Current Sports Medicine Reports:
Field Hockey Injuries
Levy Elliott Sports Medicine Clinic, Burlington, Ontario, Canada, and Escarpment Sports Medicine Centre, Milton, Ontario, Canada
Address for correspondence: Karen Murtaugh, M.Sc., M.D., CCFP, Dip. Sport Med. 474 Willard Avenue, Toronto, ON, Canada M6S 3R6 (E-mail: email@example.com).
Field hockey is a popular sport that is played throughout the world. Most of the literature on the sport has focused on describing injury patterns. This research reveals that most injuries are minor and that the most common injury is an ankle sprain. Studies also suggest that men have a higher rate of injury and that they experience severe injuries more often than women. These severe injuries include trauma to the head, face, and upper limb and usually are the result of contact with the stick or ball. Consequently, many authors suggest that all players wear face and hand protection. Current International Field Hockey Federation rules recommend minimal protective equipment (e.g., mouthguard, shin, and ankle guards), and surveys indicate that many players do not wear mouthguards regularly. Looking into the future, research should focus on developing and evaluating effective strategies for injury prevention.
Field hockey is played by men and women, at recreational and highly competitive levels, in 122 countries (13). In North America, there are over 5000 women competing in collegiate field hockey (8) and roughly 35,000 players registered with their national associations (12,47). Despite the sport's popularity, there are few publications that focus on field hockey injuries, and to the author's knowledge, there are no studies that critically evaluate any strategies for the prevention of injury or the effectiveness of protective equipment. However, there has been a renewed interest in the serious injuries that occur in this sport, and researchers are using more widely accepted injury definitions and standardized methods for reporting injury rates. The goal of this article is to put new information into context with what is known already about field hockey injuries. It also highlights important trends in injury patterns and suggests how the sport should develop evidence-based methods for injury prevention.
RATES AND TYPES OF INJURIES
Up to 75% of field hockey players have sustained at least one acute injury during a game or practice (35). When field hockey is compared with other team sports, such as basketball and soccer, the overall rate of injury is similar (26,39,41). Tables 1 and 2 summarize the results of studies that have reported on injury patterns in field hockey. It is difficult to compare these studies because injury definitions are varied and players from different age groups or competition levels rarely are included in the same sample. The lower limb is the most often injured site, and, like other sports, most of these injuries are ankle sprains (34,36). Beynnon et al. studied a cohort of female high school and college field hockey players (N = 138) and reported a first-time ankle injury rate of 0.9 (95% confidence interval (CI) = 0.4-1.9) injuries·1000 person-days−1. This rate was lower than basketball players but not significantly different from soccer or lacrosse (2). Powell and Barber-Foss reported that only 1.2% of field hockey injuries required surgery when they analyzed the 1995-1997 National Athletic Trainers' Association High School Injury Surveillance database (41). However, a more recent analysis of the same database showed that field hockey players had the highest risk of subsequent injury (relative risk = 2.8, 95% CI = 2.3-3.4) (42). In particular, there was a significantly higher proportion of hamstring strains and anterior cruciate ligament reinjuries than new injuries (P = 0.04). This report is consistent with earlier findings that 10.5% of the acute injuries in school children are reinjuries (41). This proportion rises to 27% in recreational players and 44% in elite athletes (19,20).
The next most common site of injury is the upper limb (Table 2). It has been suspected for some time that field hockey has a high rate of upper limb injury compared with other sports (35). A recent study confirms this suspicion. Bowers et al. analyzed the NCAA Injury Surveillance System (ISS) database for injuries to the hand and phalanx in stick-handling athletes from 1986 to 2002 (4). The sports studied were women's field hockey, men's ice hockey, men's lacrosse, and women's lacrosse. Field hockey was the only sport that did not require the use of gloves, and the athletes had a significantly higher risk of hand injury (odds ratio [OR] = 2.12, 95% CI = 1.86-2.41).
The types of injuries that occur in this sport are influenced by the playing surface, equipment, and other athletes. High-intensity training on artificial turf may be a major contributing factor in chronic hockey injuries such as exercise-related leg pain (29,43). Falling on this surface also is responsible for the high rate of abrasions (up to 9% of acute injuries) (18). Next, it is known that a large percentage of hand and face injuries are caused by impact from the ball or stick. In fact, Dick et al. found that approximately 60% of total game injuries were from stick and ball contact mechanisms (8). There are rules governing control of ball and stick that help to prevent dangerous play (24). However, these rules can be violated intentionally or by accident. In the 1988-89 NCAA field hockey season, 16.3% of total injuries were due to illegal action (38). At the 2004 Olympics, the team physician felt that 8 of 42 injuries were caused by foul play (26). Finally, although deliberate physical contact is not permitted in field hockey, incidental contact seems be contributing to a larger proportion of injuries in recent studies. Almost 20 yr ago, contact was responsible for only 2.2% of injuries to recreational players, but in a 2007 report it caused 13% of U.S. collegiate injuries (8,19). It is unclear whether this difference is caused by reporting methods, changes in the game, or differences in the level of play.
The most serious injuries in field hockey are from blows to the head or face from the hockey stick or ball. In 1977, Graham and Bruce (20) found that field hockey had the highest rate of head and face injuries of the nine intercollegiate sports they studied. This trend has continued as a recent survey of female players from the English Hockey Association found that 68% of players had sustained at least one injury to the head or face region (21). In fact, in a study of pediatric sport injuries, the field hockey stick caused more male facial injuries than all other male and female sports combined (49).
Most of these injuries (65%) are mild and consist of lacerations and contusions or hematomas; catastrophic injuries are possible (22,46). However, facial injuries often affect the teeth or eyes, and head injuries can cause ongoing disability. In elite players, more than half of the dental injuries require a visit to a physician and/or dentist (3,10,46,49). Field hockey also had the second highest incidence of dental injury for women at the 1989 Canada Games, accounting for 1.3% of total dental injuries (28). Next, the aggressive nature of the sport, almost universal absence of facial protection, and a stick that permits orbital penetration is a dangerous combination that contributes to the incidence of serious eye injuries (10). Field hockey had the fourth highest incidence of eye injuries among the 16 sports followed by the NCAA Injury Surveillance System from 2000 to 2004, and 11% of all head and facial injuries also affected the eye (6). Indeed, there are cases of players who lost vision in one eye after they were hit with an opponent's stick (10,37). Finally, despite the noncontact nature of the sport, concussions account for 1.7%-7.7% of total acute injuries (5,8,14,35). In Australia, head injuries were responsible for 5.1% of hockey emergency room presentations, with a 10.5% admission rate (46). Clearly, face and head injuries are common in field hockey, and researchers have documented several cases of significant trauma.
GENDER DIFFERENCES IN INJURY PATTERNS
Most studies of field hockey injury focus solely on women, and this situation limits the analysis of injury rates between genders. However, the available reports suggest that males have a higher rate of injury and that they sustain severe injuries more often than females (14,26). For example, at the 2004 Olympic Games, elite men had 3.2 times the risk of a game injury than elite women (26). Men also were more likely to sustain a time-loss injury in a match (OR = 6.0). Of injured women, 75% did not miss any days of competition, compared with only 52% of injured men (26). Further information comes from an analysis of the Victorian hospital emergency department (ED) database (1996-1997) (46). Men presented to the ED 1.7 times more than women for field hockey injuries (N = 292 field hockey-related ED presentations). Note that more men are registered as field hockey players in Australia than women (1.3 men:1 woman). Finally, Yard and Comstock found that pediatric boys had more lacerations, upper limb injuries, and facial injuries than girls (49).
INJURY AND PLAYING POSITION
Information on the types and severity of injuries sustained at different playing positions is sparse. Murtaugh reported that goalkeepers had the highest rate of injury (0.58 injuries·athlete-year−1) and 16.7 times more back and torso injuries than field players (35). The most common injury in goalkeepers was a concussion, and it occurred from contact with other players, the playing surface, or the goal itself. Midfielders had the highest injury rate of field players (0.46 injuries·athlete-year−1) and the highest rate of injuries to the head/face and upper limb of all field players. Finally, forwards and defenders had a similar rate of injury (0.37 and 0.36 injuries·athlete-year−1, respectively). However, defenders had a higher rate of lower limb injury (0.3 vs 0.2 injuries·athlete-year−1), while forwards had 2.1 times more injuries to the head and face. Another study reported weighted percentages of injuries per playing position. Midfielders had the highest percentage of injuries (27.6%), followed by defenders (23.6%), forwards (22.4%), and goalkeepers (19.5%) (8). The findings of other authors support these trends (15,33). But a more recent study of elite female athletes found that the forwards had the highest rate of injury (1.30 injuries·player−1·season−1) and that goalkeepers had the lowest rate (0.75 injuries·player−1·season−1) (36). This difference may be a result of different injury definitions. The latter study had the highest threshold for defining an injury by requiring pain and/or inability to play for at least 5 d. Unfortunately, none of the studies evaluated their results for statistical significance.
More research is needed to explain why these differences exist. It has been proposed that midfielders have the highest rate of injury among field players because they are often involved in tackling situations (35). Tackling is an attempt to gain possession of the ball, and it requires that players risk contact from the stick, ball, or each other (15,23). It also has been shown that up to two thirds of injuries occur inside the 25-yd line (8). Again this finding may be caused by tackling, set plays, or increased risk-taking as players attempt to score on goal. Further details would provide insight into the situations that lead to injury.
Based on the injury patterns in this sport, the first priority should be promoting the use of protective equipment. A recent metaanalysis indicated that the overall risk of an orofacial injury is 1.6-1.9 times higher if a mouthguard is not worn during a sport with a risk of facial injury (27). Consequently, the American Dental Association and the International Academy of Sports Dentistry recommend the use of mouthguards when playing field hockey (1). Parents agree when surveyed, and they cite field hockey, along with football, boxing, ice hockey, wrestling, and karate, as sports in which mouthguard use ought to be mandatory (7). Despite the benefits, players do not wear mouthguards consistently because of perceived ineffectiveness, discomfort, or interference with breathing (3,21). In fact, they often wait several years into their career before starting to wear one, and most are prepared to play without a mouthguard (21). The current International Field Hockey Federation (FIH) rules state that "field players are recommended to wear shin, ankle, and mouth protection" (24). This recommendation should become a formal rule, and it should be enforced. The National Collegiate Athletic Association in the United States already mandates that all field players are required to wear mouthguards at all times. Individual associations should bring this matter to the attention of their National Association and the FIH Rules Board. To improve compliance, umpires at all levels should check athletes before games for mouthguards and enforce penalties for not wearing the proper equipment.
Several authors have suggested that hockey players wear gloves along with eye and/or face protection (6,25,49). In 2007, the FIH rules were modified to allow all players to use a face or head protector during short corners (Fig.). It can be worn during regular field play if there are documented medical concerns (24). The NCAA extended the option of using face protection to all field players at all times. However, there is no known research on the appropriate design or effectiveness of the devices in use. Furthermore, it is not known how the sporadic use of these protectors will alter the nature of the game or perhaps even put surrounding players at risk of injury. Gloves have been used in indoor field hockey for some time, but if athletes are considering the use of head or face protection, it should be the priority of the sporting association to ensure that this equipment is safe.
Figure. An athlete w...Image Tools
The next step in preventing injury is to reduce recurrent injury. Other sports have developed structured warm-up routines that incorporate specific strength and neuromuscular training. These programs have reduced lower limb injuries in soccer and hand ball (31,40). The evidence is growing to support the effectiveness of using specific exercise programs to prevent the most common injuries in sport. Therefore, field hockey coaches and athletes should consider incorporating proprioceptive and strength exercises into their training regimen.
Recurrent lower limb and back injuries are common in hockey (17,34,42). It is accepted that balance training and ankle bracing reduces the rate of recurrent ankle sprains and that they may reduce first-time injuries (48). Recently, it also was shown that poor peak dorsiflexor torque at the ankle was associated with an increased incidence of ankle injuries in elite female field hockey players (36). The authors propose that increased dorsiflexor strength may assist the ankle in preventing the inversion responsible for most lateral ankle sprains. When the ankle is in an inverted and plantar flexed position, the everter and dorsiflexor muscles act eccentrically. Weak dorsiflexors allow excessive movement, placing additional stress on the lateral ligaments of the ankle joints (36). Next, prophylactic core strengthening helps to prevent back injury, and it has had success in reducing back complaints among field hockey players (11,30). The game of hockey requires players to be in a forward flexed and semirotated position for prolonged periods. Many players start their careers as children and are involved in high volumes of training. As a result, many develop asymmetries in posture (30). There is no evidence to show that more flexible field hockey players have a lower incidence of back pain (30). However, one study suggested that pain-free athletes were stronger in peak eccentric lumbar extension (11). The sport would benefit from more research into the effectiveness of specific training programs that are meant to reduce injury.
Finally, it is important to treat injuries in a way that minimizes their negative effects and prevents any related complications. Now that the injury patterns have been identified, sporting bodies can focus on promoting the care of the most common and most severe injuries. At a minimum, medical personnel in attendance at field hockey competitions should be comfortable with concussion management, splinting for hand injuries, tooth preservation, and the application of an eye patch. They also should be aware of local emergency and dental facilities (21). The only catastrophic injuries in field hockey have involved head trauma (10,37). However, a recent Australian study found that treatment of head injury was variable and subjective in nature. The most common management procedure was to remove the player from the sporting field, and unless an ambulance was required, it was considered the player's responsibility to attend a medical facility. The use of evidence-based guidelines for the initial management of head and brain injury and return-to-play decisions after mild traumatic brain injury in sport should be encouraged (32). Because of the high incidence of lacerations and abrasions (Table 1), leagues should consider requiring documentation of up-to-date tetanus prophylaxis before allowing their athletes to participate. Athletes themselves can be taught the basic techniques for wound cleaning and dressing, along with the signs and symptoms that might indicate the onset of infection. Incorporating these standard procedures could reduce the morbidity associated with the most common injuries in field hockey.
The rate of injury is highest in games, and more serious injuries seem to occur at the highest levels (Table 1). Thus it is reasonable to ensure that a physician is in attendance at major tournaments, and FIH already has this recommendation in its advice for team medical personnel. However, it is not realistic to have a physician at all games. When a certified athletic trainer is not available, the responsibility falls to the coaching staff. To increase coaches' comfort with the treatment of common and severe injuries, coaching certification programs could expand their instruction on the initial treatment of skin, head, eye, hand, and ankle injuries.
The most common field hockey injuries are lower limb sprains and contusions, while the most serious injuries involve direct trauma to the upper limb and head or face. Newer studies have described the risk of head/face and upper limb injury in more detail (4,21,22). However, there continues to be a lack of information on the differences in injury rates among genders and positions. Currently, the literature on injury prevention in field hockey consists primarily of expert opinion. The common advice suggests adhering to and enforcing the rules of the game, having sensible precautions regarding protective equipment, and having a commitment to physical preparation (15,33,45,46). Although this advice is reasonable, further research is needed into the mechanism of injury, situations that lead to injury, and the effectiveness of protective equipment. This information should be collected prospectively as new rules and new equipment are introduced into the game. It will help to guide the development of appropriate preventative strategies.
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