Since the 18th century, ice hockey has evolved into a fast-paced competitive sport involving 12 players skating at high speeds on a sheet of ice and shooting a vulcanized rubber puck at speeds in excess of one hundred miles per hour. Played on a rink surrounded by hard wooden boards with players body checking each other as a defensive technique, it is no surprise that hockey has one of the highest injury rates in competitive sports.
Various interventions aimed at making hockey a safer sport have been implemented with good success. The introduction of full facial shields has dramatically decreased the incidence of ocular, dental, and facial injuries (5). Before 1929, helmets, even for goaltenders, were not commonly used because they were thought to be unnecessary and to impair vision (6). It was not until 1979 that the National Hockey League (NHL) mandated helmets for all players (6). Wearing hockey helmets has been shown to decrease the rate of fatal and catastrophic head injuries with some studies showing a paradoxical increase in the rate of concussion likely the result of players feeling more invincible and increased awareness and reporting of concussions (12). Given that illegal play accounts for an estimated 26.3% to 66% of total injuries, increased rule enforcement is paramount in making hockey a safer sport (5). The primary mechanism of cervical spine injury is an axial load on a flexed neck which has prompted making checking and pushing from behind illegal (5). Finally, various strength and conditioning programs aimed at increasing the strength and endurance of joints and muscles is important in preventing a host of musculoskeletal injuries although more research is needed to identify which programs best increase a player’s resistance to injury during practice and games (5).
Physicians covering ice hockey games should be familiar with common injuries as well as their on- and off-ice evaluation and treatment. Frequency of hockey-related injuries varies widely in the literature given heterogeneity of exposure estimation, study design, and definition of injury. Injury rates by 1000 player-game-hours range from 40 to 52 with shoulder injuries reported as the most common upper-body injury (Table). This article offers a basic review of common injuries that will present to the sports medicine physician responsible for hockey teams.
Concussion in Ice Hockey
Concussions account for approximately 13% of all sports-related injuries (20). Rugby has the highest rate of concussion, with 4.18 per 1000 athlete exposures (AE). An AE is defined as one player participating in any game or practice, regardless of the amount of time spent playing and therefore at risk of sustaining an injury. Ice hockey is second with 1.20 per 1000 AE and American football is third highest with 0.53 per 1000 AE according to one meta-analysis published in the British Journal of Sports Medicine (28). A second article found a similar incidence for concussion in ice hockey with approximately 1.58 concussions per 1000 AE. Concussions occurred more frequently in games (2.46/1000 AE) compared to practices (1.17/1000 AE). Younger players were more likely to be concussed. Twelve to 14 yr olds (2.84/1000 AE) had significantly more concussions than 15 to 18 yr olds (1.18/1000 AE) (20). One explanation would be the introduction of body checking into the game. Players are more skilled in proper checking technique at an older age, and players who are prone to injury or less skilled tend to wash out of the game before high school hockey (20).
A concussion can occur from any direct blow to the head or torso, or an indirect blow to the brain resulting from a sudden deceleration such as a fall to the ice. The most common mechanism of injury involved player to player contact, and greater than half of these involved secondary contact with the boards according to one study (20). In this same study, 43% of concussion-causing impacts were a result of illegal contact. It was found that youth leagues that permit body checking have a higher concussion rate than those that do not permit checking (20). While the risk of concussions and other injuries are more than threefold higher in Pee Wee (ages, 11–12 yr) leagues that allow body checking, having 2 yr of body checking experience reduced the risk of injury resulting in 7 d of time loss from sport by 33% in Bantam league players (ages, 13–14 yr) who were allowed to body check at the Pee Wee level (14). The study found no difference in overall injury, concussion, and concussion resulting in more than 10 d of time loss between Bantam league players with and without body checking experience at the Pee Wee level (14). Evidence that the use of protective equipment, such as helmets, can protect against concussion is inconclusive, and mouth guards are ineffective at reducing the severity of concussion (12,28). Full face mask helmets and mouth guards have significantly reduced the incidence of eye, dental, and other facial injuries (5).
Signs and symptoms of a concussion can be broken down into four categories: physical, cognitive, emotional, and sleep. Headache is the most commonly reported physical symptom (17,18). Other physical symptoms include nausea, vomiting, balance problems, visual problems, fatigue, and sensitivity to light or noise (17,18). Cognitive symptoms include a “foggy” mental feeling, confusion, feeling slowed down, difficulty concentrating, memory problems including loss of recall of recent information, and a delayed response to questions (17,18). Loss of consciousness occurs in less than 10% of concussions (17,18). Emotional symptoms include irritability, sadness, increased baseline emotions and nervousness. Finally, sleep symptoms including drowsiness, sleeping more or less than usual, and difficulty falling asleep can be observed in concussions but are of little use in the on-ice evaluation of a player with a suspected concussion (17,18). Symptoms of a concussion may not appear until several hours after the initial incident. In players with preexisting anxiety, depression, migraines, and learning disorders a concussion may exacerbate those symptoms and make them more difficult to control (17).
The initial assessment of a player with loss of consciousness should include assessment of airway, breathing, and circulation with immediate stabilization of the cervical spine (17,18). Examination of the cervical spine should be performed on players with a suspected concussion regardless of whether loss of consciousness occurred (17,18). A thorough evaluation should include a history of the athlete’s symptoms, ascertainment of the mechanism of injury and a neurologic examination (17,18). Players with a suspected concussion should be removed from the game immediately and not be allowed to return to play if the concussion diagnosis is confirmed by further testing on the sideline or in the training room (17,18). In athletes without a loss of consciousness, cognitive testing should be completed using one of the available sideline assessment tools such as: the Maddocks questions, Standardized Assessment of Concussion (SAC), or the Sport Concussion Assessment Tool 3 (SCAT3) (17,18). If a concussion is identified the player should be removed from the remainder of the game or practice on that day. An athlete should never be allowed to return to a game or practice on the same day as a concussion is sustained (17,18). Emergent transfer to the hospital should take place in patients with deteriorating mental status, worsening symptoms, focal neurological deficit, such as abnormal pupil reaction, extraocular movements, abnormalities on a screening motor/sensory examination, or in cases where cervical spine injury is confirmed or cannot be excluded (18). The athlete should be seen in a follow-up by a physician who is familiar with treating concussions and should be withheld from all physical exertion until they are asymptomatic at rest (17,18). Once the athlete is reporting a baseline level of symptoms, the athlete can begin a stepwise return to play protocol under the supervision of the treating physician and athletic trainer, gradually increasing activity and participation as tolerated (17,18).
Cervical Spine Injuries
Ice hockey has the highest incidence of cervical spine injuries of any sport (4). This is due to the high-speed nature of the game and the relatively stiff boards that surround the playing surface. A common mechanism for c-spine injuries is a hit from behind which pushes the player into the boards with a slightly flexed neck (5,34). The axial load applied to the cervical spine in this situation leads to a cervical spine injury. Banning checking from behind, stricter enforcement of the rules, and increased spine injury prevention have substantially reduced the incidence of these catastrophic injuries (5,34).
On-ice injuries should be treated with immediate immobilization by placing a hand on either side of the player’s head to stabilize the spine. Airway and breathing should be assessed, and the helmet should be removed before transport to the hospital. While controversial, this is a recent NATA recommendation, as the hockey helmet does not afford the same stability as the helmet and shoulder pads in football (27). The shoulder pads should be removed and the injured player transferred to a backboard with a log roll technique. Return to play criteria after a cervical spine injury is not standardized, but full stable, pain-free range of motion and normal symmetric strength in the absence of residual neurologic deficits is required (27).
The upper extremity is a common site for ice hockey-related injuries and accounts for the highest percentage (44%) of youth ice hockey injuries according to one study (19). Players aged 12 to 17 yr had the highest rate of upper-extremity injuries (47% of all reported injuries) compared with all other age groups. The upper-extremity injury rate for this group was nearly double that for other age groups. Those 6 to 11 yr (27%), 18 to 24 yr (26%), 25 to 30 yr (30%), and 35 to 44 yr (28%) all had substantially lower percentages of upper-extremity injuries (19). Sprains, strains, lacerations, and contusions were the most commonly reported injuries. Other injuries include AC joint separation, glenohumeral joint dislocations, fractures, and elbow, wrist, and hand injuries (19).
AC Joint Separations
The acromioclavicular joint is the most commonly injured joint in hockey players (26). Grades 1 and 2 injuries are treated nonoperatively, whereas grades 4 to 6 are surgically repaired. Treatment of grade 3 injuries, which involves tears of the acromioclavicular and coracoclavicular ligaments, remains controversial in athletes (21). Data presented recently recommended strong consideration be given to operative repair in players who exhibit scapular maltracking early in the rehab process (7). Special consideration also should be given to early intervention, which allows intraoperative reduction of the clavicle without the need for distal clavicle excision and the potential for ligament repair and augmentation. Because hockey is a collision sport, treating surgeons should be aware that holes drilled in the clavicle or coracoid could serve as a stress riser and lead to fracture when the athlete returns to play.
Glenohumeral Joint Dislocations
Anterior shoulder dislocations occur frequently in hockey players and are usually the result of a direct blow to the posterior shoulder or a collision (with the ice or another player) that forces the extended shoulder into abduction and external rotation (39). Players with suspected dislocations can be evaluated on-ice by placing a hand under the shoulder pad and palpating the lateral deltoid. A fullness underneath the coracoid process anteriorly or soft spot posteriorly may be palpated in the case of anterior shoulder dislocations. Players with dislocated shoulders should be removed from the ice and taken to the training room for reduction. A variety of techniques exist for reducing anterior shoulder dislocations. Youm et al. (39) provides a comprehensive review of 11 reduction techniques including the Stimson maneuver, a technique preferred by the authors. The technique involves placing the athlete prone on a training table with the affected arm dangling straight down. A longitudinal force should be applied to the shoulder and slowly increased until a “pop” is felt (39). The FARES technique (fast, reliable and safe) also is a preferred technique of the authors as it can be performed without sedation and has a reported success rate of 88% to 95% (39). It involves slow, progressive abduction of the arm while providing light traction and performing gentle vertical oscillating movement (39). If the shoulder cannot be reduced with a gentle reduction technique, we recommend transporting the athlete to the emergency room for radiographs and reduction under anesthesia. While often successful in skilled hands, more forceful reduction techniques can lead to increased bone or cartilage damage and should not be attempted in the training room.
Once the shoulder is reduced, the athlete is placed in a sling and cryotherapy, nonsterodial anti-inflammatory drugs (NSAIDs) and physical therapy are initiated. The risk of recurrence after a dislocation is high in young athletes, and is inversely proportional to age. Recurrent dislocation is a commonly accepted indication for stabilization surgery, particularly in contact athletes such as hockey players (21,39). Return to play after surgery varies from 6 months to a year. Special consideration can be given to in-season athletes who are motivated to return to play and have regained symmetric motion and strength (21). A variety of stability shoulder braces, such as the Sully Shoulder Stabilizer (The Saunders Group Inc, Chaska, MN), that purport to help restrict excessive ROM, prevent repeat dislocation, and aid in proprioception exist and can be given to players for games and practices (10,21).
Clavicle fractures are another common upper-extremity injury in hockey, presenting with pain, deformity, and tenting of the skin. The growth plates on the clavicle remain open until approximately 21 yr of age in males and should be evaluated radiographically. Injuries to the sternoclavicular joint in skeletally immature athletes should be treated as growth plate injuries to the proximal clavicle until proven otherwise. Recent literature suggests operative repair for displaced midshaft fractures will lower recurrence risk (8). For fractures with significant shortening or displacement, surgical treatment may be associated with a lower rate of nonunion or symptomatic malunion (24). The optimal treatment regarding minimally displaced midshaft clavicle fractures continues with some evidence to support operative fixation leading to improved cosmesis and improved long-term results (21). Return to play can be considered after 8 to 10 wk, when full motion and strength have been regained (21).
Olecranon bursitis is a sterile inflammation that occurs in response to trauma or overuse (30). Examination reveals a swollen and tender mass over the tip of the elbow, and occasional crepitus with elbow range of motion (30). Initial management should include NSAIDs, a compressive dressing, and a well-padded splint (30). Injection with corticosteroids can be considered for recalcitrant cases in a culture proven negative case of bursitis (30). Septic bursitis presents with a red, hot, and swollen elbow and can sometimes be difficult to differentiate from nonseptic arthritis (30). In addition to a thorough history and physical, aspiration performed in a sterile manner before antibiotic administration is recommended (30). Surgical management and antibiotics are almost always necessary to eradicate the infection (30).
Metacarpal fractures occur most commonly in leagues which allow fighting, but can result from contact with pucks, sticks or collisions with boards. On physical examination, there may be a change in appearance of the knuckle compared to the adjacent fingers or opposite side and crepitation may be felt over the fracture (31). Nondisplaced fractures may be treated nonoperatively in a splint for 4 to 6 wk, while displaced fractures may require plating or pinning (31). Boxer fractures traditionally involve the fifth metacarpal neck, but can involve the fourth as well (31). Fractures on the ulnar side of the hand tolerate more displacement and angulation of up to 30 degrees can be considered acceptable (31).
Lower-body injuries account for 30% to 45% of all hockey player-related injuries with knee injuries being the most common lower-body injury (23,36). Thigh and knee injuries in NHL players account for the second and third most man-games lost respectively, with injuries to the leg and foot resulting in the highest percentage of total cost—in terms of lost salary—of all injury types (13,23).
Groin and Thigh Injuries
Early in the season, groin pain resulting from adductor strains is a commonly reported complaint. Adductor strains occur five times more frequently during training camp compared to the regular season. Risk factors for adductor strains include limited hockey specific training in the off-season, adductor-to-abductor strength ratios of less than 80%, and previous adductor injury (1). Activities such as powerful forward or cross-over skating require strong eccentric contraction of the adductors, making this muscle group particularly vulnerable. Adductor strains are usually self-limiting with avoidance of activities that elicit pain, NSAIDs, and the introduction of a warm-up and stretching program. Groin pain that persists beyond 2 to 3 wk despite the aforementioned measures warrants further workup to exclude femoroacetabular impingement (FAI) and sports hernia.
FAI is a condition encompassing a spectrum of abnormalities at the hip joint that results in impingement of the femoral neck on the acetabulum during range of motion. FAI can be divided into cam, pincer, and mixed cam/pincer impingement with cam impingement being the most common type observed in ice hockey athletes (3). Studies of youth and elite hockey players have shown a significantly higher prevalence of radiographic cam impingement compared with other athletes and the general population (11,22,29). It is thought that repetitive loading of the hip inherent to the act of skating can cause subclinical microtrauma and subsequent pathological remodeling of the femoral head (22). Cam impingement occurs as a result of bony overgrowth at the femoral head-neck junction — compared with over coverage of the femoral head by bony overgrowth at the acetabular rim resulting in pincer type impingement — and while the natural history of FAI is unclear, evidence suggests that patients with the condition are at greater risk of labral tears and chondral damage (29). Patients with FAI may grasp the lateral aspect of their hip above the greater trochanter with their thumb and index finger in an anterior-posterior orientation; this is known as the “C-sign.” Pain with flexion, adduction, and internal rotation of the hip (FADIR test) is consistent with a diagnosis of hip impingement (37). Radiographs of the hip can help with evaluation of femoral head-neck junction with magnetic resonance imaging (MRI), allowing for evaluation of labral and cartilaginous abnormalities. Arthroscopic treatment of FAI and labral tears in hockey players has good outcomes with rapid return to play, high patient satisfaction, and return to preinjury level of competition (15).
Hockey players whose groin pain is exacerbated by Valsava maneuvers or sit-ups may be suffering from a sports hernia (a.k.a., athletic pubalgia), a poorly understood condition involving the rectus abdominis and adductor aponeurosis. MRI may or may not confirm the diagnosis and failing 6 to 8 wk of conservative management, surgery to decompress the genitofemoral nerve, repair the pelvic floor, and/or resection of the adductor may be considered (1).
Iliac crest contusions (a.k.a., hip pointers) occur when the hip abductor musculature is compressed against the ilium often as a result of being checked into the boards. Initiating RICE (rest, ice, compression, elevation) and reduced weight bearing with the use of crutches is recommended (21). Quadriceps contusions often occur in defenseman trying to block a shot. Once a contusion is identified, immediate treatment with compression and ice with the leg in a flexed position should be initiated to decrease swelling and minimize spreading of the hematoma (21).
Medial collateral ligament (MCL) injuries are the most commonly reported knee injury in hockey players and are the second most common cause of missed games at the National Collegiate Athletic Association (NCAA) level (16,21). Most injuries are sustained as a result of player on player contact producing a valgus stress on the knee (16). Physical examination of the affected knee immediately after the injury, before muscle spasm and swelling have a chance to set in, and using the unaffected knee for comparison provides the most accurate examination (9). MCL injuries are graded on the amount of medial joint line opening with valgus stressing of the knee: I (opening of 0-5 mm), II (opening of 5–10 mm), III (opening of >10 mm) (9). Grade II injuries are the most commonly reported MCL injury types in NCAA hockey players (16). Valgus force placed on a knee in 30° of flexion reliably isolates the MCL. If further opening of the medial joint line occurs with valgus stress applied to an extended knee, concomitant posterior oblique ligament injury, anterior cruciate ligament (ACL), and/or posterior cruciate ligament (PCL) injury should be considered (9).
Isolated grade I and II MCL injuries are treated nonoperatively with RICE and weight bearing as tolerated with early active range of motion and quadriceps strengthening exercises (9,21). Treatment of isolated grade III MCL injuries remains controversial with evidence to support both operative and nonoperative measures. If nonoperative treatment is pursued, a hinged knee brace to prevent further valgus stress can be considered (9). There is evidence to suggest better outcomes with operative repair of grade III MCL injuries that occur in conjunction with ACL tears (21). Most athletes with isolated grade I and II MCL injuries are able to return to competition the same month, with an expected return to play of 6 to 8 wk in patients with isolated grade III injuries (21).
ACL tears in hockey players are relatively uncommon and occur at lower rates than in basketball and football athletes (32). Female hockey players are more likely to injure their ACL than their male counterparts (33). Again, expeditious examination of the knee before swelling, muscle spasm, and pain set in tends to lead to more accurate diagnoses. The Lachman and pivot shift tests are the most effective physical examination tools to diagnose an ACL injury (21). Given that ice provides a relatively low friction playing surface, some hockey players are able to complete their season with a torn ACL and postpone reconstruction to the off season, though they risk additional internal derangement (21,26). If there is excessive knee laxity or rotational instability or evidence of meniscal injury, reconstruction with patellar tendon or hamstring autograft should be attempted before any further intra-articular damage can occur (23). Most ice hockey athletes are able to return to play within 6 to 12 months with approximately 80% able to return for one or more full seasons (23,32). Players are less likely to return to play and achieve their preinjury level of performance if they suffer an ACL tear with concomitant meniscal injury (32).
Skate bite (a.k.a., lace bite) manifests as anterior ankle pain resulting from stiff, poorly broken in new skates or older skates whose tongue has become inflexible (21). Repeated pressure on the ankle against the stiff surface results in inflammation of the tendons responsible for dorsiflexion of the ankle and extension of the toes. The tibialis anterior is the most commonly affected tendon (21). “Breaking in” the skate by repeated manual flexion of the tongue of the skate, placing a piece of foam on the interior of the tongue as a cushion between the ankle and skate, and NSAIDs are all appropriate treatments for this condition (21).
Lateral ankle sprains affecting the anterior talofibular ligament and/or the calcaneofibular ligament are fairly common in athletic endeavors at all levels. “High ankle” sprains affecting the syndesmosis between the tibia and fibula are less common, representing 1% to 20% of all ankle sprains, but typically have a longer recovery time (38). Unlike other sports, the rigid nature of hockey skates helps prevent lateral ankle sprains but offers little protection to the ankle syndesmosis. Accordingly, in hockey players, ankle syndesmosis sprains tend to occur at a higher frequency than lateral ankle sprains (38). Palpation of the syndesmosis, squeeze test (compression of the fibula and tibia at the middle of the leg producing pain at the syndesmosis), Cotton test (widening of the syndesmosis on lateral translation of the distal fibula) and external rotation test (external rotation and dorsiflexion of the foot producing pain at the syndesmosis) all are physical examination maneuvers that can be used to diagnose a syndesmosis sprain (21). Nonoperative treatment includes RICE, immobilization, nonweight-bearing progressing to ankle range of motion and strengthening exercises, and finally hockey specific activities. Operative treatment includes syndesmotic fixation with either a screw or suture button device and is typically reserved for patients who have failed conservative management, are grossly unstable, or have widening of joint space on stress imaging. Stress imaging is warranted in cases where the clinical suspicion of a syndesmotic injury is high and initial radiographs are negative (25). However, stress radiographs can appear normal in cases of incomplete syndesmotic disruption (25). Due to the frequent twisting and change of direction performed by hockey players, syndesmosis sprains can take a long time to heal. Wright et al. (21,38) showed that an average of 45 d of recovery time was needed before hockey players were able to return to game play compared with 1.4 d in players who sustained a lateral ankle sprain, although up to 12 wk of recovery time has been observed.
Hockey is a fast-paced exciting game to watch and play. It provides perhaps the greatest challenge for the covering physician, who must be able to handle a wide variety of orthopedic injuries and medical conditions, ranging from sudden cardiac events, to ophthalmic, dental, and vascular emergencies. This article provides a brief summary of some of the most common orthopedic and head injuries. As the game continues to evolve, stricter enforcement of the rules of play and continued education of players and coaches regarding the risk, prevention, and consequences of catastrophic head and spine injuries and limitations of protective equipment will help make hockey a safer sport. Further research in helmet designs and increased awareness of the symptoms, risks, and consequences of head injury is needed to help lower the incidence of concussions. Continued systematic collection, evaluation, and analysis of injury data are needed to identify risk factors and implement evidence-based interventions to reduce the risk of hockey-related injuries.
The authors declare no conflict of interest and do not have any financial disclosures.
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