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Review article                                       DOI: https://doi.org/10.35469/ak.2021.320
received: 2022-01-25                                       UDC: 796.926:616-001
PHYSICAL THERAPY RECOMMENDATIONS FOR INJURY 
PREVENTION IN ALPINE SKIING
Friderika KRESAL1, Špela BRAČUN1, Laura TÖNIG1, Mojca AMON1
1Institution for Higher Education for Physiotherapy FIZIOTERAPEVTIKA, Ljubljana, 
Slovenia
Corresponding author:
Mojca AMON,
Institution for Higher Education for Physiotherapy FIZIOTERAPEVTIKA, Slovenska cesta 58, 
1000 Ljubljana
Phone: +386 31 60 84 12 
E-mail: amon.mojca@gmail.com
ABSTRACT 
Introduction: Alpine skiers face high speeds, significant forces, natural and un-
natural obstacles, and various environmental conditions on the slopes. Thus, they are 
highly exposed to certain injuries, amongst which the most common are those to the 
knee followed by injuries to the spine, shins, head, as well as arm and thumb injuries.
Purpose: The purpose was to systematically review the scientific literature on inju-
ries, risk factors, and prevention in competitive alpine skiing and to provide recommen-
dations for injury prevention in the field of physical preparation, kinesiotherapy, and/or 
specific exercises, and to determine which exercise program would be most appropriate 
for an alpine ski racer. 
Methods: PubMed, Web of Science, and COBISS databases were used with PRIS-
MA method to review the physical therapy recommendations for injury prevention in 
alpine skiing. 
Results: 10 studies were included in the final systematic review. We have not found 
any evidence-based prevention programs that are not older than 10 years on the topic 
of physical preparation for alpine ski racers. We found that most often, the literature 
describes prevention in terms of equipment, course preparation, course safety aware-
ness, and the experience of the skier. 
Conclusions: The recommendation for the most efficient prevention according to 
the current literature is to follow the above preventive measures in combination with 
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appropriate physical preparation, where we recommend relying on research evidence 
in other (non-contact) sports that have similar injury mechanisms as alpine ski racing. 
Keywords: sports medicine, injury prevention, physiotherapy, alpine skiing
FIZIOTERAPEVTSKA PRIPOROČILA ZA PREPREČITEV 
POŠKODB PRI ALPSKEM SMUČANJU
IZVLEČEK
Uvod: Smučarji se na progah soočajo z visokimi hitrostmi, velikimi silami in različ-
nimi okoljskimi pogoji. Posledično so izpostavljeni določenim poškodbam, med kate-
rimi so najpogostejše poškodbe kolena; sledijo poškodbe hrbtenice, golenice, glave in 
poškodbe roke ter palca. 
Cilji: Namen je bil sistematično pregledati znanstveno literaturo na temo poškodb, 
dejavnikov tveganja in preventive pri tekmovalnem alpskem smučanju in podati pre-
ventivna priporočila pred nastankom poškodb na področju telesne priprave, kinezio-
terapije in/ali specifičnih vaj ter ugotoviti, kakšen program vaj bi bil najprimernejši 
za preventivo pred specifično poškodbo alpskega smučarja tekmovalca. Ugotavljamo 
pomanjkanje preventivnih programov za izboljšanje telesne pripravljenosti smučarjev 
saj prevladujejo izsledki o preventivi z vidika smučarske opreme, priprave proge, oza-
veščenosti o varnosti na progi in izkušenj smučarja. 
Zaključek: Priporočila za najučinkovitejšo preventivo glede na trenutno literaturo 
so upoštevanje zgoraj omenjenih napotkov v kombinaciji z ustrezno telesno pripravo, 
pri kateri priporočamo opiranje na dokaze raziskav v drugih (nekontaktnih) športih, ki 
imajo podobne mehanizme poškodb kot alpski smučarji tekmovalci. 
Ključne besede: športna medicina, preprečevanje poškodb, fizioterapija, alpsko 
smučanje
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INTRODUCTION
Alpine skiing as an activity was not popular before the 18th century. It took another 
100 years for it to establish itself as a sport (Pfister, 2001). Today, skiing and snow-
boarding are among the most popular winter sports in the world and the organisation 
of alpine skiing competition is at the highest level (Schoenhuber, Panzeri, & Porcelli, 
2018). Injury trends have been increasing in recent years, and the current incidence sug-
gests that as many as one in three elite skiers may be injured in a single season (Tarka 
et al., 2019). Almost half of all injuries require the skier to be absent from training and 
competition for more than a month (OSTRC, 2019). As in any sport, prevention pro-
grams play an important role, preparing the skier physically to reduce the risk of injury. 
The team of physiotherapists and other health professionals is crucial for the physical 
preparation of a top alpine skier, and needs to take into account the specificities of each 
individual and the mechanisms of injury specific to skiing (Spörri, Kröll, Gilgien, & 
Müller, 2017). In addition to good physical fitness, suitable and safe ski equipment, 
properly prepared slopes, knowledge and experience, awareness of the skier and, above 
all, good psychological preparation are important for the prevention of alpine skiing 
injuries. In 2006, the International Ski Federation (FIS), in cooperation with the Oslo 
Sports Trauma Research Centre (OSTRC), developed the injury Surveillance System 
(ISS) to monitor injuries in different skiing disciplines and collect data for more de-
tailed research into the causes of these injuries. The primary aim of the organization is 
to reduce injuries among skiers, and to propose preventive measures that have not yet 
been tested in clinical practice (OSTRC, 2019).
Skiing injuries
In the World Cup, the highest level of competition, the incidence of injuries ranges 
from 23% to 37% in a single season. Almost half of all injuries occur during competi-
tion, despite the majority of runs being taken during training (Tarka et al., 2019).
According to the Oslo Sports Trauma Research Centre (OSTRC) (2019), a total of 
1083 injuries were recorded in the Alpine Skiing World Cup seasons between 2006 and 
2019 among the 3329 competitors interviewed. As many as 40% of the injuries were 
those that required the competitor to be absent from training and competition for at least 
28 days. The most common type of injury was a joint or ligament injury, followed by 
bone fracture, muscle or tendon injury, concussion, bumps and contusions, skin injury, 
and various others. Injuries to the knee accounted for the largest proportion of body part 
injured (41.3%), followed by injuries to the hand, finger and thumb (9.7%), and inju-
ries to the head or face (9.4%) (OSTRC, 2019). In their study Tarka et al. (2019) also 
cite the knee as the most commonly injured part of adult competitive skiers, followed 
by back and tibia injury, then head and upper limb injury. In younger skiers, the knee 
is also the most common place of injury, followed by the upper limb, spine and lower 
limb injuries. Anterior cruciate ligament (ACL) injury is cited as the most common 
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specific diagnosis in both adult and younger skiers. This is followed by a concussion 
and tibia fracture. 
Most injuries occur in downhill, followed by supergiant slalom (SG), then giant sla-
lom (GS), and the fewest injuries occur in slalom. In the World Cup, knee injuries, the 
most common, account for 37.7% of injuries. There are at least 5 times as many injuries 
in the World Cup as there are in the European Cup. There are almost 7 times more knee 
joint injuries in the World Cup compared to the European Cup (OSTRC, 2019). 
METHODS
This article is based on a literature review. Data were extracted from Slovenian and 
other sources (PubMed, Web of Science, and COBISS databases) throughout the world 
during the period from March 14, 2020 to July 30, 2020. The inclusion criteria for the 
peer-reviewed literature included ski injury and/or prevention, Slovenian or English 
language, and research that is less than 10 years old. The following keywords were 
used: alpine skiing, ski injuries, prevention of ski injuries, prevention program, risk 
factors in alpine skiing. The exclusion criteria were prevention measures that applied 
to other sports and did not include recommendations aimed at preventing injuries in 
alpine skiers. We also excluded studies where the full text was not available, studies 
with fewer than 15 subjects or where subjects withdrew from the study for various rea-
sons, and studies with no conclusion. We reviewed the research summaries, narrowed 
the selection using inclusion and exclusion criteria, and critically analyzed the selected 
literature.
RESULTS
The search for the keywords listed above returned 102 hits, and an additional search 
yielded one additional hit. By screening the titles we first eliminated duplicates and 
then excluded studies older than 10 years (only keeping those from the 2011‒2021 
period). Forty-three studies remained, from which we additionally excluded studies not 
related to sports injuries and/or alpine skiing by reviewing abstracts thus ultimately ar-
riving at 16 studies for full-text review. After the content review, we excluded 6 studies 
that did not relate to injury prevention. 10 relevant studies were thoroughly analyzed 
with conclusions described in the discussion. The systematic review process is pre-
sented in Figure 1. 
The characteristics of the included studies are shown in Figure 1.
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Figure 1.: The characteristics of the included studies (PRISMA flow diagram).
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DISCUSSION
The incidence of sports injuries, especially in team sports, can generally be reduced 
through fitness training and prevention programs. On this basis, we hypothesized that 
there are evidence-based prevention interventions based on pre-injury fitness level in 
alpine ski racers and derived prevention programs that could be incorporated into the 
training process of competitive skiers.
Spörri et al. (2017) in their literature review presented injury prevention for elite al-
pine skiers through a four-stage model, according to the epidemiology and aetiology of 
the injury. Based on these, they formulated an idea for preventive measures, followed 
by a test of the effectiveness of the preventive measure or program. They found that the 
risk factors directly associated with injury were insufficient lower trunk stabilization, 
gender, skiing difficulty, genetic predisposition and the combination of longer, narrow-
er skis with a smaller radius. Otherwise, the review did not provide any specific recom-
mendations related to physical fitness, exercise program, training or kinesiotherapy as 
parts of an injury prevention program. Of all the studies included, this was the only one 
that linked skiing injury to the strength of insufficient trunk stabilization and not only to 
equipment, skills and behavior on the slopes. In contrast, Audet et al. (2019) described 
risk factors for injury in skiers in terrain parks, where injuries to skiers and snowboard-
ers occur mainly due to factors such as the level of difficulty of the skiing, listening to 
music during the sport, previous injury, temperatures between ‒10°C and 0°C, night 
skiing and snowboarding, and performing more demanding maneuvers. Both studies 
found that risk factors differed according to the type of skiing but were consistent with 
the level of difficulty of the skiing, i.e., a higher level of difficulty was associated with 
a higher risk of injury in terrain park skiing or a competition slope. Hébert-Losier and 
Holmberg (2013) traced more than 80 methods for preventing musculoskeletal injuries 
and divided them into five groups - equipment, education and knowledge, caution and 
behavior, experience, and other factors. They found that most of the recommendations 
related to ski equipment or other factors, while none related to physical fitness, exercise, 
or training. They also highlighted the problem of this under-researched area. Audet et 
al. (2019) found that skiing and snowboarding carry a high risk of head, neck and back 
injury. Cusimano and Kwok (2010) found a 15% to 60% reduction in head injuries and 
a drastic reduction in concussions owing to helmet use. However, they did not associ-
ate helmet use with a reduction in the neck or cervical spine injuries. Also, Bailly et al. 
(2017) later found that the majority of injured skiers did not use a helmet. In more than 
half of the cases, the mechanism of injury was a fall. This was followed by, in order of 
frequency, collision with another skier, a jump, and collision with an obstacle, which 
also caused serious concussions. Sulheim, Ekeland, Holme, & Bahr (2017) found that 
despite increased helmet use among skiers and boarders, the incidence of head injuries 
decreased by only 2.2 per cent. They suggest as a possible reason for this the dramatic 
change in alpine skiing over the last decade due to new, faster and thus more danger-
ous ski designs, and unsafe slope layout in ski parks. According to the findings of 
Cusimano, Luong, Faress, Leroux, & Russell (2013), it could be suggested that the use 
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of a video with instructions and recommendations for safe skiing on the slopes could 
contribute to safety. Contrary to Sulheim et al. (2017), Haaland, Steenstrup, Bere, Bahr, 
and Nordsletten (2016), who studied the effects of newly introduced rules in skiing and 
ski equipment on the severity and type of injuries, found that the number of injuries per 
100 skiers in a season decreased from 36 to 27 in the period after the new rules were 
introduced. Upper limb injuries decreased for women, while upper and lower limb 
injuries decreased for men. The most important contributor to the reduction in injuries 
was the introduction of the rule to combine longer and narrower skis with a smaller ra-
dius. Ruedl et al. (2011) found that injury onset was independent of average skiing time 
before the injury, and that injured men were taller, heavier, and skied at higher levels 
than uninjured men. The main conclusion of this study was that there are no significant 
gender differences in the mechanisms of anterior cruciate ligament (ACL) injury.
After a systematic review, we conclude that the best-researched areas for injury pre-
vention are equipment, education (awareness rising) and knowledge, as well as caution 
and behavior on the ski slope. The results of our systematic review indicate a lack of 
evidence and, in particular, a lack of research into physical fitness as injury prevention 
for alpine skiers, as well as a lack of research on prevention programs. The topic of 
physical fitness as injury prevention for competitive alpine skiers has been poorly re-
searched and even somewhat forgotten (overlooked), as we have not seen any research 
addressing this type of prevention in alpine skiing in the last two years. 
Based on a systematic review, we found that there are evidence-based injury pre-
vention measures for alpine ski racers that relate to equipment, skills, and experience 
in critical or unpredictable situations on the ski slope. In this respect, reference can also 
be made to Hébert-Losier and Holmberg (2013), who found that preventive measures 
related to equipment dominate instead of prevention in the form of physical training. 
More than half of the included studies concerned the choice and use of ski helmets. The 
importance of the role of equipment in injury prevention in alpine skiers is particularly 
clear when viewed from a sports biomechanics perspective. With the development of 
alpine skiing, athletes are exposed to greater forces and reaching higher speeds, which 
require increasing improvement and modernization, even in adapted equipment. With 
the advancement of technology and materials, there is more sophisticated, aggressive 
and higher quality ski equipment on the market. The advertising of extremely high-
quality equipment can be deceptive, leading the recreational skier to exceed his/her 
technical abilities and consequently putting him/her at a greater risk of injury. In addi-
tion to the use of protective equipment, dealing with critical situations on the slopes, at-
tending ski courses and training, developing skiing skills and experience in order to be 
able to react more appropriately to unpredictable events play a major role in prevention. 
Given the underresearched area, there is still the possibility that well-designed re-
search focused on the question presented could also lead to important conclusions in 
the intended direction. In this respect, we hope to build on the research of Spörri et al. 
(2017), which highlights, among other things, the insufficient strength of trunk stabili-
zation and genetic predisposition as risk factors for injury. However, we could also re-
fer in part to the research of Langran and Selvaraj (2002) and McKenna and Hammond 
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(2007) on an individual‘s level of fitness, which found that skiing (and snowboarding) 
ability, skill level, and experience are important for injury prevention. Furthermore, 
Hébert-Losier and Holmberg (2013) focused their study on the mechanism of injury 
to the ACL. In most cases, it is a backward or forward fall combined with the rotation 
of the tibia on the femur. As early as 1995, studies by Ettlinger, Johnson, and Shealy 
had developed a method of interactive training which included a video, an instructor, 
and group and individual training dedicated to backward falls in combination with the 
rotational mechanism, and the link between the mechanism and the knee injury. The ef-
fectiveness of this method was successfully demonstrated, with a 62% reduction in the 
number of serious knee injuries. Three years later, Jørgensen, Fredensborg, Haraszuk, 
and Crone (1998) showed that the number of injuries was reduced by 30% in cross-
country skiers who watched a ski instruction video. A study by Cusimano et al. (2013), 
however, did not show that watching a safety instruction video reduced the number of 
injuries. Still, it did show that skiers were more aware of safety on the slopes, high-
lighting another very important preventive measure. The research by Ettlinger et al. 
(1995), Langran and Selvaraj (2002), McKenna and Hammond (2007) show that the 
central role in prevention is not only occupied by equipment, but also by strategies 
related to other domains, which may include, in part, specific exercises and physical 
training programs. In 1987, Morrissey, Seto, Brewster, and Kerlan proposed a series of 
specific movements, stretches and cardiovascular training to reduce the risk of many 
musculoskeletal injuries in alpine skiers. Their proposals are based on the physiologi-
cal and biomechanical forces experienced by alpine skiers during skiing. For example, 
knee flexion and extension against resistance, internal rotation of the tibia, stretching of 
the posterior thigh and calf muscles have been suggested as exercises to prevent knee 
joint injuries. These exercises are still useful in practice today, even though the nature 
of alpine skiing has changed considerably since 1987, especially in terms of speed, 
forces, slopes, conditions, and equipment. For this reason, modern recommendations 
on training are adapted to the new developments in field, according to Koehle, Lloyd-
Smith, and Taunton (2002). This can be seen when comparing the shape and length of 
skis. In the 1980s, skis with a side bow were not used. At that time, the most common 
mechanism of injury to the ACL was a backward fall with knee rotation (Natri, Beyn-
non, Ettlinger, Johnson, & Shealy, 1999; Beynnon, Ettlinger, & Johnson, 2007). How-
ever, as the use of carving skis became more widespread, and forward fall with rotation 
became the most common mechanism for ACL injury (Ruedl et al., 2009; Ruedl et al., 
2011). With advances in skiing, equipment, and technology, understanding of human 
physiology and its response to sport and exercise has also evolved. In parallel, exer-
cise methodology and concepts have evolved. Over the last two decades, deep trunk 
stabilization exercises have become a predominant component of training programs 
for a wide variety of sports. According to McGill (2010), the effective activation of the 
transversus abdominis, the paraspinal muscles, and the pelvic floor muscles is consid-
ered to be the key component for effective sports performance and injury prevention. 
In addition, neuromuscular activation training has also been identified as effective in 
preventing knee joint injuries in non-contact sports (Hewett, Lindenfeld, Riccobene, & 
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Noyes, 1999; Sugimoto et al., 2012a). The inclusion of a physiotherapeutic program of 
exercises for the neuromuscular junction is recommended for recreational alpine skiers, 
particularly in this direction, as different forces and variations have different effects on 
the recruitment patterns of the quadriceps femoris muscle (Kröll, Wakeling, Seifert, & 
Mueller, 2010; Kröll, Müller, Seifert, & Wakeling, 2011).
Musculoskeletal training and deep trunk stabilization training are included in most 
preventive kinesiotherapy programs for different types of injuries (Wilk, Macrina, Cain, 
Dugas, & Andrews, 2012). In addition to strength, flexibility is also important to reduce 
the risk of injury. A prevention program should also include stretching. Stretching has 
the effect of lengthening muscles and reducing muscle tension, resulting in correct-
ed pelvic and spinal positioning, which reduces lumbar back pain (Coburn & Malek, 
2012). However, mobility has not always been one of the most important components 
of lumbar prevention programs. In 1984, Biering-Sørensen found that lumbar mobil-
ity can also worsen current lumbar conditions or pain. Hewett, Ford, Hoogenboom, & 
Myer (2010) found that prevention programs that include strength training have the 
greatest effect on reducing the number of ACL injuries. Sugimoto, Myer, McKeon, & 
Hewett (2012b) demonstrate a lower risk of developing an ACL injury if the athlete 
adheres to a prevention program more than 66% of the time. In theory, the simultaneous 
development of the biomechanics of sport and the understanding of human physiology 
should be used in favor of designing specific exercises aimed at injury prevention. 
This would require updating programs developed more than 30 years ago by scientists 
such as Morrissey et al. (1987) and defining new recommendations for recreational and 
competitive alpine skiers. For example, in 2010, Kiani, Hellquist, Ahlqvist, Gedeborg, 
& Byberg investigated the effectiveness of an injury prevention program for female 
football players aged between thirteen and nineteen years, that included motor skills, 
control and activation training. The result showed a 77% reduction in the incidence 
of knee injuries in the group that underwent the injury prevention training program 
compared to a control group that did not undergo the same training program. Even if 
the percentage reduction in incidence in alpine skiers using a similar program would be 
much lower, it would have the potential to significantly reduce the health system costs 
and morbidity associated with participation in winter sports. Boden and Prior (2005), 
however, attribute a different role on the slopes to fatigue, which can lead to serious 
injuries and even fatalities; and the effects of endurance training on injury prevention in 
alpine skiers should also be investigated. For example, in recreational skiers, a signifi-
cant decrease in glycogen stores and an increase in blood lactate could lead to negative 
effects such as fatigue, inflammatory processes, and reduced neuromuscular function 
leading to injury (Boden & Prior, 2005). Endurance training can be used to better utilize 
glycogen stores, reduce lactate production and increase circulating anti-inflammatory 
cytokines at a given intensity (Walsh et al., 2011). In addition to neuromuscular train-
ing, trunk stabilization training and endurance training, plyometric training, which fo-
cuses on correct joint performance and mechanics, is also mentioned in the literature 
(Pfeiffer, Shea, Roberts, Grandstrand, & Bond, 2006). A preventive exercise program 
that includes several different correctly dosed and graded training components is more 
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effective than a program that includes only one training component, such as strength or 
stabilization training alone (Grimm, Jacobs Jr, Kim, Denney, & Shea, 2014; Sugimoto, 
Myer, Foss, & Hewett, 2014).
Our literature review revealed that the area of prevention in terms of fitness and as 
a risk factor for injury in alpine skiing is poorly/under researched. Many studies have 
been written on the mechanisms of injury, which, although providing a good starting 
point for the design of prevention programs, did not follow through in this vein, nor 
could we find any that did. Among recommendations for injury prevention in alpine 
skiing prevails the use of appropriate ski equipment. Although sports medicine experts 
encourage prevention programs that include sport-specific exercises, none of the stud-
ies reviewed put forward specific recommendations that could be highlighted. 
The incidence of injuries in competitive alpine skiing estimated by Tarka et al. 
(2019) is extremely high. In competitive alpine skiing in addition to a head coach, as-
sistant coaches and a fitness coach, a well-structured team of medical professionals is 
essential to provide athletes with injury prevention and treatment before, during and 
after the season. This team consists of a physiotherapist, an orthopaedic specialist or 
traumatologist, a psychologist, a sports nutritionist, a kinesiologist, and others, among 
whom close professional collaboration is highly desirable. The role of the physiothera-
pist, which is essential at this level, is to provide high-quality physiotherapy treatments 
and knowledge-based rehabilitation at the onset of injury and to provide preventive ki-
nesiotherapy measures. In sports practice, prevention is most often carried out through 
individually tailored pre-injury prevention programs, based on training to improve fit-
ness levels, which athletes can incorporate into their training process.
CONCLUSIONS
Conclusions can be drawn regarding preventive measures and recommendations, 
including the use of appropriate ski equipment - especially suitable helmets, skill and 
experience in critical or unpredictable situations on the ski slope, and the use of evi-
dence-based preventive training programs from other non-contact sports with similar 
injury mechanisms. At the same time, we can highlight an area that we have identified 
as problematic, but for which there exist no evidence-based solutions yet. We would 
like to encourage researchers to conduct research into risk factors and injury prevention 
measures in alpine skiing, focusing on the two factors already mentioned (trunk stabi-
lization and genetic predisposition) and definitively confirm or reject them. Otherwise, 
they should be guided by the desire to determine findings that would serve to design 
prevention programs for the most common injuries to alpine ski racers. As the area of 
causes and mechanisms of injury is more researched than the area of prevention, the 
latter should be a prerequisite for more extensive research. Further research should 
investigate the role and effects of targeted prescribed exercises to improve fitness that 
would reduce the incidence and complexity of musculoskeletal injuries. Research to 
demonstrate the effectiveness of prevention programs at the highest level of skiing is 
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complex, requiring a large number of subjects, and accurate recording and analysis of 
data, as well as accurate identification and consideration of other factors that may in-
fluence the occurrence of injuries, regardless of an athlete‘s fitness level. The findings 
are relevant to alpine skiers, physiotherapists, other health professionals, coaches and 
anyone else involved in the competition or preparation of alpine skiers. 
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