BrJ Sports Med 1996;30:90-93

SHORT REVIEW

Tournament water skiing trauma

Simon N J Roberts, Philippa M E Roberts

AbstractTournament water skiing is an increas-ingly popular and internationally success-ful sport in Great Britain, despite theclimate. The kinematics and injurypatterns of the three disciplines will beunfamiliar to most clinicians and aredescribed, with estimation of the stresses.Advances in equipment over the last 15years have reduced the risk of severeinjury in the tricks event, while high speedimpacts are responsible for the majority oftrauma in slalom and jump. There is asurprisingly high incidence ofinjury to thelumbar spine during the high impact jumpevent. Comparison with findings in othersports suggests that the spine may bedamaged by overuse, particularly beforeskeletal maturity.(BrJ Sports Med 1996;30:90-93)

Key terms: sports injuries; water skiing

Tournament water skiing is an increasinglypopular and internationally successful sport inGreat Britain, and is attracting financial sup-port which allows for full time participation byover a dozen athletes in this country alone.Very little has been published about injuries

Department ofOrthopaedic Surgery,North StaffordshireRoyal Infirmary,Princes Road,Hartshill,Stoke-on-Trent,Staffordshire ST4 7LN,United KingdomS N J Roberts, seniorregistrar20 Gregory Drive,Old Windsor,Berks SL4 2RG,United KingdomPM E Roberts, generalpractitionerCorrespondence to:Simon Roberts

Accepted for publication7 June 1995

sustained by these elite sportsmen, descrip-tions in the majority of textbooks being largelyconfined to gynaecological injuries and traumacaused by collision with other objects and bythe disastrous but rare propeller injuries whichhave little to do with the sport itself.

Competitive water skiingCompetitive water skiing has four completelyseparate groups: tournament, barefoot, racing,and the newly introduced show skiing (fig 1).Tournament water skiing has three disciplines,slalom, tricks, and jump, which may be enteredindividually or combined to give an overallwinner.

In all three disciplines of tournament waterskiing, the boat is driven at constant speed ina straight line down the middle of the course.In the slalom event, skiers have to ski outsidesix buoys - three on either side, equidistant(11-5 metres) from the boat's path. If they aresuccessful, the boat turns round and returnsback through the course for the skiers tonegotiate the same buoys (the first buoy alwaysbeing on the right hand side), but this time athigher speed until the competitor fails. Whenthe maximum permissible speed has beencompleted (58 kph for men and 55 kph forwomen), the line is sequentially shortened until

Figure 1 Show skiing.

90

on July 26, 2020 by guest. Protected by copyright.

http://bjsm.bm

j.com/

Br J S

ports Med: first published as 10.1136/bjsm

.30.2.90 on 1 June 1996. Dow

nloaded from

Tournament water skiing trauma_... A_

_.' ,*'I,aF / .XB- f_w_ resow

¢$'[A... ............. ..',,,_* . ... _ Z_?.; ago- If.- 4y

Did }4 a i a S r.-

loci: *.;EL "' >

k.~ ......

Z4EIIUWI....... .... .F*ue2 Sao: th tr.

the skier fails to round a buoy. At internationallevel, the first pass through the course isalready with a line shorter than the standard1825 metres, and the world record is currentlyat a line length of over a metre shorter than thedistance from the line of the boat to the lineof the buoys, meaning that the skier must notonly swing out to be level with the boat at theside (figs 2 and 3), but also lean inwards usingthe length of the body to push the ski wider.

In the tricks (or figures) event, the boatspeed is at the competitor's choice and theclock starts with the start of the first ma-noeuvre. Skiers then have 20 seconds or untilthey fall to do as many "tricks" as possible -the harder the trick, the more points areawarded, so a combination of speed and diffi-

Figre -4 Tr-" toeold"

Figure 4 Dicks - "toe hold".

culty is essential. Tricks may be performed onthe surface or in the air over the boat's wake,and may be with the tow line attached to thefoot (fig 4). Jumping over the rope (like skip-ping) while turning, and somersaults (fig 5) areparticularly high scoring.

Like the other two disciplines, jumping hasno style points; in this case it is purely thedistance covered between the ramp andlanding that counts (provided that the skier isable to regain balance and ski away afterlanding) (fig 6). The boat speed is 57 kph formen and 54 kph for women and the jumpheights 1 80 metres and 1-50 metres respect-ively. The jump is 6-4 metres long and usually

Figure 3 Slalom - acceleration.

91

S. lk,

Figure 5 Dicks somersault.

on July 26, 2020 by guest. Protected by copyright.

http://bjsm.bm

j.com/

Br J S

ports Med: first published as 10.1136/bjsm

.30.2.90 on 1 June 1996. Dow

nloaded from

Roberts, Roberts

Figure 6 Jump - at the ramp.

made of a steel frame with a flat waxed fibre-glass ramp surface (giving an angle of wedge ofabout 16 degrees for men). The distancejumped is increased by maximising speedthrough pulling out wide on the opposite sideof the boat from the ramp and swinging backacross as late, hard, and fast as the skier daresand then timing the kick off the ramp (fig 7).Clearly, the later and harder the "cut" themore speed and distance. The world record isa distance of 67-9 metres, and top skiers willstrike the ramp at over 100 kph.

Traditionally, jumping has been regarded as

the most dangerous activity, but higher speedswith twisting falls and sharp jerks from slackrope are common in slalom, where there are

Figure 7 Jump - in the air.

very rapid changes in speed and direction. Thishas been found to be a particular problem inearly season, when skiers may not yet haveprogressed to "all-out" jumping while alreadyslaloming to their limit. Until a few years agowhen safety releases were developed and im-proved, there were several cases of knee liga-ment injury and femoral fracture during "toe-hold tricks", where the rope is held by the foot,skiers often being quite unable reliably torelease themselves from the tow rope followinga fall.

Types ofinjuryInjuries in elite tournament water skiers aredifferent from those described in recreationalparticipants'-5 in that they ski in a highlycontrolled environment from which naturalhazards such as poor driving and dangers onthe shore are largely eliminated. Althoughcompetitors are fitter, the stresses are muchhigher and less predictable.The best data have been produced by the

American Water Ski Association who, in sanc-tioning a tournament, insist that all injuriesseen by the medical officer are reported tothem on a standard proforma with a follow upquestionnaire for the definitive diagnosis. Inour survey of 87 of the best internationalcompetitors in the world, just over two thirdsof the injuries were sustained during trainingand would therefore not be reported inAmerica. The spectrum of injuries was alsoslightly different.Of the acute injuries, those in the lower limb

are largely as a result of skis catching in thewater at high speed, particularly while jump-ing. Grades 1 and 2 collateral ligament injuriesof the knee are common, with less cruciate andmeniscal injuries than expected. Ankle injuriesare uncommon, perhaps because of the highboots worn by elite competitors.The upper limb (especially the shoulder) was

injured as slack was taken up in the tow rope- largely during the slalom event. Blisters andcallosities are troublesome in early season butself limiting.

Chronic low back pain is very common inelite tournament water skiers, as has previouslybeen reported.' Of 87 such competitors, 18 hadhad to miss training or competition within a 12month period due to low back pain althoughnone had any neurological symptoms.

Spinal pathology has been described in anumber of sports,-9 particularly in water skiingwhere participation at a young age is necessaryto achieve excellence. Horne et al described theradiological changes found by screening com-petitors in the national water ski tournament inCanada, and correlated these with the numberof years exposure to the jump event, especiallybefore skeletal maturity.6 We have found thatslalom is as high risk an activity as jumping, atleast in unmasking symptoms in the presenceof pre-existing pathology, but this is largelyseen in early season - often when skiers wereup to near their best in slalom but before fullspeed jumping had begun, and was associatedwith the sudden "snatch" of slack rope beingtaken up.

92

T,77

on July 26, 2020 by guest. Protected by copyright.

http://bjsm.bm

j.com/

Br J S

ports Med: first published as 10.1136/bjsm

.30.2.90 on 1 June 1996. Dow

nloaded from

Tournament water skiing trauma 93

The speeds and forces in water ski jumpinghave been estimated both by calculation andmeasurement (Smith G, unpublished data).and are thought to be 5-9 g both on strikingthe jump and landing, over a period of 95 ms.Intra-abdominal pressures have beenmeasured at 120-192 mm Hg even in jumpsof approximately half world record length.Elite competitors achieve speeds of up to twicethat of the boat by cutting hard across thewakes - the later the cut is left, the more speedneeded and the most severe injuries haveoccurred through leaving this cut too late andhitting the steep side of the ramp, sustaining adirect blow which, while uncommon, hasresulted in fatalities.The ability of binders to stabilise the ankle

yet release only in the event of a fall is a sourceof concern. Elite athletes will often use thehighest and tightest binders which will transmitforces most readily to the ski, but may notrelease in a fall, and the newly designed snow-ski type of boots, which release off the skirather than foot, have yet to make a significantimpact. Heel pads are worn routinely forjumping and need to be changed regularly toretain their function.

Prophylactic and therapeutic knee andlumbar spine support braces are being usedincreasingly and indeed many manufacturersinclude stiff bands along the sides of the kneesin their jump wet suits. While these withprotect the knee from a direct blow, the onlypossible support they may give is by cutaneousproprioceptive enhancement.

It is difficult to imagine a functional shouldersupport which would do any more good thanthe knee braces, although "arm slings" (beltspassing round the waist with a loop around thedistal humerus, holding the shoulder in full

adduction) are in wide use. No elbow injurieswere reported as a consequence of these in thisstudy, though it is a recognised hazard.

ConclusionTournament water skiing is an increasinglypopular and competitive sport. Two areascause concern: first, the high incidence of lowback pain enforcing rest from the sport, andespecially the possibility of an effect of highlevel competition on the immature spine; andsecond, knee injuries associated with theinability of binders to provide optimal supportand release the foot when necessary. Wesuggest that tournament skiers should slalombelow their maximum level in early seasonuntil they are fully "match fit" to avoid backinjuries; and the development of safe bindingsshould be continued. More data are needed,but it has already been suggested that longdistance jumping is an inappropriate event forchildren.

We would like to thank Leon J Larson for allowing us to usethe data he has collected for the American Water SkiAssociation.

1 Banta JV. Epidemiology of waterskiing injuries. West J Med1979;130:493-7.

2 Hummel G, Gainor BJ. Waterskiing-related injuries. Am JSports Med 1982;10:215-8.

3 Kizer KW. Medical hazards of the water skiing douche. AnnEmerg Med 1980;9:268-9.

4 Mann RJ. Propeller injuries. South MedJ3 1976;69:567-9.5 Stanisavljevic S, Irwin RB, Brown LR. Orthopedic injuries

in water-skiing: etiology and prevention. Orthopedics1978;1:125-9.

6 Home J, Cockshott WP, Shannon HS. Spinal columndamage from water ski jumping. Skel Radiol 1987;16:612-6.

7 Pizzutillo PD. Spinal considerations in the young athlete.Instructional Course Lectures 1993;4:463-72.

8 Rossi F. Spondylolysis, spondylolisthesis and sports. J SportsMed Phys Fit 1978;18:317-40.

9 Stanitski CL. Common injuries in preadolescent andadolescent athletes. Sports Med 1989;7:32-41.

on July 26, 2020 by guest. Protected by copyright.

http://bjsm.bm

j.com/

Br J S

ports Med: first published as 10.1136/bjsm

.30.2.90 on 1 June 1996. Dow

nloaded from