Common, usually settles, and serious back injuries on the slopes are rareEmerging evidence
A sore lower back after a day or a week on the slopes is common, and it usually settles. The NHS says back pain "usually improves within a few weeks", and that "Very rarely, back pain can be a sign of a serious problem such as a broken bone, cancer or an infection". In people with a new episode of low back pain, average pain fell from 52 to 23 out of 100 within 6 weeks.
Serious back injuries on the slopes are rare. In British Columbia, spinal fractures or spinal cord injuries ran at 0.01 per 1,000 skier days, four times lower than in snowboarders; in a Colorado series the rate was "very low (0.001/1000 skier-days)"; and across 43 studies of amateur skiers and snowboarders, injuries of any kind ran at about 1.9 per 1,000 days on the snow, mostly to the limbs.
Sources 1, 2, 3, 4, 5
Long days in the stance: what the racing studies measuredEmerging evidence
Downhill skiing holds the hips and knees bent and the trunk leaning forward, run after run, and much of it is braking work for the thighs. In 8 European Cup racers, the greatest load in a giant slalom turn reached "up to 2.89 times the body weight", with the trunk at that moment bent forward by about 39 degrees, sideways by about 15 and twisted by about 8; the authors conclude that this "combined occurrence of frontal bending, lateral bending, and torsion in the loaded trunk" may be part of how overuse back injuries arise in racing.
In 8 highly skilled ski instructors, every form of skiing shook the whole body (whole-body vibration), more so with skidded turns, and the authors conclude that vibration, especially with high forces, does "contribute to a high risk for low back pain" in active skiers; that is their inference, as the study measured no pain. On an icy, water-injected racing slope, vibration through the lower back was 5.7% higher than on a machine-groomed one. These are measurements in racers and instructors, not studies of pain: none followed recreational skiers' backs, and no study of back pain in recreational downhill skiers was found.
Sources 6, 7, 8
Racers, mogul skiers and instructors: back pain is common, but about as common as in people who don't skiMixed evidence
Back pain is common in competitive skiers. In 45 students at a Norwegian ski high school, 67% had low back pain at their first examination, up from 36% on entry; the authors put the rise down to "Excessively rapid progression of training and faulty technique", and with treatment and advice on training it fell to 29% a year later. In 26 Swiss national team women, off-season overuse problems were commonest at the knee, then the back and hip. One review found the highest rates of low back pain "among skiers, floorball players and rowers", and another found lifetime back pain highest in rowing and cross-country skiing.
But where skiers were compared with people who don't ski, back pain was about as common. In 75 young elite skiers and 27 non-athletes, lifetime back pain was 50% against 44%, not a significant difference, though skiers with pain rated it higher. In 16 young elite mogul skiers, scans showed more disc changes than in 28 non-athletes, but lifetime back pain was similar (50% against 42%), and "No correlation could be found between disc degeneration and back pain in this study". In 108 youth racers aged 13 to 15, 37.0% had at least one abnormal finding on a lumbar scan, including stress changes in the bony arch at the back of a vertebra in 10.2%, all of them boys. In 272 US ski instructors, 75% had had low back pain, and the authors say this lifetime figure "was similar to the general population".
Sources 9, 10, 11, 12, 13, 14, 15, 16
Falls, twists and collisions: what breaks, and how oftenEmerging evidence
Most ski injuries are to the knees and other limbs, and serious spinal injuries are uncommon. In Japan, 1.4% of 6,302 injured skiers had a spinal injury, and "about 70% of spinal injuries caused by skiing resulted from a simple fall". In 126 skiers with spinal injuries over 11 years in Colorado, the commonest pattern was a compression fracture (38%), most often at the base of the neck or where the upper and lower back meet, and 17% had a spinal cord injury. In a Swiss trauma centre serving the Bernese Alps, 63 of 73 adults with severe spinal injuries from snow sports were skiers, and "The most commonly affected site was the lumbar spine".
In US hospital data, injured skiers were older than injured snowboarders (an average of 39.5 against 23.5 years), and once in hospital both were about equally likely to have a spine injury. In US emergency departments over 20 years, 52.8% of skiers' spinal fractures followed a fall at ground level. With thin bones (osteoporosis), the NHS says "Even a minor fall could lead to a break".
Sources 17, 18, 19, 4, 20, 21, 22, 23
Snowboarders' backs: more jumps, more serious injuries and more tailbonesEmerging evidence
Snowboarders have more serious spinal injuries than skiers, mostly from jumps. In British Columbia, spinal injuries were four times as common in snowboarders (0.04 against 0.01 per 1,000 days), and jumps of more than 2 metres caused 77% of snowboarders' spinal injuries against 20% of skiers'. At one Japanese ski area, 4.9% of 8,723 injured snowboarders had a spinal fracture, most often of a small side process of a lumbar vertebra (33.2%), and failed jump landings, terrain parks and ages 20 to 39 raised the risk; 15 of 18 snowboarders with spinal cord injuries had failed an intentional jump.
Snowboarders also break the tailbone more often: in US emergency departments, 21.5% of their spinal fractures were of the tailbone against 11.5% in skiers, and more came from falls at ground level (69.2% against 52.8%). In one Japanese ski area, 3.3% of snowboarders' injuries were spinal, against 1.4% of skiers'. These are rare events, and the everyday back pain advice and the plan below are the same for snowboarders and skiers; the terrain park and jumps come back last.
Sources 3, 24, 25, 22, 19
Lifts, carrying skis and the journeyEmerging evidence
In New Zealand, lift injuries were 2% of hospital admissions for skiing and snowboarding injuries; "Most arise from skier error when embarking or disembarking, or from improper lift operation", and 28 of 44 people had a fracture, one of them of the lumbar spine. In a Utah children's trauma centre, 7% of hospital admissions for ski and snowboard injuries were falls from a chairlift, mostly in children aged 7 or under. No study of back pain from sitting on lifts was found.
No study of carrying skis or boots was found either. The British Chiropractic Association (BCA) advises: "Always be careful when carrying skis/boards. Leave them standing upright so you don’t have to bend to pick them up. Carry them over your shoulder, swapping shoulders regularly". Long drives and flights add a long, still sit at each end of the trip; our back pain when driving and flying guides cover these.
Sources 26, 27, 28
Cross-country skiingEmerging evidence
In 257 elite Norwegian cross-country skiers, 63.0% had low back pain in the past year, more than non-athletes (almost twice the odds), and they "more frequently reported having low back problems using classic than freestyle skiing techniques". This was elite athletes; in our reading the same advice applies to recreational classic skiers.
Source 29
When a scan or test mattersStrong evidence
Most back pain after skiing needs no scan. The National Institute for Health and Care Excellence (NICE) says "Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica". In 3,110 people without back pain, disc degeneration showed on scans in 37% at 20 and 96% at 80, and in young mogul skiers disc changes didn't match pain.
A scan matters after a fall or a heavy landing with pain in one spot over the spine, for anyone from 50 or with thin bones after a fall, with leg weakness or the cauda equina signs, and for a young skier whose back hurts arching backwards. Many small spinal fractures in snowboarders were side-process fractures, which an X-ray or a computed tomography (CT) scan finds.
Sources 30, 31, 14, 24, 4
How it usually goesEmerging evidence
Aches settle in days. NHS inform says "In many cases, new or flare-up of long-standing back problems should begin to settle within 6 weeks without the need to see a healthcare professional". Across 33 groups of 11,166 people, average pain in a new episode of low back pain fell from 52 out of 100 to 23 at 6 weeks and 6 at a year. In the Norwegian ski school, overuse back pain fell from 17 students to 3 within a year with advice and treatment, while pain linked to small structural changes in the spine didn't. After a spinal fracture, recovery takes longer and the fracture team guides it. No one can promise a date.
Sources 32, 2, 9
When it isn't skiing: the causes the warning signs cover
Some back pain has causes skiing didn't create, and the warning signs follow the pages behind them. Numbness around the genitals or bottom, new bladder or bowel trouble or both legs weak can be cauda equina syndrome, a 999 call in the words of the NHS back pain and sciatica pages. After a fall, the NHS falls page says to call 999 if someone may have hurt their head, neck, back or hip; NHS inform's neck injury page and the NHS whiplash page say which neck symptoms need help the same day; and the NHS osteoporosis page says to call 999 or go to A&E for severe pain after a fall or injury. A fall onto the bottom can bruise the tailbone, as the NHS tailbone page describes.
On the slopes, chest pain that spreads to the arms, neck or jaw, or tightness that comes on with effort and eases with rest, can be the heart: the NHS heart attack and angina pages give the 999 and NHS 111 signs. A long journey to a resort is why the site's line on a clot in the lungs is here. Back pain with a fever, after cancer, or with weight loss or night pain is rare, and the back hub's lines say what to do.
The other warning signs follow the pages they were first written from. A burst abdominal aortic aneurysm (a swelling of the body's main artery) can cause sudden, severe tummy or back pain, a 999 call on the NHS aneurysm page; the NHS kidney infection page says when back or side pain with a very high or very low temperature needs an urgent GP appointment; and the NHS foot drop page covers difficulty lifting the front of the foot. A Leicestershire NHS leg pain leaflet lists the leg symptoms that need a GP or NHS 111 urgently, such as leg weakness that is getting worse; NICE's guideline on spinal metastases covers new back pain in people who have or have had cancer; and NICE's spondyloarthritis guideline sets out the inflammatory back pain features that mean a referral to a rheumatologist. A hot, swollen joint can be septic arthritis, and the NHS septic arthritis page lists a high temperature, "although not everyone has one".
After a fall, NICE's spinal injury guideline lists the dangerous ways to hurt the neck that put someone at high risk, among them a fall from more than 1 metre or 5 steps and a dive. Small spinal fractures from thin bones are described on the Royal Osteoporosis Society's symptoms page and the US orthopaedic surgeons' OrthoInfo page, and the UK osteoporosis guideline (NOGG) and NICE's osteoporosis guideline cover how they are found and who needs a bone check; an Essex NHS trust's leaflet says that if broken fragments press on the nerves and the legs become weak, "we need to see you urgently". In a study that followed 500 children from the age of 6, a stress fracture in the spine (spondylolysis) was found in 4.4% at 6 and 6% in adulthood, its slip rarely got worse after the teenage years, and 45 years on, those who had one did about as well as other people. On a long journey to the slopes, the NHS DVT and pulmonary embolism pages describe a clot in the leg and one that reaches the lungs, and the NHS fainting page says to call 999 for someone who fainted while exercising.
Sources 1, 33, 23, 34, 35, 36, 48, 49, 50, 52, 53, 55, 54, 56, 68, 57, 51, 61, 62, 63, 64, 65, 66, 67, 60, 59, 58
