Sunnybrook & Women's College Health Sciences Centre and University of Toronto, Toronto
York University, Toronto
McGill Sport Medicine Clinic and Department of Neurosurgery, McGill University, Montreal
Division of Neurosurgery, University of Toronto, Toronto, Canada
Department of Physical Education, Exercise, and Sport Science, University of North Carolina, Chapel Hill, North Carolina, U.S.A.
Address correspondence and reprint requests to James D. Carson, MD, Sunnybrook & Women's College Health Sciences Centre, 76 Grenville St., Toronto, ON, Canada, M5S 1B2. E-mail: email@example.com
Over the past four decades, the game of ice hockey has developed one of the more intriguing paradoxes in sports. In the early 1960s, helmets became more popular for the prevention of sporadic head injuries. In 1965, helmets were ruled mandatory in minor hockey, and the National Hockey League (NHL) followed suit in 1979. However, attempts to protect the heads and faces of players may have led to the head actually becoming a target.
Ice hockey is a vigorous and exciting collision sport and, as such, injuries will occur. It appears that serious head injuries are increasing in ice hockey. National Collegiate Athletic Association game concussion injury rates have increased almost steadily from 0.7 per game during 1986 to 2.6 per game during 2000. 1 In a study of 4,550 Canadian Hockey League major junior players, from 1991 through 1996, Clayton found that injuries to the head and face increased from 19% to 28% (of total injuries) during the first 4 years. 2 Four percent of the annual reported injuries were concussions. 3 This increased to 17% for the 1999–2000 season. 3 Of these concussions, 51% were caused by legal body checking, mostly to the head. 3 However, despite this apparent trend, there appears to be indifference among sport organizations and the public. We believe that there has been insufficient action taken by hockey organizations and the public to rectify what appears to be an alarming trend. Considering the finances involved in maintaining an ice hockey team, we wonder why sports organizations do not appear to take the necessary measures to protect their assets.
The rules of ice hockey strategically permit a player to impede an opponent who has possession of the puck. Such “body checking” or “stick checking” often results in the opposing team regaining control of the puck. As many as four times fewer injuries are seen in young teenage leagues that prohibit body checking in comparison with leagues that allow body checking. 4 Yet in full contact leagues, the rules of the game do prohibit certain types of checking. For example, striking an opponent with one's elbow or with either end of the stick are illegal and result in a penalty. However, a shoulder-to-head check is considered a “clean” check—within the rules in most leagues.
In ice hockey, head checking can be referred to as an incident where a player is struck above the shoulders with the body, shoulder, elbow, knee, or stick of an opposing player. Many sustained injuries are the result of illegal checks, but devastating injuries can also occur as a result of legal checks to the head. In a study of 28 teams over one season, Bednarz found that 56% of concussions were caused by collisions between players. 5 Often, a player struck in the head by an opponent's body is in a vulnerable position with the head lowered and body bent at the waist. In this position, the player is most likely neither braced for nor expecting the pending impact. The forces are large and are concentrated toward the head, resulting in serious consequences including permanent brain or spinal cord injuries. Between the years 1966–1996, 243 spinal injuries occurred in Canada while playing hockey. Sixty-three of these injuries resulted in major spinal cord injury and the need for a permanent wheelchair. 6 Six of these hockey players sustained fatal injuries. 6
The head is vulnerable in ice hockey due to the associated high speeds, which amplify the impact forces as a player is thrust into the boards, an opposing player, or onto the ice. It has been determined that, in game situations, modern NHL players reach speeds of approximately 30 miles per hour. 7 It can be difficult to control the body at that speed, especially on ice. These immense speeds are a major factor contributing to concussions sustained, although direct trauma is not required and injury may not be preventable with protective equipment. Research is needed to confirm our suspicion that the speed factor places the head in ice hockey players in greater jeopardy than other team sports such as basketball, soccer, and even American football.
Head injuries in sports have become a source of controversy, both in terms of diagnosis and management. While there is no question that epidural, subdural, or intracerebral hematomas can be life threatening, some neurosurgeons state that there is no such thing as a minor head injury. 8 Concussion is defined as a traumatically induced alteration in mental status, not necessarily with loss of consciousness. 9 Although findings have not been universally confirmed or accepted, 8 most studies suggest that multiple concussions can lead to permanent functional impairment as a result of cumulative brain trauma. In most head injuries occurring during athletic activity, there is a significant acceleration, and diffuse damage may occur even if the coverings of the brain are not broached. Although there may be apparent complete recovery of the athlete, residual vulnerability and possible residual injury persists. Return-to-play guidelines are not yet based on firm evidence, and well-controlled scientific studies are lacking. Traditionally, grading systems have not emphasized the importance of ongoing postconcussive symptoms, and none of them have been validated. 10 Athletic head injuries differ from those of other etiologies in their preventable nature. 11 Thus, from a moral and a legal liability position, it behooves sports organizations to develop rules, procedures, and policies that protect players from initial and recurrent brain injury.
We should not be afraid of rule changes. Rule changes can lead to improved safety without jeopardizing the nature of the game. One of the best examples is in American Football. In 1968, there were 36 fatalities and approximately 30 paralyzing injuries. Analysis of the data indicated that changes were necessary in the teaching of the fundamentals of tackling and blocking. 12 A rule change was implemented in 1976, along with a helmet standard in 1978. The number of deaths and paralyzing injuries decreased dramatically, and in 1990 there were zero deaths in American football. This was the first time since data collection started in 1931 that there were no deaths in football. 13–15 In the 1980s, swimming was associated with a number of catastrophic cervical spine injuries related to the racing dive. Data showed that the new racing dive involved the swimmer getting more depth, but that in a majority of pools, races started in the shallow end. Rule changes in regard to water depth for racing dives almost eliminated these accidents. There was also a concern in Little League Baseball that the head-first slide was involved in a number of paralyzing injuries. Elimination of the head-first slide eliminated the problem. 16,17
In ice hockey, several changes have been geared toward the prevention of sport-related injuries. Changes include those related to rules, equipment, facilities, and those that are the responsibility of the coach mandating players' attitude, awareness, education, and respect in the game. A significant change was the implementation of a no-checking-from-behind rule, which may have resulted in a reduction in cervical spine injuries. 6 Noteworthy equipment changes include making helmets with visors mandatory up to the junior level. Helmets are mandatory in the NHL. Facial visors decreased the amount of players blinded in play from 43 in the year 1974–1975 18 to only three players blinded during 1999–2000. The NHL has instituted a safety committee in response to an apparent increase in the number of concussions—but will this be enough?
The roles of the officials need to be scrutinized in regard to their responsibility in promoting and ensuring safe leagues. Penalties are commonly not given in plays where an injury occurred. The under-punished violence in ice hockey appears to be directly related to the public demand. The media often lures spectators to watch hockey by the glorification of fighting. A certain level of aggression is part of the game of hockey, although it should not be tolerated in excess. A no-head-checking rule would protect players while still maintaining the vigorous environment.
To decrease the number of injuries, the officials must maintain an environment with consistent rule enforcement. If players were aware that they would be consistently reprimanded for illegal actions, then they would be less likely to commit such acts. To stop illegal behavior, the player must fear the consequences. National Hockey League Rule 40 states, “A match penalty shall be imposed on any player who deliberately attempts to injure an opponent and the circumstances shall be reported to the Commissioner for further action.” With our current knowledge of the severity of head injuries, how can these “clean” head checks not be considered intent to injure?
The common occurrence of violent acts occurring in hockey is in part attributed to the ineffectiveness of the punishments, the public demand for violence, and an attitude of invincibility on the part of the players. Over the years, equipment changes have been employed in attempts to make hockey safer. The changing equipment is thought to have also contributed to the players feeling protected from the hardships of the game. These feelings of invincibility may make players take unnecessary risks and use unnecessary aggressive tactics.
We believe there has truly been an increase in head-checking in ice hockey. However, we acknowledge that it is important to acquire better data to provide stronger evidence. Have the rules and their enforcement kept pace? We believe not. We feel that the medical profession needs to raise awareness and to advocate for a “no head-checking” rule, for stricter rule enforcement and more vigorous penalization. The proposed “no head-checking rule” should be implemented in all levels of hockey and in all locations where ice hockey is played. Everyone must send the message that there is no role for the head as a target in ice hockey. We simply must have a “no head-checking rule” in all ice hockey.
1. National Collegiate Athletic Association. National Collegiate Athletic Association Injury Surveillance System.
Indianapolis: NCAA, 2001.
2. Clayton P. A five-years review—injury report data in the Canadian Hockey League. In: Biasca N, Montag W, Gerber C, eds. Safety in Ice Hockey. Zurich: International Ice Hockey Federation and Menarini AG, 2000: 26–30.
3. Clayton P. Canadian Hockey League injury data collection.
Calgary, AB: CHL, 2000.
4. Regnier G, Bioleau R, Marcotte G, et al. Effects of body-checking in the Pee-wee (12 and 13 years old) division in the province of Quebec. In: Castaldi CR, Hoerner ER, eds. Safety in Ice Hockey. Philadelphia: American Society for Testing and Materials, 1989: 84–103.
5. Bednarz RL. Concussions in youth ice hockey players. In: Ashare AB, ed. Safety in Ice Hockey. Third Volume. ASTM STP 1341. West Conshohocken, PA: American Society for Testing and Materials, 2000: 150–164.
6. Tator C, Carson J, Cushman R. Hockey injuries of the spine in Canada, 1966–1996. Can Med Assoc J 2000; 162: 787–788.
7. Lovell M, Burke C. Concussions in ice hockey: The National Hockey League Program. In: Cantu RC. Neurological Athletic Head and Spine Injuries. Philadelphia: W.B. Saunders Co., 2000.
8. Cantu RC. Return to play guidelines after a head injury. Clin Sports Med 1998; 17: 45–60.
9. Kelly JP, Nichols JS, Filley CM, et al. Concussion in sports—Guidelines for the prevention of catastrophic outcome. JAMA 1991; 266: 2867–2869.
10. Johnston K, Lassonde M, Ptito A. A contemporary neurosurgical approach to sport-related head injury: the McGill concussion protocol. J Am Coll Surg 2001; 192: 515–524.
11. Warren Jr, WL Bailes JE. On the field evaluation of athletic head injuries. Clin Sports Med 1998; 17: 45–60.
12. Torg JS, Truex Jr, R Quedenfeld TC, et al. eds. The National Football Head and Neck Injury Registry. Report and conclusions 1978. JAMA 1979; 241: 1477–1479.
13. Mueller FO, Cantu RC. The annual survey of catastrophic football injuries: 1977–1988. In: Holloszy JO, ed. Exercise and Sport Science Reviews. American College of Sports Medicine Series. Baltimore: Williams & Wilkins, 1991; 261–268.
14. Mueller F, Diehl J. Annual Survey of Football Injury Research 1931–1997.
Waco TX: American Football Coaches Association, 1997:1–8.
15. Mueller F. Fatalities from head and cervical spine injuries occurring in tackle football: 50 years experience. Clinics in Sports Medicine.
Philadelphia: W.B. Saunders Co., 1998:169–182.
16. Clarke KS. Epidemiology of athletic neck injury. Clinics in Sports Medicine. 1988; 17: 83–97.
17. Mueller F, Cantu R. National Center for Catastrophic Sports Injury Research—Fifteenth Annual Report 1982–1997.
Chapel Hill, NC: NCCSI, 1997:1–81.
18. Pashby TJ, Pashby RC, Chisholm LDJ, et al. Eye injuries in Canadian hockey. Can Med Assoc J 1975; 113: 663–666.