Ice Hockey Injuries
Peter H. Seidenberg
INTRODUCTION
Ice hockey is an extremely fast-paced, high-contact game that requires the mastery of many skills (22,49). Many of these skills (skating, stick handling, body checking, shooting, and goal tending) are unique to the sport (41).
The sport dates back to the 1850s, with formal rules first established in Canada in 1881 (48).
It is a National Collegiate Athletic Association (NCAA), international, and Olympic sport that made its debut in the Antwerp Olympic Games in 1920 (48).
It is increasing in popularity yearly in the United States. During the 2009-2010 season, there were 580,714 registered players, coaches, and officials in USA Hockey. This includes 61,612 girls’ and women’s players (48).
USA Hockey is the governing body for amateur hockey in the United States.
Females were involved in Canada as early as 1892.
The International Ice Hockey Federation coordinated women’s world ice hockey tournaments in 1992, 1994, and 1997, and it first appeared as a medal sport in the 1998 Olympic Games.
Today, the NCAA considers female ice hockey an emerging sport, and USA Hockey registrants include 42,292 female players and 1,684 exclusive women’s teams.
Many women are playing on men’s teams, even up to the minor league level.
The physician providing medical care for ice hockey athletes needs to be proficient in treating a wide variety of traumatic and atraumatic problems that range in severity from mild to life threatening.
EQUIPMENT
All leagues now require helmets, which should fit snugly and use a four-point fit (like football helmets) (22,49).
The hockey helmet must be able to withstand low-mass, high-velocity impacts from the puck and high-mass, low-velocity forces from running into the boards (6).
USA Hockey recommends the use of Hockey Equipment Certification Council (HECC)-approved helmets, full face masks, and full mouthpieces for all players during both practices and games (14,49).
The mouthpiece should be internal and should cover all the remaining teeth of one jaw. It is required to be colored (not clear) in age 19 and under leagues. A form-fitting mouthpiece is recommended (49).
International play does not require mouthpieces; however, they are still highly encouraged (22).
The purpose of mouthguards is to protect dentition (23).
Full face masks are mandatory for all youth and college leagues (49) and are slowly gaining popularity on the professional level.
Kevlar throat protectors are required in many leagues and countries (22).
Gloves, elbow pads, shin pads, shoulder pads, hip pads or padded hockey pants, and protective cup are recommended (49).
There has been a recent trend of wearing hockey gloves with shorter cuffs for the purpose of allowing increased wrist motion (22).
□ This may be at the cost of increased risk of wrist and forearm injury.
Shin pads should cover from the top of the knees to the ankles (22).
All protective equipment except helmets, face masks, padded hockey gloves, padded hockey pants, and goalie leg pads are worn under the uniform (49).
Goalkeeper protective equipment (49)
Blocker worn on stick hand.
Trapper glove worn on the nonstick hand. Looks similar to a baseball mitt with protective padding extending up the forearm.
Leg guards up to 12 inches in width on each leg.
Full masks are required. Form-fitting masks are not recommended and are illegal except in adult leagues. Use in adults requires signing a waiver.
Approved HECC helmets are required unless the above form-fitting mask includes a back skull plate.
Throat protector
Chest protector
Cup
Goalie skates
Skates have a protective heel tip (not required for the goalie)(49).
Probably the most important piece of equipment used by the hockey player (13).
Speed skates are prohibited (49).
Many players prefer leather skates that have external plastic shields for ankle support and protection (18).
Athletes usually prefer ice skates to be snugly fit and may not wear socks so as to improve the feel of the ice (22).
The puck is made of vulcanized rubber and weighs between 5.5 and 6.0 ounces. It is 1 inch thick and 3 inches in diameter (49).
For midget league play, a 4.0- to 4.5-ounce puck is recommended.
Equipment that is in poor repair or that has been altered for the purpose of causing harm to other players is prohibited. Use of such equipment results in penalization of the offending player (49).
PHYSIOLOGY OF ICE HOCKEY
Skating during a game involves repeated accelerations, decelerations, turning, and stopping (18,41).
The players skate forward, backward, and side to side, often with sudden changes in direction (18,41).
During competition, players will typically work at > 70% of their [V with dot above]O2max with a substantial amount of play at > 90% [V with dot above]O2max (16,18).
However, with the frequent stoppage of play per shift (on average 2-3) and with 3-4 minutes of rest between shifts, the resulting mean [V with dot above]O2 consumed per game is 55%-66% of maximum.
Players can lose 4.5-6.5 pounds via sweat per game (41).
If games are played in consecutive days, glycogen stores are often not replenished (41).
Elite ice hockey players average 10% body fat (41).
Physiologic differences by position (41)
Energy expenditure
□ Playing time
□ Goalies have the least number of substitutions and may play an entire game.
□ Defensemen have more playing time than forwards and typically have less rest time between shifts.
□ Goal tending requires quick, short explosive movements interspersed with periods of relative rest.
□ High reliance on adenosine triphosphate (ATP)-phosphocreatine system.
□ Forwards and defensemen have a high reliance on both glycolytic and aerobic metabolism.
□ During games, adult forwards and defensemen skate greater than 4 miles.
□ Energy expenditure is one-third aerobic and two-thirds anaerobic; postgame lactate increases over eight times the pregame level.
Forwards have greater anaerobic activity and typically skate faster than defensemen or goalies.
Despite the above differences by position, muscle fiber composition remains equivalent between positions.
Flexibility (41)
Goalkeepers are significantly more flexible than forwards or defensemen.
Forwards and defensemen have been found to have equal flexibility.
Properly coordinated acceleration and deceleration of motion of body segments produces maximal velocity.
Motion is concentrated in the lower arm.
However, maximal velocity is produced through maximal use and full rotation of the trunk.
Accuracy of the shot is enhanced via trunk stabilization and restricted use of body segments.
EPIDEMIOLOGY OF INJURIES
Ice hockey is classified as a collision sport by the American Academy of Pediatrics (39).
There are many opportunities for injury in this aggressive, fast-paced sport.
Contact/collision occurs with the hard ice surface, unpadded boards, goal posts, equipment from other players (skate blades, sticks), the puck, and the bodies and, at times, fists of opponents (41).
□ In elite hockey, the puck can travel at speeds up to 120 miles per hour, producing impact forces > 1,250 pounds.
□ Professional players can skate at speeds up to 30 miles per hour.
□ Sliding on the ice after a fall can occur at speeds up to 15 miles per hour.
Equipment that is in poor repair also places the athlete at increased risk for injury; however, even when adequate protection is worn, injury is still possible. Studies have found that 58% of injuries occur on body parts that were covered with protective equipment (31).
Overall injury rates
Aggregation of injury data is limited by varying definitions and methods for reporting in the literature.
Data from injuries presenting to U.S. emergency departments demonstrate the following distribution of injury location (15,21):
□ Upper extremity: 36.0%-43.8%
□ Head: 12.3%-16.3%
□ Lower extremity: 16.1%-19.1%
□ Trunk: 9.3%-13.8%
□ Face: 10.0%-23.0%
□ The above data are limited by the fact that not all ice hockey injuries result in a visit to the local emergency department.
Overall injury rate is 5.6 injuries per 1,000 player-hours (1.5 per 1,000 hours in practice, 54 per 1,000 hours in games) (31). Due to difficulty quantifying player-hours, many studies will instead describe injury rates per athletic exposure.
Injury is more common in the game setting (76%) than in practice (23%), even though practice represents significantly more time. Injuries are thus 5-25 times more common in game settings (1,2,3,31,43).
Acute and traumatic injures account for 85% of injuries, whereas overuse injuries represent 15% of all injuries (47).
Approximately 16% of injures are related to rule infractions (31).
During games, Pelletier et al. (36) found that 27.1% of injuries occurred during the first period, 35.6% occurred during the second period, and 26.6% occurred during the third period. In contrast, other investigators suggest that third-period injuries are roughly equal to first- and second-period injuries combined (31) or that injures are twice as common in the third period (43).
Age-specific injury rates: Injuries appear to increase with increasing age, with a peak in early adulthood (Table 95.1).
Studies suggest that injury rates in youth hockey show a dramatic increase during the first year that body checking is permitted, regardless of the age that checking is instituted (27,51).
Table 95.1 Injury Rates by Age of Athlete (43)
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