Author Reply to “Risk Factors for an Anterior Cruciate Ligament Injury Are Hardly Comparable Between Ski Racers and Recreational Alpine Skiers”

We sincerely thank Drs. Ruedl, Posch, and Burtscher for their thoughtful comments1 on our recently published systematic review, “Multiple Intrinsic and Extrinsic Factors Increase the Risk of Anterior Cruciate Ligament Injury in Skiers: A Systematic Review.”2 We appreciate their recognition of the importance of this topic and the opportunity to further discuss the nuances of anterior cruciate ligament injury mechanisms in different skier populations. We agree that ski racing and recreational skiing involve distinct environments, equipment setups, and athlete characteristics, and therefore injury mechanisms and risk factor profiles are not identical. As highlighted in their letter, elite racers often ski under tightly controlled conditions with customized equipment, high physical fitness, and maximal skill level. Conversely, recreational skiing spans a wide range of abilities, ages, and equipment conditions. These differences influence the relative contribution and interaction of intrinsic and extrinsic risk factors. In Bhatt et al.,2 we synthesized available evidence from elite racers, junior competitive skiers, and recreational participants, given the heterogeneous and fragmented literature. Our intent was not to suggest that all factors apply equally across populations, but rather to provide a comprehensive map of reported risk factors and to identify commonalities and divergences where possible. We fully acknowledge that the strength and direction of individual factors may differ between racers and recreational skiers. Moreover, we concur that ski racing-specific injury mechanisms have been thoroughly documented in elite video analyses,3 and that studies in recreational populations underscore intrinsic and extrinsic factors such as fitness, skill, equipment, and environmental conditions.4, 5 As such, we further endorse the call for future investigations that stratify risk by skier type and level of competition. From a prevention standpoint, population specificity is essential. For recreational skiers, priorities may include fitness and neuromuscular training, equipment setup and maintenance, and slope-safety practices. We have previously highlighted the promise of neuromuscular training in anterior cruciate ligament injury prevention through ski-specific exercises designed to improve coordination, balance, and agility.6 For elite racers, preventive strategies may focus on ski preparation protocols, binding regulation, and course and net design considerations. As the letter authors emphasize, tailored approaches are critical to maximize injury prevention efforts. In conclusion, we view our review as a foundation highlighting the multifactorial nature of anterior cruciate ligament injuries in alpine skiing and drawing attention to areas where evidence remains limited. We are grateful to the letter authors, whose prior work was foundational for this review, for reinforcing the importance of distinguishing between skier subgroups, and we agree that future high-quality, population-specific studies will be essential to refine risk models and inform prevention strategies. The author (A.D.P.) declares the following financial interests/personal relationships which may be considered as potential competing interests: A.D.P. reports consulting/advisory roles, equity or stock ownership, and travel reimbursement from Hospital for Special Surgery; ownership interests in myGemini, HS2, LLC, HSS ASC of Manhattan, myHealth Track, PerfectFit, and Smith & Nephew; and receipt of consulting and nonconsulting fees, as well as travel and lodging support, from Stryker Corporation. The other authors (A.M.B., M.F.L., C.D.P., E.B., P.M.I.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.