ski_mountaineering_scientific_knowledge_of_this.6

GENERAL MEDICAL CONDITIONS
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Ski Mountaineering—Scientific Knowledge of

This New Olympic Sport: A Narrative Review
CX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/30/2024
Volker R. Schöffl, MD, PhD, MHBA;1,2,3,4 Paul Zimmermann, MD;5,6

Thomas Küpper, MD, PhD;7 and Christoph Lutter, MD, PhD, MHBA, Msc8,9
performed as a military patrol event,

Abstract which consisted of cross-country skiing,
Ski mountaineering (skimo) has been accepted as a new sport for the 2026 ski mountaineering, and rifle shooting in
Milan-Cortina Olympics. The equipment used in this competitive ski moun- the Charmonix Olympics (3,4). Because
taineering varies from leisure ski mountaineering equipment mainly in one of the lack of public attention, it was re-
point: the minimal weight. At the elite athlete level, skimo demands both moved as an Olympic discipline and cat-
maximal endurance performance and a high-intensity anaerobic capacity for egorized as an Olympic demonstration
the sprint and vertical races. Race time significantly correlates to V̇O2max, body sport for the Winter Olympics from 1928
mass index and racing gear mass. Available literature only rarely comments on to 1948. Since then, skimo as a military
competitive skimo injuries. Injuries are not only due to falls in downhill skiing patrol has been considered a precursor
but also can result from external hazards, such as avalanches and cold. The high of other sport disciplines, such as the
training load of athletes in combination with a low body weight, low body fat, biathlon (3,4). After exclusion from
and exposure to cold cause high rates of respiratory infections in athletes. the Olympic program due to several
The inclusion of skimo into the Olympic program is expected to result in certain avalanche/crevasses deaths, skimo devel-
changes, such as higher training loads for the athletes and increased scientific oped from an unorganized leisure-sport
interest into training methods. to a professional sport, which is currently
organized and regulated by the Interna-
tional Ski Mountaineering Federation
Introduction (ISMF) (4). The first official World Championships were held
Ski mountaineering (skimo) was accepted as a new Olympic in 2002 and since 2004 regular World-Cups are organized by
sport to the 2026 Milan-Cortina Winter Olympics by the Inter- the ISMF. In 2020, skimo was again recognized as an Olympic
national Olympic Committee (IOC) in July 2021 (1). This may discipline in the Youth Olympics (Lausanne). Consequently, with
be a surprise to some, especially in countries where skimo as a the inclusion into the program of the 2026 Milan—Cortina Win-
competition sport is not well known but is indeed a logical con- ter Olympics, further progression of the sport is to be expected
sequence of a long journey (2,3). The sport has already been an (2,3). With being an Olympic sport more financial means are
Olympic discipline in 1924. Back then, a team of four athletes existing from most of the national federations to improve training,
1 training methods, and professionalism. Also, possible race struc-
Departments of Orthopedic and Trauma Surgery, Friedrich Alexander
2
Universität Erlangen-Nürnberg, and; Orthopedic and Trauma Surgery, tural developments can be expected and are already in place with
3
Klinikum Bamberg, Bamberg, FRG, GERMANY; Section of Wilderness a new discipline “team relay,” which will be one of the two dis-
Medicine, Department of Emergency Medicine, University of Colorado
4
ciplines (with a sprint race) at the Olympic Games.
School of Medicine, Denver, MA; School of Clinical and Applied Sciences,
5
Leeds Becket University, Leeds, UNITED KINGDOM; Department of
6
Cardiology, Klinikum Bamberg, Bamberg, FRG, GERMANY; Center of
7
Sports Medicine, Klinikum Bamberg, Bamberg, FRG, GERMANY; Institute
Skimo as a Competition Sport
of Occupational & Social Medicine, RWTH Aachen Technical University, The competitive formats of the sport include individual
8
Aachen, FRG, GERMANY; Department of Orthopedics, University Hospital
9
races, vertical races, sprint races, team races, and relays. Indi-
Rostock, Rostock, FRG, FRG, GERMANY; and School of Clinical and Applied vidual races have downhill sections that alternate with ascents
Sciences, Leeds Becket University, Leeds, UNITED KINGDOM
and steep climbing sections during which athletes must climb
Address for correspondence: Volker R. Schöffl, MD, PhD, MHBA, Section of with their skis attached to their backpacks (race duration,
Sportsorthopedics and Sportsmedicine, Department of Orthopedic and 90–150 min) (5,6). Vertical races consist of only one uphill
Trauma Surgery, Klinikum Bamberg, Bamberg, FRG, Bugerstraße 80, 96049 section (duration approximately 30 min). Sprint races include
Bamberg, Bamberg, FRG, Germany; E-mail: volker.schoeffl@me.com. short alternating uphill and downhill sections (duration 5 min)
1537-890X/2202/61–66
(7). Team races consist of two to three athletes performing an
Current Sports Medicine Reports up and downhill race together. Relays consist of three to four
Copyright © 2023 by the American College of Sports Medicine athletes performing on a short circuit, which lasts about
www.acsm-csmr.org Current Sports Medicine Reports 61
Copyright © 2023 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
15 min each (8). The disciplines selected for the 2026 Milan-Cortina is tested for each individual. Weight is a main focus from the
Winter Olympics include a sprint and a mixed gender relay (1). athlete’s perspective, as they want to carry the least weight
The equipment used in competitive and leisure skimo varies possible. However, the minimal weight requirements in skis,
mainly in one area, the weight. Modern competition boots bindings, and shoes (Fig. 1) can increase the injury risk (11).
weigh around 500 g each, skis around 700 g each, and the ul- Ski-stoppers were firstly mandatory for international competi-
tralight bindings around 70 g each. The ISMF requires a min- tions by the ISMF for the 2021/2022 season (Fig. 1).
imal weight of 750 g for skies plus bindings in men and 700 g
for women (shorter skies) (8,9). Certain safety equipment is Physiological Demands of Skimo Athletes
demanded in addition to the race suit, e.g., small backpack, The scientific literature on the physiological aspects of com-
helmet, avalanche tracker, shovel, probe, etc. (see Table). petitive skimo is limited. The investigated winter sport repre-
The use of ski brakes is compulsory from the 2021/2022 sea- sents one of the most enduring sports as it involves the whole
son on (10). Mandatory equipment is controlled at the start body, is associated with high-energy demands, and is often per-
and finish and the signal transmission of the avalanche beacon formed in high altitude (5,12). Skimo demands both maximal
Table.
ISMF equipment description for all skimo races (10).
CE or UIAA
Item Description (Extract of the Full Description) Norm
A passport or a national ID card or copy required to be stowed away in the backpack or race suit. Every competitor
must present an official ID document or a copy if required — passport or
national ID card.
A pair of skis with metallic edges covering at least 90% of their length, and a minimal width
of at least 80 mm in the front, 60 mm under the boot, and 70 mm in the rear
part; ski length must be at least 160 cm for men and 150 cm for women.
Bindings which allow heel movement during ascents and are blocked for descents; they
may or may not be equipped with security straps.
The binding system must have both a lateral and a forward complete release
system (the boot is allowed to completely separate from the ski). The use of
ski brakes is compulsory from the 2021/2022 season on.
Minimal weight for skis and bindings:
Men: 750 grams per ski.
Women: 700 grams per ski.
Boots Each boot must have at least two (2) independent closing systems.
The notched soles have to cover 100% of the boot surface.
Minimal weight for boots (shell and dry inner):
Men: 500 g
Women and U18 men: 450 g
A pair of ski poles (carbon or other material) of a maximum diameter of 25 mm, and with
nonmetallic baskets.
A pair of removable anti-slipping skins Skins originating from wild animals are strictly forbidden. The skins have to
cover at least 40% of the snow contact length of the ski.
Upper body clothing Three layers
Lower body clothing Two long-legged layers
An avalanche detector conforms to standard EN 300718 457 kHz frequency. Yes
A helmet conforming to: Yes
UIAA 106 and EN 1077 class B standards
EN 12492 and EN 1077 class B standards
A snow shovel conforming to ISMF standards
A snow probe conforming to ISMF standards
A survival blanket
A pair of gloves
A pair of UV- protection eyewear
A backpack with sufficient carrying capacity to hold all the equipment required by the
regulations, with two rear and/or lateral fastening straps for carrying skis.
A whistle
Supplementary equipment that may be e.g., crampons, harness, via ferrata kit, additional clothing, etc.
required by the jury
62 Volume 22 Number 2 February 2023 Ski Mountaineering
Figure 1: Full light weight carbon race shoe and light weight competition binding with ski stopper (Figure courtesy of Dynafit®).
endurance performance (aerobic capacity) and a high-intensity during uphill and downhill sections, as well as maintaining
anaerobic capacity for the sprint and vertical races (7). Skimo maximal endurance performance during the overall race dura-
has, therefore, been rated among the most strenuous endurance tion (3,5,6,13). These individual sport-specific challenges con-
sports with the highest “hypoxic dose” (i.e., time spent in hyp- tribute to the individual characteristics of skimo athlete’s heart
oxic environment) (5,6,13,14). In comparison to other winter and enhanced aerobic performance, which have been described
endurance sports, e.g., cross-country skiing or biathlon, skimo in previous research (12,22–24).
includes more vertical ascents and descends and the physiolog-
ical adaptations differ significantly as compared with other CPET in Skimo Athletes
winter sport athletes (12). In a normal Skimo World-Cup indi- To evaluate the cardiopulmonary demands of skimo athletes,
vidual race a vertical height gain of around 1800 m is normal. sport-specific CPET was developed (Fig. 2), in addition to stan-
As compared with biathlon or Nordic cross-country skiing ath- dardized CPET bicycle ergometer and treadmill protocols
letes, skimo athletes are generally smaller and younger. These (4,6,7,13,25–28) or heart rate variability analysis during field
characteristics have to be taken into consideration when evalu- tests (5,29). The levels of V̇O2max and other spiroergometric
ating them for peak performance (12). Endurance training, of- maximum parameters of skimo athletes are comparable to
ten performed at altitude, is the main focus in their training top level cyclers or triathletes (4,7,15,26). Schöffl et al. (4) devel-
schedule (12). Altitudes in training and competition often reach oped a specific skimo indoor step test protocol for high-level ath-
over 3000 m, increasing the hypoxic stress on the athletes letes, using skies on a treadmill with increasing speed in compar-
(2,3,7,15). In this context cardiopulmonary and sport-specific ison to a bike test. They found that skimo and bike test results
cardiac remodeling due to structural and functional remodeling varied with respect to the majority of test parameters and statis-
of the athlete's heart can be proven (12). Zimmermann et al. tical findings (4). As these variations of ventilatory thresholds
(12) found in cardiac echography a sport-specific structural re- (VT 1 and VT 2) and maximum parameters (V̇O2 peak) were in-
modeling due to left ventricular, and atrial remodeling, as well consistent in both directions (in some parameters they were
as functional sport-specific remodeling analyzed by speckle higher in the skimo test while in others they were higher in the
tracking analysis, especially for the global longitudinal strain. bike test) they concluded that a sport specific testing was essential
In addition to these cardiac morphological adaption, cardiopul- for exact training monitoring and guiding (4). In a later approach
monary exercise testing (CPET) can prove cardiorespiratory the test was modified into a step test with increasing incline and
functional adaption (2–7,15,16). Race time significantly corre- compared with a newly developed outdoor field test protocol (7)
lates to V̇O2max, body mass index, and racing gear mass (Fig. 3), or ramp test protocols through other research groups
(3–6,14–17). Of special interest is the loss of aerobic performance (15,26). Using a different skimo ramp test protocol, Menz et al.
at these altitudes, which correlates to approximately −10% to (26) found significant correlations of V̇O2max skimo to V̇O2max
−15% per 1000 m of altitude above the threshold altitude — uphill running on a treadmill with recreational athletes. Zimmer-
defined as 1500 m above sea level (4,18–20). This decrease in per- mann et al. (22) recently confirmed that in CPET testing skimo
formance is notably independent of the level of training (21). athletes demonstrate a higher respiratory ventilatory uptake
Nevertheless, variable morphological and structural factors (V̇O2/kg VT2) as compared with Nordic-Cross Country and Bi-
influencing athlete's sport-specific adaptation and subsequently athlon athletes. This finding confirms prior research by Bortolan
race performance have to be taken into consideration (12). In et al. (2), and Cassirame et al. (29), who also demonstrated a pos-
this context, anthropometric characteristics, whereby skimo itive relationship between oxygen uptake levels, heart rate vari-
athletes represent in general small and lightly elite endurance ability at VT2, and skimo athlete race performance. It is felt that
athletes, as well as race experience contribute to individual ath- these adaptations in aerobic capacity are required to be success-
lete’s race performance. Skimo in general is estimated to be ful in a sport that has repetitive variations in intensity through the
one of the most strenuous endurance sports with the highest course of a race. These intensity fluctuations are based on the
“hypoxic dose,” as it is characterized by high intensity intervals change in terrain (different uphill incline and running speed),
Figure 2: Skimo specific spiroergometry laboratory test.
changes in uphill racing technique (running, walking, or ski car- yet reported (31). Palmer et al. (32) report about the sports in-
rying passages), the difference of the uphill tracks (e.g., many juries and illnesses at the Lausanne 2020 Youth Olympic Win-
switch backs), and different physical demands in the changing ter Games and found skimo among the group with the lowest
zone and downhill ski sections. All studies could show the high injury incidence but among the leading disciplines for illnesses.
cardiopulmonary fitness of skimo athletes (2). Within the German skimo national team (two winter seasons,
team of eight world-cup competing athletes), three major inju-
Acute and Chronic Injuries ries were reported (one anterior cruciate ligament tear, one
Available literature only rarely comments on skimo injuries syndesmosis tear, and one case of cerebral concussion) (11).
in training or competitions. Most studies on injuries report Minor injuries are common and can occur from falls during
about skimo as a leisure sport activity but not as a competition the downhills, chronic overstrain, and mechanical irritations.
sport (30). The ISMF Medical Commission is currently work- Because of the fact that equipment weight is crucial, athletes
ing on an injury surveillance system, but data have not been use full carbon shoes with minimal inner lining. Therefore,
Figure 3: Field test with a mobile CPET (cardio pulmonary exercise testing) unit.
mechanical irritations with ulcerations on the heels are fre- athletes it is important to set up effective screening tools
quent (11). Also, injuries during the start of competitions hap- (33), and if appropriate inaugurate therapy (3). As being “light”
pen if mass starts are performed. The tips of the ski poles can in both, equipment and body weight plays a big role for many ath-
then easily injury other competitors, as well as cause falls due letes, nutritional status and energy intake during training and
to stumbling over each other or breakage of the ultralight car- competitions can be insufficient and cases of anorexia athletica
bon ski poles (11). In addition to injuries from falls, over- or relative energy deficiencies are reported (2–5,37,38).
strain, and mechanical irritations, environmental injuries need
to be considered. Because of the exposure to cold and wind, Further Developments as an Olympic Sport
frost bites can occur and the risk of an avalanche accident is With the inclusion into the Olympic program, several changes
present. While this is mostly minimized during the competi- within the sport are to be expected (2,3). Based on an expected
tion phase, it is always present during training. While during increase in public attention to the competitive aspect of the sport,
the competitions, tracks are chosen to not have a high risk of skimo will gain importance among Nordic winter disciplines.
avalanches; however, most athletes generally train by them- The overall number of competitions (professional and leisure
selves in open terrain and are constantly exposed to the exter- competitions) will rise and attract more people to the sport (3).
nal dangers of the mountains (avalanches, weather changes, More sponsors will be drawn into the sport increasing its attrac-
cold, crevasses, rock fall, etc.). Knowledge of correct use of av- tion to athletes even more. With the Olympic status, the national
alanche safety equipment (tracker, probe, shovel etc.) is man- federations will have wider access to the Olympic sport facilities
datory, not only in competitions but even more in training. and trainings analysis and methods will become more sophisti-
Windchill exposure during downhills, due to the fact that only cated. Consequently, the overall training load is likely to rise
very thin competition suits are worn and the athletes sweat dur- (3). As a result, close medical supervision, nutritional, and sports
ing ascent can lead to severe hypothermia. Unfortunately for science support will be important (3).
skimo World-Cups no minimal temperature cut offs yet exist, Skimo is an endurance sport and in being so, it also is a
compared to other Nordic winter disciplines, where below −20° sport which may be prone to doping (3). Besides running, trail
C competitions are prohibited. Further studies are necessary to running, and Nordic ski roller training many skimo athletes
evaluate the specific risk for skimo injuries as a competition sport. train road cycling in the summer; some of them together with
professional bike teams. The overall high doping affinity of
Medical Conditions in Competitive Athletes the bike sport is well known and may lure athletes in the wrong
In addition to acute and overstrain injuries, chronic internal direction. Thus, while in many countries all skimo higher level
medical conditions need to be addressed in elite athletes. Due athletes are already under anti-doping supervision, this must be
to the high training load of athletes in combination with a further expanded where not yet accomplished (3). Also, more
low body weight and body fat and the exposure to cold and antidoping education to athletes is important. While the mini-
wind chill (31) high rates of respiratory infections are reported malist equipment is already at the minimal weight requirements
(11). This also is represented in the data of the Youth Olympic of the ISMF, focus should be on safety concerns of reduced
Games, where skimo athletes had the second highest incidence weight skis, boots, and bindings. For the winter season 2021/
for illnesses (curling, 21%; ski mountaineering, 15%) (32). 2022 firstly ski stoppers became mandatory for international
Over training reflects an issue, as well as leucopenia and iron competitions. As athletes are depending on snow, not only for
deficiencies, in combination with leanness and low body mass. competitions but also for training, global warming may pose a
Athletes in skimo are more prone to infections than athletes in risk to the further development of the sport. As for all winter
Nordic cross-country skiing or biathlon where similar race sports the future of their general existence is unclear and with
suits are worn and athletes sweat during the racing time. How- the current energy crisis, artificial snow is very costly and also
ever, most of these other disciplines allow a quick change of from an environmental standpoint, questionable.
sweaty race suits after arrival at the finish line; in individual
races skimo athletes reach mountain tops during the race and Conclusion
go for a fast downhill without adding warmer additional In conclusion, skimo will be likely undergoing further changes
clothes to reduce wind chill (11). After the downhill, multiple with the inclusion into the Olympic Games. Athletes are already
uphills and downhills follow, increasing environmental expo- known to be lean and highly trained for aerobic endurance. Fur-
sure. Consequences of the high rates of infection and environ- ther professionalization of the sport must not result in risk to ath-
mental exposures include myocarditis, cold and exercise in- lete health, and training regimes need to be under close sport sci-
duced asthma, and other respiratory diseases (11,33–35). entific and sports medical supervision. With the athletes training
Durand et al. (33) report about 48% of skimo athletes having in open snow terrain, focus also must be given on safety from
abnormal airway responses after a skimo race. Despite a high external dangers (e.g., avalanches or crevasses), as well as the
proportion of self-reported symptoms, 73% of this group had training and use of safety equipment.
never been diagnosed with this problem. Exercise induced
bronchoconstriction, which is caused by exercising in frigid
conditions and dehydration of small airways, is common The authors declare no conflict of interest and do not have
in many winter sports (e.g., cross-country skiing) (35). In any financial disclosures.
skimo, however, there is the additional effect of altitude
(5,7,15,17,33,34,36). Based on the hypoxia, this also leads to References
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GENERAL MEDICAL CONDITIONS

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