Ice hockey presents a variety of common and challenging injuries to the sports medicine practitioner. Few other sports combine the power, speeds upwards of 30 mph, balance, agility, and hand-eye coordination required to play hockey on ice. The combination of anaerobic burst needed for competitive play combined with aerobic endurance for recovery leads to special needs for conditioning. Combining these speeds with the solid objects of the puck, sticks, boards, and opponents makes hockey a unique sport. This article reviews injury patterns, recognition of common specific injuries, the female hockey player, and rinkside preparedness.
There are believed to be at least 500,000 hockey players in the United States. In comparison, Canada, which has a population one-tenth that of the United States, has a registered hockey player population of more than 530,000 players. Of these Canadian players, 477,872 are male and 54,563 female. This includes Canadian Hockey-sponsored adult recreation programs. Tyke or Initiation was the largest hockey group, with 113,377 people registered (7). In the past decade, the number of women playing hockey has increased dramatically. In Canada, between 1987 and 1997, the number of registered female players increased by 250% (3). In the United States, the numbers increased by 260% between 1990 and 1995 (3).
Various studies have focused on patterns of hockey injury. It commonly is agreed that injuries are more likely to occur in games than in practice (15,20,36). It also has been shown that injury rates were four to six times more likely in youth hockey tournament play compared with regular season games (28). As expected, one study found a history of previous injury in 89% of injured players, with 28% reinjuring the same body part (6).
There are differences when comparing injury patterns among age groups. An estimated 32,750 individuals with ice hockey-related injuries were treated in U.S. emergency departments in 2001-2002, including over 18,000 youths under 18 yr old. The number of injuries peak through adolescence (ages 12-17 yr; 47% of all injuries) (17,36). Injury rates in youth hockey show a spike the first year that body checking is introduced (36). There also is general agreement that the risk of injury in youth ice hockey was increased among the oldest player groups who are permitted to body check, suggesting that injury rates are higher among larger, faster players (12).
Body checking is when a player uses hips, shoulder, or torso to contact another player who has, or was the last to have, possession of the puck. This is legal in many men's hockey leagues and certain "checking" leagues for youth/amateurs. It is illegal in women's hockey. It also is illegal to check from behind or to use the stick in checking (cross-checking).
Injury patterns also show difference when considering the level of competition. Voaklander et al. reported that injury rates for recreational and old-timer leagues were lower than reported rates for major/elite hockey players. The proportion of players injured through body contact was less. There was more of a predilection for the lower extremity being injured (34). Likewise, there are increased injury rates in more elite divisions of youth hockey (12).
HEAD AND NECK INJURIES
Rates of injuries show a tendency to affect the head, neck, and face region, which account for 20%-30% of injuries. This includes cervical spine injury, concussion, contusion, laceration, facial fracture, and globe injury (22).
Because of the common nature of head and neck injuries in hockey, there is a wealth of literature and injury data. Concussions are the most common head injury in sports and occur in hockey from the direct blow of an opponent, boards, or ice, or from acceleration forces after being struck from behind. Accordingly, it has been made illegal to body check from behind at the competitive levels where body checking is otherwise allowed.
Management of concussion in sports is one of the most controversial topics in sports medicine. Historically, there have been different grading scales and evaluation tools with regards to concussion, which were based largely on expert opinion rather than research. In 2001, the International Ice Hockey Federation, International Olympic Committee, and Federation Internationale de Football Association Medical Assessment and Research Centre (FIFA, F-MARC), convened a panel of experts in sports-related concussion to review the literature on concussion. The stated purpose of this conference was to "provide recommendations…for the improvement of safety and health of athletes who suffer concussive injuries in ice hockey, football (soccer), and other sports." This group, the Concussion in Sports Group, has met to review and revise these recommendations on two other occasions. The most recent group met in 2008 and produced their most recent consensus statement on concussion, the Third International Conference on Concussion in Sport, held in Zurich, Switzerland. This group has defined concussion as "a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces" (23). There continues to be much publicity in the lay press about concussions in professional and amateur athletes. The primary controversies revolve around return-to-play issues, the role of computerized neuropsychometric testing, management of prolonged postconcussion symptoms, and the effects of repeated concussion. There is general agreement that no athlete should be allowed to return to play while symptomatic from a concussion.
The incidence of concussions reported in regular seasonal National Hockey League (NHL) competition ranged from a high of 1.81·1000−1 athlete exposures in 1998-1999 to a low of 1.04·1000−1 athlete exposures in 2005-2006 (35). There is other supporting evidence that concussion rates may be decreasing, but there was a trend towards more time lost from activity as a result of concussion (4). A smaller study of recreational adults in a United States nonchecking league found a rate of 1.1·1000−1 athlete exposures (6). Data suggest that concussions are underreported and poorly understood (37). A study performed in the greater Toronto area showed that a significant number of players, parents, coaches, and trainers only were able to describe one or no symptoms of concussion, demonstrating misconceptions about the subject (8).
In the United States, cumulative neck injuries presenting to emergency departments between 1990 and 1999 have been studied. It was found that 5038 injuries were due to hockey, 19,341 due to soccer, and 114,706 due to football. This includes all cervical injuries, including fractures, dislocations, contusions, sprains, and lacerations. Neck fractures or dislocations in hockey accounted for 105 injuries compared with 214 for soccer and 1588 for football, respectively. It is difficult to draw any firm conclusions when considering neck fractures or dislocations when averaging for number of player exposures, as there were some years in which ice hockey had no reported fractures or dislocations (9). When comparing neck injuries overall, the rates for soccer and hockey are comparable, with football being significantly higher (9).
In Canada, Tator et al. have measured incidence of spinal injuries in Canadian hockey for the 6-yr period 2000-2005 and examined trends from 1943-2005. This was updated in 2009. Data about spinal injuries with and without cord injury were collected through questionnaires from practitioners, ice hockey organizations, and media reports. They noted 40 cases for 2000-2005, which brings the total registry to 311. This represents a recent decline that may be related to improved education and/or specific rules against checking/pushing from behind (33).
Management of cervical spine injury should be handled as any emergency procedure, starting with the ABCs (Airway, Breathing, Circulation). Hockey is similar to football in that the helmet and shoulder pads should be left in place while the facemask is removed. Immobilization on a spine board is imperative for any suspected spinal fracture or dislocation. Any spinal bony tenderness or acute neurologic deficit must be treated with immobilization and transport for definitive care.
Facial injuries have been studied largely from a preventive standpoint with multiple studies performed to see whether protection has prevented injury. In American amateur hockey, the use of full facial protection reduced the rate of head and facial injuries significantly more than partial or no protection (32). A study of hockey players evaluated in Ontario emergency departments for head, neck, and facial injuries showed that injuries occurred more frequently when not using face protection (27). One systematic review found good evidence to support that full facial protection reduces the number and risk of overall head and facial injuries compared with partial or no facial protection (2).
In one Finnish study of 479 males, dental injuries accounted for 11.5% of all ice hockey-related injuries. Dental injuries are permanent and often cause complications later in life (19). Being hit by a stick was the most common cause of injury (29). It commonly is regarded that dental injuries are preventable with mouth or face guards.
Treatment of dental fractures includes trying to find the broken portion of tooth and protecting it in a transport medium such as commercially available solutions, saline, milk, or saliva. It is not advisable to have the loose portion held in the athlete's mouth. The residual tooth should be stabilized if possible, and exposure of the residual tooth to air and occlusion should be limited. For tooth avulsions, the tooth should be handled gingerly. The tooth should be handled carefully by the crown, rinsed gently, and reimplanted if possible. If unable to reimplant, use transport medium and transfer for emergent dental care.
While relatively uncommon, airway injuries and neck lacerations have been known to occur. When they do occur, they can be catastrophic. Currently available neck laceration protectors do not eliminate the risk of neck laceration from a skate blade (31). These injuries should be treated promptly by a provider following Advanced Trauma Life Support/Advanced Cardiac Life Support (ATLS/ACLS) algorithms. Recognition of significant bleeding should prompt the provider to apply direct pressure and emergently transfer to a hospital with on-call vascular surgery, if cervical vessels are thought to be involved (4a). Injuries to the airway obviously require a prompt and appropriate diagnostic and treatment plan and a high index of suspicion (21).
The stinger (burner) syndrome is an acute injury to the brachial plexus. This injury usually is the result of downward displacement of the shoulder, with simultaneous lateral flexion of the neck toward the contralateral shoulder. By definition, this event is a transient neurological event characterized by pain and paresthesia in a single upper extremity. The symptoms most often involve the C-5 and C-6 spinal roots (24). Although cervical strengthening is used for secondary prevention, there is little evidence to support this strategy.
UPPER EXTREMITY INJURIES
Of ice hockey injuries, 8%-20% involve the upper extremities, with the most common injuries being acromioclavicular (AC) joint injuries and injuries to the glenohumeral joint, including dislocation. These both commonly are caused by a direct blow from an opposing player or boards, or hitting the ice. Treatment of AC injuries depends on the severity. Glenohumeral dislocation should be reduced quickly after a thorough physical including neurovascular examination and plain radiographs (22). Immediate reduction may be attempted by experienced physicians, although repeated attempts are discouraged without imaging.
Other upper extremity injuries occurring in ice hockey include contusion, wrist sprain, scaphoid fracture, and ulnar collateral ligament sprain of the thumb. Fractures of the metacarpals may occur from fighting. One analysis of 760 upper extremity injuries showed the overall injury rate was 14.8·1000−1 player-years. Of the injuries, 32% were contusions, 28% sprains or strains, and 27% fractures (25).
CHEST AND ABDOMINAL INJURIES
Chest and abdominal injuries commonly are caused by direct contact with puck, stick, boards, or goal. This can result in contusions or rib fractures. There have been rare case reports of commotio cordis. Commotio cordis is defined as a cardiac concussion with significant electrical disturbance when force is applied to the thorax during a vulnerable phase of ventricular repolarization (26).
Groin and lower abdominal strain injury are major problems in ice hockey and will be considered together. Emery et al. found that during the 1998/1999 NHL training camp and season, there were 52 injuries of the lower abdomen/groin in the training season and 152 in the regular season. Total participants were 1557 players. When weighted for athlete exposure to sport there were 2.87 injuries·1000−1 athlete exposures in training season and 1.33·1000−1 athlete exposures in the regular season. Most of these groin/lower abdominal injuries were reported as groin muscle strains (82.7%), and no hernias were reported (14). These data further support a previous study of groin and abdominal pain spanning 1991/1992 through 1996/1997 (14).
Because of the common nature and frequent diagnosis of groin strains, studies have been conducted to identify risk factors. The most important risk factors for groin injuries in the NHL were fewer sport-specific training sessions before the season, years in the NHL, and previous groin injuries (13).
Lower abdominal/groin pain that is refractory to current treatment also has been studied. This condition commonly is referred to as "slapshot gut." This condition is similar to a "sports hernia" but is unique in hockey in that a right-handed shooter will get symptoms predominantly in the left groin. An 18-yr review of chronic groin injuries followed a group of 98 elite hockey players who underwent surgical exploration. A total of 97 out of 98 were able to return to play after mesh repair of the external oblique and division of the ilioinguinal nerve. The procedure was associated with low morbidity (5). A smaller study of 11 professional ice hockey players with similar symptoms found similar results. Of note, physical exam, ultrasound, bone scan, computed tomography (CT) scan, and magnetic resonance imaging (MRI) were consistently negative (18).
LOWER EXTREMITY INJURIES
The lower extremities account for another 20%-30% of hockey injuries (22). Common lower extremity injuries include hip pointers, quadriceps contusion, and skate (lace) bite. A hip pointer occurs when the hip abductor muscles are contused against the ilium or iliac wing. Quadriceps contusion is similarly caused by trauma, particularly the puck striking a defenseman. "Skate bite" occurs because of pressure from the skate tongue pressing on the anterior ankle. This is common early in the season with new skates that haven't been broken in or with older inflexible skates (20).
Knee injuries include medial collateral ligament (MCL) injury and meniscus tear. The MCL is the most commonly injured ligament in hockey (20). Lateral collateral ligament (LCL) sprains are rare because most contact injuries occur while the player is in a valgus rather than varus stance. Anterior cruciate ligament (ACL) injuries can occur. Ice hockey is one of the few team sports that can be played by an athlete with an ACL tear with minimal chance of injuring the knee further. Some patients may be able to rehabilitate the knee with the hopes to play in the same season. However, skaters with significant instability or concomitant meniscal tears should consider reconstruction (20).
Sprains of the distal tibiofibular syndesmosis (high ankle sprains) are much more difficult to heal compared with lower ankle sprains. This injury typically occurs when the player's skate is forcefully externally rotated, often when stuck in a rut in the ice. While common ankle sprains frequently can be taped and supported, syndesmotic sprains are more difficult to protect and may take 6 wk or more to heal (20).
WOMEN IN HOCKEY
Female participation in ice hockey has increased significantly over the last two decades. Previously it has been noted that the body of literature pertaining to female ice hockey injuries has been small (22). The most significant difference in female ice hockey is that body checking is not permitted at any level of play. A study of 314 female ice hockey players from Edmonton, Canada during the 1997-1998 season were studied by Dryden et al. They found that a total of 102 players reported 125 injuries for a rate of 7.5 injuries·1000−1 player exposures. Most common were injuries to the lower extremity (31.2%) and the most common diagnosis was sprain/strain (52%). The predominant injury mechanism was player contact, as a result of collision or body-check (40%) (11). This observed injury rate was lower than the reported rate of 12.2 injuries·1000−1 player exposures for male recreational and collegiate ice hockey players previously noted by Voaklander (34).
A newer study suggests that the rate of women's injuries is similar to men's. Also, it was found that the most common injury at the higher levels of play was concussion (30). Commentary on this notes that the newer study may differ as it investigated more highly competitive women's teams (16). When reviewing the NCAA Injury Surveillance System from 2000 to 2004, Agel et al. also found concussions in female hockey players to be the most common injury in games and practice and that the rate of concussions was trending upwards (1).
A critical literature review has been conducted to determine whether gender differences with regards to concussion exist. This review of the past 10 yr suggests some evidence that female athletes may be at a greater risk. However, it is acknowledged that because of the nature of diagnosing a concussion, this could be influenced by a reporting bias (10).
Practical considerations in providing rinkside care include planning for a place to observe the contest and for access to the ice. There is no shame in being assisted onto the ice by an uninjured player and this is certainly less embarrassing than a fall at center ice. Of course, emergency medical services access must be a part of preseason planning. Emergency planning also should include access to a defibrillator or an automated external defibrillator (AED) as well as a spine board.
The physician providing sideline coverage also should have access to a treatment room where a player can be examined in a private, quiet place. It also is important to coordinate with athletic trainer/coaches as to how to manage procedures like suturing of lacerations and primary fracture splinting. Temporizing measures to achieve hemostasis can allow participation until more definitive care can be given. This might include the use of adhesive wound closure strips or topical skin adhesives for lacerations until after the game or between periods. It is best to have these supplies available at the playing facility, but the provider may need to use the closest emergency department.
Ice hockey is an exciting sport that is growing in popularity, especially among women. Injuries from body contact occur in both checking and nonchecking leagues. A basic knowledge of injury patterns and special challenges confronting the team physician can improve the care to these athletes. This knowledge also can help educate young physicians or physicians new to hockey so that they may be more comfortable providing the necessary care. While catastrophic injuries can occur, requiring the medical provider to be alert and prepared, the old adage "common things are common" helps keep perspective on covering a unique sport like hockey.
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