figure skating must recognize the ISU's jurisdiction over international matters. USFS, founded in 1921, is responsible for uniform standards of proficiency and promotion of the sport of figure skating nationwide (4). It is composed of member clubs, individual members including collegiate, school affiliated clubs, as well as Learn to Skate USA programs (4).
Figure Skating: The Basics
All skills in figure skating extend from the basic skating edges. There are four basic edges; forward outside, forward inside, backward outside, and backward inside edges. These describe the direction in which the skater is moving, as well as the way their skate's blade is cutting into the ice. If it is an outside edge, their body leans laterally and if an inside edge, their body leans medially. Turns, steps, and spins require balance in transition from one edge to another. Jumps involve take-off from various edges and landing on a back outside edge. This is accomplished using the figure skate which is composed of a stiff, tightly fitted leather boot that provides ankle stabilization and an attached steel blade with a toe pick on the front (5).
The disciplines in figure skating competitions include singles, pairs, ice dance, synchronized skating, theater on ice, and adult skating. Singles and pairs skaters perform jumps and spin elements with pair skaters adding overhead lifts, throw jumps, and death spirals. Ice dancers do not jump but emphasis is placed on the precise execution of skating steps. They also perform spins and lifts, though the latter are not allowed overhead and instead depend on rapid spinning, creating significant centrifugal force. Synchronized skating comprises teams of 8 to 20 skaters, with up to 16 skating during a competitive performance. Teams have a wide variety of elements including intersections, group spins, and step sequences performed in various formations that emphasize speed and unison. At the senior level, teams also perform overhead group lifts and some pairs elements. Theater on ice comprises teams of skaters who create theatrical performances using more elaborate costumes and props are allowed. Adult skating also is increasingly popular and adult skaters may participate in all skating disciplines. Some have skated since childhood, while others begin to skate for the first time in adulthood. In all these disciplines, skaters continue to increase the difficulty of skills they perform which can increase the risk of injury.
Skill development in figure skating occurs through preparation for tests. Any USFS member is eligible to test and the evaluation of whether or not an athlete has passed is presided over by judges to determine proficiency (6). Passing a skills test determines the level of competition a skater may enter (6). These levels in increasing order of difficulty or skill are preliminary, juvenile, intermediate, novice, junior, and senior.
Figure Skating Injuries
Understanding the types of injuries sustained within a particular sport is helpful in planning for medical coverage at the rink side, which is the equivalent of the sideline in figure skating. Unfortunately, studies on figure skating injuries are limited. Han et al. completed an epidemiological review of the literature on figure skating injuries (7). Earlier studies suggested a greater incidence of overuse injuries compared to acute injuries (8). More recent studies evaluating skating injuries by discipline suggest singles skaters have a greater incidence of overuse injuries, whereas pairs, ice dance, and synchronized skaters are at greater risk for acute injuries (7,9,10). This is not surprising as the repetitive nature of figure skating training lends itself to overuse injuries, especially in singles skating which places emphasis on jumps. Skaters will make repeated attempts in an effort to learn and perfect new jumps and other skills which invites repetitive microtrauma to the tissues. Skaters will often present during competitive events with newly developed or exacerbated overuse injuries as a result of increased training in preparation for the event (5). As there is seldom a preparticipation evaluation for figure skaters, this may be their first presentation for assessment (5).
Given the skills of lifts and throw jumps in pair skating, it is reasonable to expect a greater incidence of acute injuries on top of the overuse issues. For ice dancers, the close and intricate steps, with quick transitions in positions, along with lifts, can lead to more acute injuries as well. Synchronized skaters perform intricate steps in very close proximity to each other while skating at high speeds creating a greater risk of injury, in potentially multiple athletes simultaneously, should even one skater misstep or fall. Of course, athletes also may compete in multiple disciplines, resulting in a combination of both overuse and acute injuries (5).
Fortin and Roberts compiled data from a national figure skating competition for singles, pairs, and ice dance with on-site evaluation of 55 injuries. The musculoskeletal injuries recorded during the competition not only involved mainly the hip and lower extremities (56.4%) but also the shoulder and upper extremities (25.4%), back (14.6%), and neck (3.6%) (11). Head injuries have been described in three retrospective chart review studies. Dubravcic-Simunjak et al. (9) in 2003 identified an incidence of 2.9% in elite junior skaters and in 2006, among synchronized skaters, identified 81 skaters (15.3%) with a history of head injury (10). Fortin and Roberts' review of medical histories from a national competition found 28 (9.8%) injuries (11,12).
Medical staff providing rink side coverage for figure skating must be prepared to handle musculoskeletal injuries, lacerations, and head injuries, including concussion assessment and management.
Figure skating clubs submit bid applications to host skating competitions. The local organizing committee (LOC) sponsoring the event typically recruits sports medicine providers from local practices to provide the required medical support. The figure skating national governing body, USFS, sets rules and policies pertaining to competition events in the United States, while the ISU provides governance of policies and procedures for international events including the Grand Prix Series, World Championships, and the Olympic Games. Importantly, if an international event is held in a city in the United States, ISU rules would apply. Both organizations are advised by sports medicine committees and specific guidelines for medical coverage of events have been developed (see references 13,14 for information on obtaining the guidelines).
The competitive level of the event will determine the specific coverage requirements. For example, what is needed for a local competition will differ for a national competition. In the United States, competition can be either qualifying or nonqualifying (12). Skaters interested in advancing through the competitive pipeline to participate in national or international competition would participate in qualifying events. The National Qualifying Series will be introduced this year, allowing skaters to achieve a sectional and national ranking by participating in approved USFS competitions (12). Each competition performance will earn points over part of the competition season. Placement at selected events also will determine advancement in the competition pipeline (12). Skaters in the juvenile, intermediate, and novice divisions with qualifying ranking will participate in a development training camp while junior and senior skaters will advance to the U.S. Figure Skating Championships, also known as “Nationals” (12). Figure 1 depicts the progression of qualifying USFS competitions (12). Nonqualifying competitions allow the skater to gain experience performing but points and awards earned will not count toward advancement within the qualifying ranking (12). While the details of this competitive structure will change over time and can differ between countries, it remains important to understand the nature of the event for which coverage is being planned.
Depending on the level of the event, drug testing may be required and will follow either the United States Anti-Doping (USADA) or World Anti-Doping (WADA) Association’s doping control guidelines. Figure skating medical providers should be familiar with these guidelines specific to the event they are covering. They are available on the ISU web site within the Medical and Anti-Doping Figure Skating Memorandum for an ISU sanctioned event (13), as well as on the USFS web site within the Medical Standard of Care Guidelines for Qualifying Competitions (14).
All competitions publish a precompetition schedule outlining practice and competitive skating sessions. This includes unofficial and official practices. The former may include any skater who purchases skating time and thus a variety of participants of different levels could be on the ice at the same time. Official practices typically are specific to one or two competitive categories within a discipline. This can present a challenge as multiple skaters, who are not familiar with each other’s skating styles and ice use, are practicing at the same time under stressful conditions, potentially heightening the risk of injury. Finally, each skater's or team's competitive performance is preceded by a warm-up period. Singles, pairs, and ice dancers will warm up in small groups prior to competing sequentially. Pairs and ice dancers are likely at higher risk of injury during this time due to the potential for collision, though this has not been studied. In contrast, synchronized skaters do not participate in joint warm-up periods with other teams.
A USFS medical liaison is available if desired, to assist in the preparations for an event (14). Members of the National Sports Science & Medicine Network frequently have extensive experience in providing medical coverage for figure skating events and could be a valuable resource to the LOC medical team (14). These individuals are not typically an active member of the medical team and serve in an advisory capacity only (14).
A chief medical officer (CMO) and an assistant chief medical officer (ACMO) should be assigned for the event (13,14). These individuals will assemble the medical team and create schedules for coverage (13,14). In addition, development and distribution of a medical operations manual which includes assessment forms and other key information is useful for volunteers. In the experience of the authors, for larger events it also is highly beneficial to appoint a medical coordinator to provide support to volunteers and guidance for protocol implementation. Medical staff can include physicians, athletic trainers, emergency medical personnel, nurses, and physical therapists (13,14). All medical personnel should be trained in and familiar with emergency procedures, as well as the specific emergency action plan (EAP) in place for the event (13,14). Physicians with fellowship training and experience in sports medicine are preferred to serve as CMO and ACMO with one of these medical officers present at all times during official practices and competitions (13,14). All medical personnel should be identifiable by a uniform jacket or vest (13,14).
For official practices, two medical personnel must be stationed at the rink side and one medical staff member must be in the medical treatment room (13,14). Among these people, one must be a physician (13,14). If there is a second practice ice rink within the same venue it should be staffed with two medical personnel (13,14). However, should the second practice ice rink be at a different location than the main venue, then one of the medical staff must be a physician (13,14). A good rule to follow is that any time a skater steps on the ice, medical personnel should be rink side.
During competition, one medical staff member should be stationed in the medical treatment room while four medical personnel are required to be stationed at the rink side, again with at least one of these practitioners being a physician (13,14). At the rink side, it is advisable that teams of two medical personnel be stationed at opposite ends of the competition arena and near a gate for easy ice access (13,14). Optimally, these stations should be positioned diagonally across from each other and have radio communication between them (13,14). This will provide a clear line of sight for the medical staff and ease of access to an injured skater. Should a provider need to step onto the ice, use of nonslip shoe covers (cleats or crampons) are recommended (see Fig. 2). Finally, dressing in multiple layers and bringing a blanket to cover cold benches at the rink will help make coverage more comfortable.
To volunteer at USFS events, licensed medical professionals must complete a background check, register with USFS as a member, and complete SAFE Sport training (15). The U.S. Center for SafeSport is committed to eliminating all forms of abuse in sport (15). Among other things, the program requires the “Two-Deep Leadership” policy be applied when caring for athletes (15). This policy stipulates that a third party, preferably an adult, must be present during the care of an athlete or care must take place in an open area where an adult can observe and be close enough to intervene if necessary (15). Awareness of this policy, and other similar event requirements, is essential to allow adequate time for training of health care providers. Each provider should be licensed in the state in which the event is taking place, maintain certification in cardiopulmonary resuscitation, and provide their own professional liability insurance.
Scope of care/medical services
Medical treatment room
The medical treatment room and the path toward it should be well identified (5). The medical staff are responsible to provide services to eligible participants for acute injuries and illnesses during the competition (14). Eligible competition participants include competitors, coaches, judges, and officials (14). It is helpful to prearrange for expedited access to care for acute or subacute issues, as well as X-rays through facilities local to the venue (14). Standardized referral forms may help with this process.
Common issues reported include musculoskeletal problems (both acute and chronic), respiratory and gastrointestinal illnesses, lacerations/wound care, head injuries, and concussions (13). In the most recent consensus statement on concussion in sport, the latter is defined as a traumatic brain injury due to a direct blow to the head, or elsewhere on the body with forces transmitted to the head, resulting in new and temporary neurologic symptoms and signs (16). In keeping with the statement, the authors advise evaluation with use of a standardized assessment tool such as the Sports Concussion Assessment Tool version 5 (16). Skaters diagnosed with a concussion should not be allowed to skate for the remainder of the competition. They should be advised to seek a medical assessment by a physician or licensed medical professional with concussion management training for treatment and return to sport recommendations, including final clearance, prior to returning to practices at their local arena.
In skaters with known respiratory conditions, such as asthma, cold air within the arena may act as a trigger for their symptoms. While treatment should be administered in all emergent situations, it is important to be aware that albuterol use may be restricted to a certain dosage amount and could require a formal therapeutic use exemption from the USADA or WADA. This also can be true of other common medications, and it is important to note that doping regulations can change annually. Knowledge of a skater's medical history and the antidoping rules for your event, as well as a careful physical examination will assist in correct diagnosis and treatment.
Skaters also have frequent exacerbations of boot-related skin conditions such as blisters, corns, and “lace bite.” Lace bite presents as soft tissue swelling and erythema over the anterior ankle from boot and tongue friction leading to extensor or anterior tibialis tenosynovitis (Fig. 3) (17). Proper padding supplies should be available to relieve skaters' discomfort including a variety of silicon padding products. Gel dressings can decrease friction over the site and, when combined with donut type padding, can alleviate pressure. Appropriate supplies should be stocked in the medical treatment room to manage these common issues (14). A full list of supplies is available in the document outlining medical standards of care which will be provided to the event's CMO by USFS (14).
Physiotherapy and/or athletic training services should be available during international events either at the venue and/or at the host hotel (13). It is not required to have these services available during USFS events, but it is extremely beneficial to the skaters if access can be arranged if needed (13,14). Based on the experience of these authors, it is very helpful to have physical therapists or athletic trainers present on site if possible, and it is preferred if they have experience in the sport of figure skating. This is especially true for championship events that include more elite-level skaters.
All medical documentation must remain confidential and compliant with HIPAA regulations (13,14). A separate injury report form should be completed for each medical or injury assessment, and a summary log sheet of all treatments also should be kept (13,14). For an ISU event, the ISU injury surveillance forms must be used (13).
Rink side coverage
Development of an EAP for the event is essential (18). All medical team members should be provided with the details of the EAP prior to the event and it should be reviewed when they arrive for coverage. The EAP should be posted inside the rink and cover medical emergencies, such as serious upper or lower extremity trauma, head injury, spinal trauma, lacerations, cardiovascular collapse, and respiratory compromise, such as exercise-induced bronchospasm (13). It should be clear whether paramedics will be on site or on call, and how communication will take place with them. Their entry and exit path from the venue must always be unobstructed. Communication equipment should be tested to ensure its function. Supplies kept at rink side should include emergency equipment at a location close to the gate or access point to the ice surface. A nonexhaustive list of essential items is provided in the Table below. It is advisable to practice the rescue of a skater on the ice surface before the event. This should be done with the skater in both a prone and supine position using cervical spine immobilization techniques, such as logrolling. If available, a scoop-type stretcher, rather than a backboard, is often easiest to use on the slippery ice surface. Use of nonslip shoe covers (cleats or crampons) for medical personnel is highly recommended and should be readily available, if not worn at all times, during practices and competitions. While providing appropriate and timely care takes precedence, health care professionals should recognize that costumes are typically very expensive, ranging from hundreds to thousands of dollars. Costumes should be cut only if absolutely necessary for medical care. Similarly, if skates must be removed, avoid cutting the laces or the boot if possible. Ensure the laces have been maximally loosened, pull the tongue of the boot forward, stabilize the athlete's leg above and remove the boot. Because figure skates are quite tight, removal can create traction on the leg which should be minimized in the context of a lower extremity injury.
A medical first aid kit is helpful to have at the rink side, along with a small cooler with bags filled with crushed ice, to handle nonemergent issues that frequently occur during the timed warm-up immediately prior to competition. Since figure skating blades are very sharp and the ice surface may be rough, skaters often sustain small lacerations and abrasions. It is most efficient to have gauze, gloves, wound wash, band aids, steri-strips, and blood stop materials readily available for quick access to manage these small wounds with limited interruption for the skater. One must also be prepared for more significant lacerations especially during pairs, ice dance, and synchronized skating events. Common practice is to keep gloves and gauze in a pocket for easy access.
The dry air conditions of most arenas also may contribute to dry eyes for contact lens wearers, as well as increased risk of nosebleeds due to dry nasal mucosa. For this reason, saline eye drops, petroleum jelly, and pledgets also should be close by. For cosmetic and costuming purposes, skin colored tape is preferred, at least as the outermost layer of a dressing. A sewing kit for unexpected costume problems also can be quite useful and skaters will be very appreciative of your help in this regard.
In most instances, the skater will come to the boards of the ice for assistance even after a bad fall. However, in the event of a more serious injury, the ISU has established a protocol for on-ice emergencies that is used during most skating competitions. ISU Communication 2049 outlines procedures for on-ice emergencies during events (19). This involves the referee, who is a skating judge and who oversees the officiating during competition and the operations during the official practices. At ISU events, there also is a designated ISU event coordinator who should be in radio contact with both the referee and the chief medical officer. If the medical personnel at the rink side identifies a medical emergency situation, they will communicate with the referee and the ice surface will be cleared (19). Medical staff along with any team physician present for the skater will enter the ice to assess the skater and transfer them to the medical room for evaluation (19). If the skater is accompanied by a team physician, that physician will evaluate the skater and determine his/her ability to continue in the competition (19). Otherwise the CMO will complete the evaluation and determine eligibility to continue (19). The evaluating physician will then inform the referee of the skater’s disposition for competition (19). The referee has the final say in whether a skater continues based on whether or not there are concerns regarding safety (19). The medical staff need to complete appropriate competition withdrawal documents whenever necessary (19). At the conclusion of a competition, conducting a postevent debriefing with the medical team is helpful in improving future coverage (18).
A similar on-ice emergency protocol is used for U.S. events to maintain the highest quality and standard of care for the skaters. The Sports Science & Medicine Committee of USFS conducts educational webinars for referees annually to provide information regarding acute and emergent issues that may occur. This gives the officials at events an understanding of appropriate emergency responses to ensure safety.
Figure skating has evolved with athletes continuing to push the limits of the sport. As medical providers at the rink side, by understanding the discipline and competitive level of the skaters, we can anticipate common injuries and prepare for serious events through elaboration and practice of an EAP. Multiple resources exist from both the USFS and ISU organizations and the most updated versions of online protocols should be reviewed when planning medical coverage.
The authors declare no conflict of interest and do not have any financial disclosures.