The United States Figure Skating Association (USFSA) regulates the testing and competition of 170,000 members, a number that represents a 63 percent increase over just one decade. This surge in popularity can be partially attributed to figure skating becoming more financially accessible in lieu of the newer focus on only the freestyle aspect of the sport. The success of American figure skaters like Michelle Kwan and Brian Boitano have also increased the popularity of the sport. This greater participation has subsequently brought about a higher level of competition. Both the athletic and artistic aspects require expert conditioning, technique, dance ability and aesthetic presentation. As a result, elite skaters can spend three to five hours a day, five to six days per week on the ice. In addition to their rigorous on-ice practice schedule, these athletes may spend several more hours engaged in off-ice conditioning and ballet classes. On- and off-ice training dramatically increases when the skater reaches more advanced levels, often coinciding with adolescence and a time of asynchronous bone and soft tissue development. The stress of performing repetitive jumps and other difficult moves during this period of development presents a unique set of circumstances under which skating injuries can occur.1 Given the potential for various injuries among figure skaters, there is a strong need for practitioners who demonstrate a fundamental understanding of the sport and the equipment involved (see “What You Should Know About Skating Boots” below). Understanding The Biomechanics Of Skate Gait Stroking, the basis of skate gait, is essentially skating across the ice using a series of push-offs to facilitate momentum. Proper stroking technique is important in that the skater desires maximum speed without having to expend needless energy or put unnecessary stress on the body. Stroking, in conjunction with good balance and posture, consists of the interplay of inside and outside edges. Simply stated, the skater obtains the inside edge by gliding on the medial side of the blade and obtains the outside edge by gliding on the lateral side. Though the skater constantly changes edges and direction, fundamental skate gait remains the same. The skater begins with the push off of one blade against the ice to create gliding on the weightbearing side. At the beginning of each stroke, there is a slight flexion of the free or non-weightbearing hip. This is followed by forced hip abduction as the blade concurrently pushes off the ice and produces momentum on the weightbearing skate. The extremity that provided the push then purchases the ice, the body weight shifts accordingly and the mechanism reverses. The weightbearing knee should be slightly bent throughout to keep the center of gravity over the blade rocker and prevent forward canting from the intrinsic heel of the skate. Accordingly, flexibility of the posterior leg is important to prevent injury secondary to this stress. Key Considerations In Evaluating Skating Injuries While the podiatrist may assume the boot manufacturer has a level of anatomical understanding when it comes to the foot, evaluating a skater’s biomechanics and the problems that can occur therein is more suited to the orthopedic professional. In addition to emphasizing that the skater bring his or her skates to the appointment, clinicians must weigh several factors in evaluating the injuries of these patients. • Who came with the skater? In addition to parental involvement in the actual visit, it is important to ensure that someone is able to communicate any necessary treatment/training modifications to the skater’s coach. • Evaluate the overall skater. What age and sex is the skater? Does he or she skate in singles, pairs or ice dancing? What level is the skater at? Novice, junior and senior skaters are practicing double and triple jumps. This will provide a guideline as to the physical intensity of the skater’s practices. • Does the skater appear underweight? Both male and female skaters are at risk for eating disorders such as anorexia, which can lead to osteoporosis and other serious health issues.2,5 Making a referral to the pediatrician or primary care physician may be advisable. • Evaluate the boots. Are they too stiff? There should be a slight bend to the upper when applying average force with the hands. Many skaters have various pathologies related to stiff boots. If the skater is practicing double and triple jumps, there is need for more support but not more than previously described. Contrarily, are the boots breaking down? If worn, crease lines are usually prominent along the medial and lateral upper. Tongue creases are common and not necessarily indicative of detrimental wear. • When were the blades last sharpened? Overly sharp blades stick and dull blades skid. Depending on the weight of the skaters, how much the skaters practice, the intensity at which they skate and their personal preferences, they should sharpen their blades every three weeks to three months with regular use. • If the boots are new, were the blades mounted correctly? A properly placed blade to a boot is like neutral position to an orthotic casting. If the skater is having a difficult time with the inside or outside edge of either skate after a sharpening or replacement, a professional should reevaluate the blades. Most training rinks have someone with expertise in this area or they can refer the skater to a local professional who has this experience. Some boot manufacturers do provide this service. • Is there indication for an orthotic? Orthoses for both the skates and street shoes are reasonable for any skater as skate boots lack arch support. Graphite or thin polypropylene with intrinsic posting and a thin top cover works best. Metatarsal pads or bars are also appropriate for skaters with histories of metatarsal head stress fracture, sesamoiditis or any metatarsalgia. Send tracings of the manufacturer’s insoles with the prescription and if possible, send an older pair of skate boots. The goal is to make a small enough device that is wide enough so the skater does not pronate into the gap between the orthotic and the medial aspect of the skate. • Is there rubbing from the boot causing soft tissue injury? If a boot modification is necessary, it is helpful to write down detailed instructions for the patient to take to the manufacturer regarding the location and suggested alteration. Marking the area with a pencil can be helpful. Pertinent Pearls Regarding Acute Injuries Out of 236 male and female figure skaters at four consecutive World Junior Figure Skating Championships, a study revealed 25 percent of female skaters and 27.9 percent of male skaters sustained some kind of acute skating injury over the course of their careers. The authors of the study found that acute injuries were semi-specific depending on the discipline of the skater involved.1 For instance, contusions and lacerations were common in ice dancing where the man and woman are required to stay close together while engaged in quick changes of direction and hand holds. These injuries were also common for those involved in pair skating, which requires high lifts and big throws. Other acute injuries included traumatic fracture of hands, wrists and arms as well as sprains and strains of shoulders, knees and wrists. Ankle sprains were the most frequently reported injury among all the skating disciplines.1 Interestingly, the researchers noted these injuries occurred most often during off-ice activities. In her article, “The Young Skater,” Angela Smith, MD, postulates that the skater spends so much time in a stiff boot that the peroneal muscles weaken. This is similar to what happens to muscles when in a cast for an extended period.2 When skaters subsequently engage in off-ice training, they are more likely to sprain an ankle. Boots that have worn out or boots without enough upper support may also be the culprit of an on-ice sprain, particularly if the skater engages in rigorous jumping. When it comes to the prevention and treatment of a figure skater’s acute ankle sprain, there is a two-pronged approach. One should emphasize improving muscle strength via balance and proprioception exercises, which the skater can integrate into an off-ice, cross-training regimen. Clinicians should also encourage skaters to wear a skate boot that provides adequate support while still allowing some ankle plantarflexion/dorsiflexion to promote intrinsic strength. Other acute skating injuries include Achilles tendon rupture (secondary to jumping), peroneal or posterior tibial tendon rupture, fracture and plantar fascial strain/rupture. What You Should Know About Chronic Injuries Lipetz and Kruse say the foot is the most common location of injury to a figure skater, and that most of these foot injuries are overuse injuries.4 Dubravcic-Simunjak, et. al., note that stress fractures are the most frequent chronic injuries in female skaters. Stress fractures of the most common sites — the metatarsals, tibia, fibula and navicular — can occur in both the take-off and landing extremity.1 This suggests that skaters not only place a high level of force on the landing leg but also exert a significant amount of force to vault into the air in order to achieve sufficient height, rotation and distance across the ice. In support of the effect these forces have on adolescent figure skaters, Oleson, et. al., found that lower bone mass secondary to young age and the prolonged wearing of a stiff skating boot did not contribute to these types of injuries.5 Stress fractures and other injuries may actually feel better in the skates while being made worse by them. A stiff boot is like a short cast and a skater with an injury such as a metatarsal stress fracture may experience minimal or no pain while engaged in lower intensity skating. This creates a false sense of wellness or improvement in the skater’s mind. However, the injury is likely to worsen with rigorous practice. Particularly when one is treating a young skater or one such patient with an enthusiastic parent, it may be preferable to utilize a non-weightbearing cast over a removable Cam walker or stiff-soled shoe for a period of time in order to keep patients off the ice until the injury has healed. How Boot Fit Can Contribute To Injury Skate boots can cause and exacerbate soft tissue conditions. For instance, when skaters use a new or excessively stiff boot, there may be insufficient ankle dorsiflexion, which causes forward leaning and an eccentric load on the back leg in an attempt to maintain the center of gravity over the skate rocker. With continuous forward canting, the skater must maintain excessive knee flexion and ankle dorsiflexion to maintain balance. This can strain the posterior elements and contribute to Achilles injury or tendonitis. These are common in skaters, especially those who are predisposed to these conditions.6 Over-training, poor technique and the mechanical pressure and rubbing of a stiff posterior upper against the Achilles can also cause tendonitis (see “Treating Tendinitis Conditions Related To Boots” below).4 Contrarily, if the boot is too loose and the heel is allowed to move up and down excessively (more than 1/2 inch), Haglund’s deformity or retrocalcaneal bursitis may occur.2 If the boots are relatively new, advise the skater of the etiology of the condition so the manufacturer can perform any necessary posterior upper modifications such as stretching, molding or the addition of extra padding. Another posterior ankle/leg soft tissue injury caused by boot fit is irritation or dermal thickening of the lower posterior leg due to repeated plantarflexion. However, one can easily remedy this by adding a modification called a dance back. To do so, one would remove a portion of the posterior-superior upper and insert a soft, closed-cell foam material. The manufacturer can do this during or after boot fabrication. The manufacturer can also “punch out” other areas of boot irritation such as those over bony prominences. Padding can also be used for such problems. Clinicians can recommend moleskin, felt and silicone devices such as Bunga Pads (Absolute Athletics) to the skater. The boot manufacturer and ice arena pro shops usually carry these materials. Skate boots can also cause abrasions, blisters and ganglion cysts. As an example, a 13-year-old female skater presented in my office with a large ankle joint ganglion cyst just anterior to the lateral malleolus. The skate boot was secondhand and excessively stiff. There was no bend to the upper with forceful effort. There had been no modifications for malleoli or bony prominences. I proceeded to aspirate the ganglion and used a corticosteroid injection followed by compression. I advised the skater that she needed new boots or, at the very least, her current pair would have to be molded to accommodate pressure points. The skater missed her follow-up but related that she felt “fine” during a phone conversation two months after treatment. She had obtained new boots. Bursitis, hammertoes, Sever’s disease and plantar fasciitis (especially in skaters with tight posterior leg muscles or increased longitudinal arches) are other chronic pedal conditions that have been linked to figure skating.3 It is not currently known whether hallux valgus, limitus or rigidus are directly correlated to skating or its equipment. However, painful bursa and neuritis can form over deformities due to the rigidity of the boot. Again, heat-molding of the boot by the manufacturer and/or padding is appropriate. Why Off-Ice Conditioning Is So Important A skater uses a variety of muscle groups to execute the most difficult of triple jumps down to the placement of a finger and facial expression. Combining proper technique with adequate strength and flexibility can reduce the risk of injury. Such conditioning begins off-ice, where skaters should incorporate into their training a regimen of strengthening and stretching as well as cardiovascular work. However, any mature athlete understands the benefits of rest and one should recommend to the skater to have one day a week away from strenuous physical activity in order to allow for recuperation. A special consideration for skaters is the environment in which they train. Ice arenas are damp and cold, and elite skaters frequently train in the early morning. Properly warning up off and on the ice is important prior to and after practice. Skaters should also do this after resurfacing of the ice or breaks. Older skaters should be particularly cognizant of the need for proper stretching and warming up in order to prevent injury. What You Should Know About Skating Boots Since many acute and chronic injuries are caused by the skating boot itself, it is a good idea to have skaters bring their skates to the appointment for evaluation.1-4 A skate is not just a blade mounted to a boot. The apparatus can vary drastically in regard to the position of the blade, the fit of the boot, any modifications made and the materials used in the construct. Although boot and blade combinations are mass produced and sold cheaply in various sporting good and department stores, competitive skaters will likely obtain their boots from a reputable boot company or dealer, purchase their blades separately and have them properly mounted by a professional. A custom fitted boot with a quality set of blades can cost in excess of $1,000. Many skaters opt to purchase stock boots, which are a good alternative to the more expensive custom boots in lieu of the expense involved in replacing skates which continue to be outgrown. However, even these stock boot/blade combos can cost hundreds of dollars. For custom skate boots, the professional fitter will take various foot measurements. (One may take a plaster cast such as that for a custom molded shoe although this is not standard.) The measurements attempt to accommodate for all bony prominences like malleoli as well as other osseous considerations such as hallux abductovalgus deformities. Stock boots may or may not include accommodation for normal bony anatomy but the manufacturer can easily mold or “punch out” the leather of both custom and stock boots. It is important for podiatrists to know that custom and stock boots lack intrinsic arch support or orthoses although most professional boot companies provide foam box casting services by their personnel at additional cost. Treating Tendinitis Conditions Related To Boots Other common tendinitis conditions related to skate boots are that of the extensor hallucis, tibialis anterior and posterior tibial tendons.6 Extensor tendonitis or lace bite results from lateral slipping and compression of the tongue across the top of the foot and ankle with dorsiflexion. One can add midline lace hooks or alternate lacing, or supplement the skate tongue with porous rubber, felt or lamb’s wool in order to treat this problem in conjunction with antiinflammatory medication and ice. Skating can exacerbate or even cause posterior tibial tendinitis because the standard boot construct lacks intrinsic arch support. Custom orthoses are certainly indicated in this case. In Conclusion Educating the skater, coach or trainer and/or parents in regard to the etiology of the skater’s condition is essential to ensure compliance. Clinicians should emphasize a gradual return to the ice with off-ice conditioning and a slow increase in the difficulty of moves after returning to the ice. Keep in mind that prior to or during the competitive season (October to March), skaters will be especially anxious to get back on the ice so it is important to have a thorough discussion about the importance of compliance. The particulars of figure skating are unique to a certain sect of athletes. Clinicians should recognize that youth, finances and external motivation are key factors in a skater’s treatment course. Not only must the health care provider treat the skater’s injury and contributing factors, he or she should educate the skater and his or her support system to ensure there is not a premature return to the ice that risks further aggravation or re-injury. Dr. Janowicz is a podiatrist for Kaiser Permanente in Oakland, California and a member of the United States Figure Skating Sports Medicine Society.
References 1. Dubravcic-Simunjak S, Pecina M, Kuipers H, Moran J, Haspl M. The Incidence of Injuries in Elite Junior Figure Skaters. Am J Sports Med 31(4):511-17, 2003. 2. Smith AD. The Young Skater. Phys Med Rehab 19(4):741-55, 2000. 3. Bloch RM. Figure Skating Injuries. Phys Med Rehab 10(1):177-88, 1999. 4. Lipetz J, Kruse RJ. Injuries and Special Concerns of Female Figure Skaters. Phys Med Rehab 19(2):369-80, 2000. 5. Oleson CV, Busconi BD, Baran DT. Bone Density in Competitive Figure Skaters. Phys Med Rehab 83(1), 2002. 6. Muller DL, Per Renstrom, AFH, Pyne JIB. Ice Skating: Figure, Speed, Long Distance, and In-Line, Sport Injuries, Mechanisms. Prevention. Treatment. Edited by Fu, FH and Stone, DA, Williams and Wilkins, 1994.