When a figure skater launches into a quadruple Axel, their body experiences impact forces exceeding eight times their body weight. When a cross-country skier tackles a 50-km run, their heart pumps oxygen at rates that only a few athletes in the world can sustain. And when a hockey player sprints from the penalty spot, they burn glycogen at an intensity that rivals that of a 100-m sprint.

Sports medicine has studied the physiologic requirements of winter sports ahead of the 2026 Winter Olympics in Milano Cortina, Italy, and prepared to face unique challenges where cold, altitude, and extreme physical demands create circumstances very different from those of summer sports.

The Ice Marathoners

If we could photograph the heart of an Olympic cross-country skiing champion during a race, we’d see a muscle at the limits of its capabilities. A study published ahead of the Beijing 2022 Winter Olympics reports that elite skiers reach some of the highest maximum oxygen uptake (VO_2max) values ever recorded, with sex differences ranging from 15% to 50% related to body composition and hemoglobin mass.

The training paradox surprises many coaches. Despite an emphasis on high intensity, the same research, coordinated by the Department of Sports Physiology at Peking University, Beijing, China, shows that skiers spend most of their time in low- to moderate-intensity sessions, with strategic insertions of very high-intensity work. This “polarized” approach appears to be the key to Olympic success.

There is a hidden price: Prolonged exposure to cold air during exercise significantly increases the risk for asthma and exercise-induced bronchospasm, a condition that affects a substantial percentage of elite Nordic athletes, about 20%-30%, according to European studies, compared with a prevalence below 10% in the general population.

Muscle Metabolism in Downhill

Descending the Olympia delle Tofane — the iconic alpine skiing course in Cortina d’Ampezzo — at 140 km/h, absorbing multiple gravitational forces, requires a completely different physiologic profile. A classic review of downhill physiology documents aerobic demands at 90%-95% of maximal power, with heart rate peaking toward the finish, when lactate floods the muscles.

A training day can deplete about 32 mmol/kg of muscle glycogen. Experienced skiers show preferential depletion of slow-twitch fibers — an adaptation that optimizes movement economy. The distinctive characteristic? Leg strength: Skiers display levels significantly higher than those of athletes in other sports, necessary to manage the titanic forces during high-speed turns.

The Enigma of Figure Skating

Behind the grace of an Olympic program lie treacherous challenges. A Danish study conducted nearly 30 years ago measured VO_2max values between 54.7 mL/kg/min and 68.8 mL/kg/min, with intensity reaching 89% of maximal oxygen consumption during competition — levels comparable to pure endurance sports.

But it is the darker side that worries physicians. A recent systematic review shows injury prevalence ranging from 2.1% to 34%, with overuse injuries particularly common. Ankle sprains dominate the statistics, patellar tendinopathy is the most common overuse injury, and stress fractures emerge as a significant problem among female single skaters.

Nutritional research also paints a worrying picture of the discipline, although in recent years sports federations have become much more attentive to eating disorders: Elite adolescent figure skaters frequently exhibit energy restriction and inadequate intake of vitamin D, calcium, magnesium, and zinc. The pressure to maintain a lean physique clashes with energy demands, creating fertile ground for the female athlete triad — eating disorders, amenorrhea, and osteoporosis.

Rapid Glycogen Depletion

Watching a hockey game can be deceptive. Except during sprints, players often seem to rest more than play. But a 2022 review revealed that during 30-80 seconds on the ice, with only 15-25 minutes of actual playing time, athletes cover nearly 50% of the distance at very high intensity.

Surprising results came from Danish laboratories. Research conducted at Aarhus University in Aarhus, Denmark, which took muscle samples just 30-45 seconds after leaving the ice, found glycogen depletion comparable to soccer players despite the drastically shorter duration of competitive time. This is not new: Classic metabolic studies have shown that about 60% of quadriceps glycogen was consumed during the game, with painful consequences in the following days for both recovery and performance.

The Injury Revolution

There is, however, good news from Austria regarding athlete health. A massive study of 98 million skier-days from 2017 to 2022, published in 2023, documents only 0.44 injuries per 1000 skier-days — a collapse compared with the five to eight injuries per 1000 skier-days seen in the 1990s. The authors attribute the transformation in slope safety to technological evolution.

Still, lower limb injuries remain dominant (43%-77%), with the knee being the preferred target (35%), as shown by the unfortunate case of US skier Lindsey Vonn. Anterior cruciate ligament injuries particularly affect women. Head injuries, although rare, cause more than half of skiing deaths. Classical biomechanical research has identified injury mechanisms related to tibial acceleration, which over time led to the development of “smart” bindings capable of detaching in a crash to limit damage and fractures.

Energy Balance in Cold

Preparing the body to compete at -10 °C and 2800 m above sea level is a challenge that goes beyond caloric intake. A review dedicated to athlete recovery for Milano Cortina 2026 defines sleep and nutrition as irreplaceable pillars. Altitude and cold profoundly alter basic needs: A 2021 study shows that exposure to low temperatures increases energy expenditure while suppressing appetite, creating a perfect scenario for energy deficit.

In biathlon — the Winter Olympic discipline that combines cross-country skiing with precision rifle shooting, requiring both sustained endurance and steady marksmanship under physiologic stress — a 2025 study outlines sophisticated carbohydrate-integration strategies that periodize energy availability. High protein intake emerges as a nonnegotiable necessity to support muscle repair and recovery in cold, high-altitude environments. These principles have inspired menus served in the dining halls of Italian Olympic villages.

Gaps in Winter Research

For sports physicians working at Milano Cortina 2026, each discipline brings a unique risk profile: respiratory screening in Nordic sports, monitoring energy balance and bone health in skating, recovery management in hockey, and preventing knee injuries in alpine skiing.

Much still needs to be studied. A bibliometric analysis by researchers at the University of Lausanne, Lausanne, Switzerland, reveals that winter sports have produced far less research than summer sports.

This story was translated from Univadis Italy, part of the Medscape Professional network.