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Review
Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries Robert F LaPrade,1,2 Rachel K Surowiec,1 Ada N Sochanska,1 Brandon S Hentkowski,2 Brandie M Martin,2 Lars Engebretsen,3 Coen A Wijdicks1 1
Steadman Philippon Research Institute, Vail, Colorado, USA 2 The Steadman Clinic, Vail, Colorado, USA 3 Department of Orthopaedic Surgery, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway Correspondence to Dr Robert F LaPrade, Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO 81657, USA; [email protected] Accepted 1 November 2013
ABSTRACT Ice hockey is a high contact sport where players are inherently at an increased risk for traumatic and timeloss injury. With its increasing popularity and high incidence of injury, further research is necessary to understand the risks and injuries associated with the sport and to develop performance-based outcome measures to guide return to play. This review, tailored to the practicing sports medicine team physician, focuses on the stepwise identification, treatment, time loss, return to play and subsequent risk of injury for the most common areas of injury: the head, shoulder, hip and knee. Injuries were categorised into upper and lower extremity with an emphasis on glenohumeral and acromioclavicular joint injuries, femoroacetabular impingement, medial collateral ligament tears, and high ankle sprains. With return to play a primary goal for these high-level athletes, recovery in ice hockey becomes a complex issue with efficient protocols tailored to the requirements of the sport vital to the athlete and clinician alike. By reviewing the treatments and sportspecific care, athletes can be better managed with the ultimate goal of returning to their preinjury level of play. Level of Evidence: Level IV.
INTRODUCTION
To cite: LaPrade RF, Surowiec RK, Sochanska AN, et al. Br J Sports Med 2014;48:4–10.
Ice hockey is a high contact sport where players are inherently at an increased risk for time-loss injury.1 Engebretsen et al2 reported that in relation to the number of registered athletes in the 2010 Olympics, the risk of sustaining an injury was highest for ice hockey with 13–35% of registered athletes affected.2 In addition, ice hockey had the highest incidence of athlete-to-athlete trauma. The percentage of injuries that occur during games is 13.5% knee injuries, 8.9% acromioclavicular (AC) joint injuries, 6.2% upper leg contusions and 4.5% pelvis and hip muscle strains.3 Therefore, injuries of the upper extremity will be reviewed with a focus on glenohumeral and AC joint injuries.4 Furthermore, the most common lower extremity injuries for the hip, knee and ankle will be reviewed. For this work, injury was defined as the cause for a player to be removed from competition before completing a full session, miss a subsequent session or sustain a trauma that posed a need for medical attention.1 4–6 Although many time loss injuries are concussions, which impact the player from continuing on-ice activity, the focus of this review is musculoskeletal injuries and treatment.3 It should be observed that if an athlete has sustained a concussion while in practice or competition the athlete should not be allowed to return to play that same
LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
day.7–9 Before being able to return to full participation the athlete should follow an established return to play exertional progression once they present asymptomatically at rest (table 1).7 The purpose of this review was to gain a well-rounded understanding of common injuries acquired in ice hockey. The understanding of the most common musculoskeletal injuries in ice hockey will strengthen the knowledge of treatments and preventative measures and ultimately progress the athlete to a safe and timely return to sport.
SHOULDER AC joint separation The most common mechanism of AC joint injury is a direct blow to the player’s shoulder which drives the player’s acromion inferiorly leading to a tear or stretch in the AC and/or the coracoclavicular (CC) ligaments.10–14 In an injured player, physical examination will demonstrate limited shoulder range of motion (ROM) while palpation of the AC joint will reveal tenderness, localised pain and possible deformity.11 To evaluate for fractures or separations of the AC joint, standard anteroposterior, lateral and axillary radiographs are recommended.14 The treatment of AC joint injuries in hockey is usually based on the classification and grades as proposed by Rockwood (table 2).11
Treatment The treatment is based on the severity of the AC separation. Treatments for grade I and II separations include the use of a sling, analgesics, cryotherapy, immobilisation, early ROM, taping and rest.5 11 12 14 Recent studies have demonstrated good outcomes for a similar non-operative treatment of grade III AC separations in ice hockey.14 15 Unlike grade III injuries, grades IV–VI separations require surgical intervention through CC ligament reconstruction, CC repair or ligament transfer.15 During the recovery phase players should avoid activities that may aggravate the injury or limit ROM.11
Return to play Recovery time and criteria for return to play for the majority of AC joint injuries is displayed in figure 1. The player should have full return of strength and shoulder motion on the affected side. Tape and AC joint pads may be added to protect the AC joint for pre-emptive pain management and to dissipate contact forces (figure 2).5 The period for ‘failing to progress’ is not clear and thus, recovery time is variable.11 1 of 8
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Review Table 1 Gradual return-to-play protocol after a concussion (from the 4th International Conference on Concussion in Sport, Zurich) Rehabilitation stage
Function exercise at each stage
Objectives of each stage
1. No activity 2. Light aerobic exercise
Recovery Increase heart rate
5. Full contact practice
Symptomatic-limited physical and cognitive rest Walking, swimming, or stationary cycling, keeping intensity 10 mm).32–34 However, recent research has reported that a grade III MCL injury is present on valgus stress radiographs when medial compartment gapping is greater than 3.2 mm when compared with contralateral knee at 20° of flexion.34
Treatment Grade I and II MCL injuries have been treated with nonoperative management through cryotherapy, compression and elevation. The RICE protocol is used to decrease the swelling of the knee joint by minimising bleeding through the use of a LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
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Review
Figure 3 Stepwise Identification of medial collateral ligament MCL injury.31 compression wrap or an elastic sleeve.35 Throughout this treatment, initiation of active knee motion is used to prevent stiffness with associated strengthening exercises. The treatment for medial knee injuries is dependent on whether the injury is isolated or combined with other ligament injuries. Non-operative treatments for grade III injuries focus on restoring quadriceps function, improving knee motion and controlling oedema through a focus on exercises that restrict side-to-side activities. It is recommended to use a hinged knee brace in the early phases of rehabilitation and discontinue it after the competitive season is completed.35
Return to play If proper rehabilitation for an MCL injury is followed, the athlete can usually return to sport after 0–2 weeks for grade I injuries and 2–4 weeks for grade II injuries.32 Likewise, if the athlete follows a well-guided rehabilitation programme, most athletes return to full competition 6–8 weeks following isolated MCL grade III injuries. For rehabilitation, ROM and quadriceps reactivation is recommended to decrease the amount of time loss for the athlete.33
Subsequent risk and future An MCL reconstruction may occasionally be required for highlevel athletes who wish to return to play and who have continued instability from an MCL tear. However, the reconstruction of grade III MCL injuries remains controversial.36 It is recognised that the non-operative treatment of some grade III MCL tears may lead to chronic valgus instability or rotatory instability.35 Despite the best rehabilitation efforts, associated quadriceps weakness, abnormal movement patterns, laxity and reduced knee function have been documented.37 Using an anatomic reconstruction, good outcomes have been achieved. Lind et al38 reported that medial stability according to the International Knee Documentation Committee (IKDC) criteria was normal to nearly normal in 98% of patients, although the overall IKDC score demonstrated that 13% of patients were rated as abnormal with combined MCL reconstruction at follow-up. When presenting concurrently with an anterior cruciate ligament (ACL) tear, reconstructed grade III MCL tears demonstrated significantly higher functional scores than those athletes who were treated non-operatively.39
Anterior cruciate ligament Identification Tears of the ACL are not common in ice hockey players and players who have minimal instability from an ACL tear can LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
32
occasionally continue playing through the season.5 When they occur, they are most commonly due to on-ice collisions with another player or the goalpost. Examination in the training room immediately after injury, before pain, swelling and muscle guarding set in, are usually very accurate in arriving at a diagnosis. The Lachman and the pivot shift tests have proven to be effective clinical diagnostic tools. However, the Lachman test is the most effective test in the diagnosis of ACL tears (figure 4).40
Treatment ACL tear management focuses on the ability to restore normal function, reduce symptoms, and an attempt to return to play.40 The low friction activity of on-ice skating can occasionally allow a player to return to play during the season and to plan for an ACL reconstruction after the competitive season is completed. If a player has knee instability while training or with on-ice activity, it is recommended to have the ACL reconstructed using a patellar tendon or hamstring autograft.5
Return to play In athletes presenting with an ACL tear combined with cartilage injury, the clinical goals are to restore a more normal state of knee motion, relieve symptoms and return the athlete to near preinjury activity. The International Sports Medicine Association identified that for an ACL reconstruction and/or rehabilitation
Figure 4 Lachman test to diagnose anterior cruciate ligament tear. One hand used to secure and stabilise the athlete’s distal femur while the other firmly grasps the proximal tibia. The leg should be at 20–30°. A gentle anterior translation force is applied to the proximal tibia (demonstrated by the red arrow). The examiner assesses for a firm/solid or soft endpoint. 5 of 8
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Review programme to be considered successful, the knee must be absent of symptomatic knee joint instability, quadriceps and hamstring strength asymmetry, the presence of no more than mild-knee joint effusion.41 There is however, a lack of standardised objective criteria to accurately assess the ability of a patient to safely return to their previous level of activity following ACL reconstruction.
Subsequent injury risk The risk of a second ACL injury is highest during the first year following the athletes return to sport.42 Additionally, risk to the contralateral limb is significantly higher than the reconstructed limb suggesting that reinjury is not exclusive to the original involved limb.43
ANKLE Skate (lace) bite Skate bite, also known as lace bite, typically presents when new skates are introduced and not broken in or when skates become old and inflexible.5 The inflexibility of the skate tongue along with repeated ankle dorsiflexion within the skates puts pressure on the anterior aspect of the ankle irritating the tibialis anterior tendon.5 This may result in tendonitis and decrease the athlete’s ability to participate in on-ice activities. The treatment for this injury is the fashioning of a soft piece of foam rubber to the outside of the hockey sock or skate to relieve pressure and decrease irritation (figure 5).5 Likewise, manually breaking in the skate’s tongue by bending it repeatedly will decrease pressure on the tibialis anterior tendon. Although anti-inflammatory drugs can be used, the only way to fix the problem is through ‘breaking the skates in’.43
High ankle sprains: syndesmosis injury Identification One of the most debilitating ankle injuries for ice hockey players are high ankle sprains also known as a syndesmosis injury.5 High ankle sprains are less common and affect the ligaments that are proximal to the lateral ankle ligaments traditionally involved in lower ankle sprains. High ankle sprains occur when the foot is twisted externally, resulting in microtears or tears of the junction between the tibia and fibula just above the level of the ankle.44 The ligaments affected are the anterior inferior tibiofibular ligament, the inferior tibiofibular ligament, the inferior transverse tibiofibular ligament and the interosseous ligament.44 Various
Figure 5 Lace bite protection. Lace bite pads can be purchased and attached onto the skate’s tongue (inside) and help to alleviate pressure or pro-wrapped directly to the players foot (A). Combination padding such as a boot bumper contains gel pads molded inside an elastic lining to protect against friction and abrasion of the boot and skate laces (B). 6 of 8
tests such as direct palpation, the squeeze test, external rotation stress test, cotton test and the fibula translation test have been used to diagnose a syndesmosis injury.44 The ankle typically presents as normal on routine X-rays even with a syndesmosis injury, but when the ligaments are stressed through a squeeze or external rotation test there may be an abnormal alignment of the ankle joint on fluoroscopy depending on the severity of the injury.45 The authors have found that having the athlete remove their skates and stand and gently twist their ankle in the locker room will usually help to diagnose this injury immediately off ice.
Treatment The initial treatment for high ankle sprains includes the RICE protocol. Proper assessment may include anteroposterior (AP), mortise, and lateral ankle radiographs to assess for fractures, which often occur due to a similar injury mechanism and can have similar symptoms. Once swelling in the ankle has decreased and ankle motion has increased, the athlete can start an ankle-strengthening programme.5 A three-phase approach has been proposed by Williams et al.46 in which the first phase begins as the acute, protection phase. The focus initially is on immobilisation, weight bearing and the control of the inflammatory process.46 Athletes then progress to the subacute phase with a focus on normal mobility, increased strength, improved neuromuscular control and the promotion of joint mobility.46 Finally, the advanced training phase consists of a confident return to play by including more aggressive training exercises and sport-specific activities.46 The programme may protect the ankle from being reinjured and provide appropriate proprioceptive training to re-recognise joint location.5 Continuing to skate on the ankle will delay the healing of the involved ligaments and may limit further on-ice activity.
Return to play High ankle sprains have been particularly bothersome in ice hockey players because of the frequent twisting and turning
Figure 6 External ankle support for use following a low ankle ligament sprain. An external ankle support may be beneficial to aid with earlier mobilisation due to the continuous weight bearing support it provides within the ankle. LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
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Review
Figure 7 Musculoskeletal time-loss injuries.
required for on-ice activities which can delay their return to participation compared to other sports. Once an athlete has minimal swelling and appropriate strength, a functional on-ice evaluation should be performed to assess readiness for return to play. This is especially important for high ankle sprains because an athlete should not play through pain because of risk of reinjury. High ankle sprains can take up to 12 weeks to heal in ice hockey players.5
CONCLUSIONS The current review provides an overview of the most commonly encountered ice hockey injuries (figure 7) and evidence-based methods of treatment of the most common time loss extremity injuries. Most time-loss injuries in ice hockey can be managed non-operatively with a functional return to on-ice activity. Ice hockey is a contact sport with unique injury patterns. Knowledge of these injuries and treatment regimens will help to minimise downtime and safely return athletes to competition.
Low ankle sprains Identification Low ankle ligament sprains (anterior talofibular ligament, calcaneofibular ligament and the posterior talofibular ligament) occur most often with the foot in plantar flexion, inversion and adduction.47 48 The athlete will report ‘rolling over’ on his or her ankle and describe acute lateral ankle pain.48 The ‘rolling over’ action causes damage to the lateral ankle ligaments resulting in swelling, pain, problems with weight bearing and haematoma.47 48 Over time, the pain and swelling will diffuse and palpation of the injured area will help to localise the ligaments that have been torn.48 To assess ankle instability it is recommended to perform the anterior drawer test and the talar tilt test.48 Standard ankle radiographs can also be performed to rule out fracture.
What are the new findings? ▸ Most time-loss injuries in ice hockey can be managed non-operatively. ▸ The most common shoulder injuries in ice hockey include acromioclavicular joint separations, clavicle fractures and glenohumeral dislocations. ▸ Ice hockey has unique injury patterns. ▸ There remains a need for additional scientific information with regard to external risk factors of injury.
Treatment It is generally accepted that almost all low ankle sprains in ice hockey players can be treated through non-operative and functional measures.47–49 The RICE therapy should begin immediately to limit bruising and swelling.48 Lace-up ankle supports and taping have also been reported to be effective in reducing swelling and injury prevention.47 External support has shown to be beneficial to aid with earlier mobilisation due to continuous weight bearing support within the ankle (figure 6).47 Functional rehabilitation through balance exercises is recommended to decrease time until recovery, focusing on improving ankle motion.48 50 Ankle sprains do not usually require surgical treatment.47 However, with chronic instability, severe injuries or concurrent injuries, surgical ligament repair or reconstruction maintains the advantage of less common recurrence when compared with non-operative treatments.47
Return to play Most low ankle sprains are managed non-operatively and with a functional rehabilitation programme. This is because the ice hockey boot provides excellent support and protection for low ankle sprains. Return to play usually occurs within a few days to a week, although complete ligament healing may take from 6–12 weeks.51 LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
How might it impact on clinical practice in the near future? ▸ Valuable information on the identification, treatment and return-to-play is presented for common musculoskeletal ice hockey injuries. ▸ This work will give all shareholders in the athlete a resource to guide treatment and recovery. ▸ As care of high-level athletes continues to evolve, more work should be performed to optimise return to play in ice hockey specific injuries.
Acknowledgements The authors would like to thank Luke O’Brien, PT for his assistance in the descriptions of proper physical examination of injuries and rehabilitation protocol. In memory of Scott Winkler, former Colorado College Division I ice hockey player, who passed away unexpectedly on 12 June 2013. Contributors RFL, RKS, ANS, BSH, BMM, LE and CAW involved in substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; and were responsible for drafting the work or revising it critically for important intellectual content, and final approval of the version to be published; agreement to be accountable for all the aspects of the work 7 of 8
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Review in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding This study was funded by the Steadman Philippon Research Institute. Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed. 28
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Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries Robert F LaPrade, Rachel K Surowiec, Ada N Sochanska, Brandon S Hentkowski, Brandie M Martin, Lars Engebretsen and Coen A Wijdicks Br J Sports Med 2014 48: 4-10 originally published online November 27, 2013
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Review
Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries Robert F LaPrade,1,2 Rachel K Surowiec,1 Ada N Sochanska,1 Brandon S Hentkowski,2 Brandie M Martin,2 Lars Engebretsen,3 Coen A Wijdicks1 1
Steadman Philippon Research Institute, Vail, Colorado, USA 2 The Steadman Clinic, Vail, Colorado, USA 3 Department of Orthopaedic Surgery, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway Correspondence to Dr Robert F LaPrade, Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO 81657, USA; [email protected] Accepted 1 November 2013
ABSTRACT Ice hockey is a high contact sport where players are inherently at an increased risk for traumatic and timeloss injury. With its increasing popularity and high incidence of injury, further research is necessary to understand the risks and injuries associated with the sport and to develop performance-based outcome measures to guide return to play. This review, tailored to the practicing sports medicine team physician, focuses on the stepwise identification, treatment, time loss, return to play and subsequent risk of injury for the most common areas of injury: the head, shoulder, hip and knee. Injuries were categorised into upper and lower extremity with an emphasis on glenohumeral and acromioclavicular joint injuries, femoroacetabular impingement, medial collateral ligament tears, and high ankle sprains. With return to play a primary goal for these high-level athletes, recovery in ice hockey becomes a complex issue with efficient protocols tailored to the requirements of the sport vital to the athlete and clinician alike. By reviewing the treatments and sportspecific care, athletes can be better managed with the ultimate goal of returning to their preinjury level of play. Level of Evidence: Level IV.
INTRODUCTION
To cite: LaPrade RF, Surowiec RK, Sochanska AN, et al. Br J Sports Med 2014;48:4–10.
Ice hockey is a high contact sport where players are inherently at an increased risk for time-loss injury.1 Engebretsen et al2 reported that in relation to the number of registered athletes in the 2010 Olympics, the risk of sustaining an injury was highest for ice hockey with 13–35% of registered athletes affected.2 In addition, ice hockey had the highest incidence of athlete-to-athlete trauma. The percentage of injuries that occur during games is 13.5% knee injuries, 8.9% acromioclavicular (AC) joint injuries, 6.2% upper leg contusions and 4.5% pelvis and hip muscle strains.3 Therefore, injuries of the upper extremity will be reviewed with a focus on glenohumeral and AC joint injuries.4 Furthermore, the most common lower extremity injuries for the hip, knee and ankle will be reviewed. For this work, injury was defined as the cause for a player to be removed from competition before completing a full session, miss a subsequent session or sustain a trauma that posed a need for medical attention.1 4–6 Although many time loss injuries are concussions, which impact the player from continuing on-ice activity, the focus of this review is musculoskeletal injuries and treatment.3 It should be observed that if an athlete has sustained a concussion while in practice or competition the athlete should not be allowed to return to play that same
LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
day.7–9 Before being able to return to full participation the athlete should follow an established return to play exertional progression once they present asymptomatically at rest (table 1).7 The purpose of this review was to gain a well-rounded understanding of common injuries acquired in ice hockey. The understanding of the most common musculoskeletal injuries in ice hockey will strengthen the knowledge of treatments and preventative measures and ultimately progress the athlete to a safe and timely return to sport.
SHOULDER AC joint separation The most common mechanism of AC joint injury is a direct blow to the player’s shoulder which drives the player’s acromion inferiorly leading to a tear or stretch in the AC and/or the coracoclavicular (CC) ligaments.10–14 In an injured player, physical examination will demonstrate limited shoulder range of motion (ROM) while palpation of the AC joint will reveal tenderness, localised pain and possible deformity.11 To evaluate for fractures or separations of the AC joint, standard anteroposterior, lateral and axillary radiographs are recommended.14 The treatment of AC joint injuries in hockey is usually based on the classification and grades as proposed by Rockwood (table 2).11
Treatment The treatment is based on the severity of the AC separation. Treatments for grade I and II separations include the use of a sling, analgesics, cryotherapy, immobilisation, early ROM, taping and rest.5 11 12 14 Recent studies have demonstrated good outcomes for a similar non-operative treatment of grade III AC separations in ice hockey.14 15 Unlike grade III injuries, grades IV–VI separations require surgical intervention through CC ligament reconstruction, CC repair or ligament transfer.15 During the recovery phase players should avoid activities that may aggravate the injury or limit ROM.11
Return to play Recovery time and criteria for return to play for the majority of AC joint injuries is displayed in figure 1. The player should have full return of strength and shoulder motion on the affected side. Tape and AC joint pads may be added to protect the AC joint for pre-emptive pain management and to dissipate contact forces (figure 2).5 The period for ‘failing to progress’ is not clear and thus, recovery time is variable.11 1 of 8
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Review Table 1 Gradual return-to-play protocol after a concussion (from the 4th International Conference on Concussion in Sport, Zurich) Rehabilitation stage
Function exercise at each stage
Objectives of each stage
1. No activity 2. Light aerobic exercise
Recovery Increase heart rate
5. Full contact practice
Symptomatic-limited physical and cognitive rest Walking, swimming, or stationary cycling, keeping intensity 10 mm).32–34 However, recent research has reported that a grade III MCL injury is present on valgus stress radiographs when medial compartment gapping is greater than 3.2 mm when compared with contralateral knee at 20° of flexion.34
Treatment Grade I and II MCL injuries have been treated with nonoperative management through cryotherapy, compression and elevation. The RICE protocol is used to decrease the swelling of the knee joint by minimising bleeding through the use of a LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
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Figure 3 Stepwise Identification of medial collateral ligament MCL injury.31 compression wrap or an elastic sleeve.35 Throughout this treatment, initiation of active knee motion is used to prevent stiffness with associated strengthening exercises. The treatment for medial knee injuries is dependent on whether the injury is isolated or combined with other ligament injuries. Non-operative treatments for grade III injuries focus on restoring quadriceps function, improving knee motion and controlling oedema through a focus on exercises that restrict side-to-side activities. It is recommended to use a hinged knee brace in the early phases of rehabilitation and discontinue it after the competitive season is completed.35
Return to play If proper rehabilitation for an MCL injury is followed, the athlete can usually return to sport after 0–2 weeks for grade I injuries and 2–4 weeks for grade II injuries.32 Likewise, if the athlete follows a well-guided rehabilitation programme, most athletes return to full competition 6–8 weeks following isolated MCL grade III injuries. For rehabilitation, ROM and quadriceps reactivation is recommended to decrease the amount of time loss for the athlete.33
Subsequent risk and future An MCL reconstruction may occasionally be required for highlevel athletes who wish to return to play and who have continued instability from an MCL tear. However, the reconstruction of grade III MCL injuries remains controversial.36 It is recognised that the non-operative treatment of some grade III MCL tears may lead to chronic valgus instability or rotatory instability.35 Despite the best rehabilitation efforts, associated quadriceps weakness, abnormal movement patterns, laxity and reduced knee function have been documented.37 Using an anatomic reconstruction, good outcomes have been achieved. Lind et al38 reported that medial stability according to the International Knee Documentation Committee (IKDC) criteria was normal to nearly normal in 98% of patients, although the overall IKDC score demonstrated that 13% of patients were rated as abnormal with combined MCL reconstruction at follow-up. When presenting concurrently with an anterior cruciate ligament (ACL) tear, reconstructed grade III MCL tears demonstrated significantly higher functional scores than those athletes who were treated non-operatively.39
Anterior cruciate ligament Identification Tears of the ACL are not common in ice hockey players and players who have minimal instability from an ACL tear can LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
32
occasionally continue playing through the season.5 When they occur, they are most commonly due to on-ice collisions with another player or the goalpost. Examination in the training room immediately after injury, before pain, swelling and muscle guarding set in, are usually very accurate in arriving at a diagnosis. The Lachman and the pivot shift tests have proven to be effective clinical diagnostic tools. However, the Lachman test is the most effective test in the diagnosis of ACL tears (figure 4).40
Treatment ACL tear management focuses on the ability to restore normal function, reduce symptoms, and an attempt to return to play.40 The low friction activity of on-ice skating can occasionally allow a player to return to play during the season and to plan for an ACL reconstruction after the competitive season is completed. If a player has knee instability while training or with on-ice activity, it is recommended to have the ACL reconstructed using a patellar tendon or hamstring autograft.5
Return to play In athletes presenting with an ACL tear combined with cartilage injury, the clinical goals are to restore a more normal state of knee motion, relieve symptoms and return the athlete to near preinjury activity. The International Sports Medicine Association identified that for an ACL reconstruction and/or rehabilitation
Figure 4 Lachman test to diagnose anterior cruciate ligament tear. One hand used to secure and stabilise the athlete’s distal femur while the other firmly grasps the proximal tibia. The leg should be at 20–30°. A gentle anterior translation force is applied to the proximal tibia (demonstrated by the red arrow). The examiner assesses for a firm/solid or soft endpoint. 5 of 8
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Review programme to be considered successful, the knee must be absent of symptomatic knee joint instability, quadriceps and hamstring strength asymmetry, the presence of no more than mild-knee joint effusion.41 There is however, a lack of standardised objective criteria to accurately assess the ability of a patient to safely return to their previous level of activity following ACL reconstruction.
Subsequent injury risk The risk of a second ACL injury is highest during the first year following the athletes return to sport.42 Additionally, risk to the contralateral limb is significantly higher than the reconstructed limb suggesting that reinjury is not exclusive to the original involved limb.43
ANKLE Skate (lace) bite Skate bite, also known as lace bite, typically presents when new skates are introduced and not broken in or when skates become old and inflexible.5 The inflexibility of the skate tongue along with repeated ankle dorsiflexion within the skates puts pressure on the anterior aspect of the ankle irritating the tibialis anterior tendon.5 This may result in tendonitis and decrease the athlete’s ability to participate in on-ice activities. The treatment for this injury is the fashioning of a soft piece of foam rubber to the outside of the hockey sock or skate to relieve pressure and decrease irritation (figure 5).5 Likewise, manually breaking in the skate’s tongue by bending it repeatedly will decrease pressure on the tibialis anterior tendon. Although anti-inflammatory drugs can be used, the only way to fix the problem is through ‘breaking the skates in’.43
High ankle sprains: syndesmosis injury Identification One of the most debilitating ankle injuries for ice hockey players are high ankle sprains also known as a syndesmosis injury.5 High ankle sprains are less common and affect the ligaments that are proximal to the lateral ankle ligaments traditionally involved in lower ankle sprains. High ankle sprains occur when the foot is twisted externally, resulting in microtears or tears of the junction between the tibia and fibula just above the level of the ankle.44 The ligaments affected are the anterior inferior tibiofibular ligament, the inferior tibiofibular ligament, the inferior transverse tibiofibular ligament and the interosseous ligament.44 Various
Figure 5 Lace bite protection. Lace bite pads can be purchased and attached onto the skate’s tongue (inside) and help to alleviate pressure or pro-wrapped directly to the players foot (A). Combination padding such as a boot bumper contains gel pads molded inside an elastic lining to protect against friction and abrasion of the boot and skate laces (B). 6 of 8
tests such as direct palpation, the squeeze test, external rotation stress test, cotton test and the fibula translation test have been used to diagnose a syndesmosis injury.44 The ankle typically presents as normal on routine X-rays even with a syndesmosis injury, but when the ligaments are stressed through a squeeze or external rotation test there may be an abnormal alignment of the ankle joint on fluoroscopy depending on the severity of the injury.45 The authors have found that having the athlete remove their skates and stand and gently twist their ankle in the locker room will usually help to diagnose this injury immediately off ice.
Treatment The initial treatment for high ankle sprains includes the RICE protocol. Proper assessment may include anteroposterior (AP), mortise, and lateral ankle radiographs to assess for fractures, which often occur due to a similar injury mechanism and can have similar symptoms. Once swelling in the ankle has decreased and ankle motion has increased, the athlete can start an ankle-strengthening programme.5 A three-phase approach has been proposed by Williams et al.46 in which the first phase begins as the acute, protection phase. The focus initially is on immobilisation, weight bearing and the control of the inflammatory process.46 Athletes then progress to the subacute phase with a focus on normal mobility, increased strength, improved neuromuscular control and the promotion of joint mobility.46 Finally, the advanced training phase consists of a confident return to play by including more aggressive training exercises and sport-specific activities.46 The programme may protect the ankle from being reinjured and provide appropriate proprioceptive training to re-recognise joint location.5 Continuing to skate on the ankle will delay the healing of the involved ligaments and may limit further on-ice activity.
Return to play High ankle sprains have been particularly bothersome in ice hockey players because of the frequent twisting and turning
Figure 6 External ankle support for use following a low ankle ligament sprain. An external ankle support may be beneficial to aid with earlier mobilisation due to the continuous weight bearing support it provides within the ankle. LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
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Figure 7 Musculoskeletal time-loss injuries.
required for on-ice activities which can delay their return to participation compared to other sports. Once an athlete has minimal swelling and appropriate strength, a functional on-ice evaluation should be performed to assess readiness for return to play. This is especially important for high ankle sprains because an athlete should not play through pain because of risk of reinjury. High ankle sprains can take up to 12 weeks to heal in ice hockey players.5
CONCLUSIONS The current review provides an overview of the most commonly encountered ice hockey injuries (figure 7) and evidence-based methods of treatment of the most common time loss extremity injuries. Most time-loss injuries in ice hockey can be managed non-operatively with a functional return to on-ice activity. Ice hockey is a contact sport with unique injury patterns. Knowledge of these injuries and treatment regimens will help to minimise downtime and safely return athletes to competition.
Low ankle sprains Identification Low ankle ligament sprains (anterior talofibular ligament, calcaneofibular ligament and the posterior talofibular ligament) occur most often with the foot in plantar flexion, inversion and adduction.47 48 The athlete will report ‘rolling over’ on his or her ankle and describe acute lateral ankle pain.48 The ‘rolling over’ action causes damage to the lateral ankle ligaments resulting in swelling, pain, problems with weight bearing and haematoma.47 48 Over time, the pain and swelling will diffuse and palpation of the injured area will help to localise the ligaments that have been torn.48 To assess ankle instability it is recommended to perform the anterior drawer test and the talar tilt test.48 Standard ankle radiographs can also be performed to rule out fracture.
What are the new findings? ▸ Most time-loss injuries in ice hockey can be managed non-operatively. ▸ The most common shoulder injuries in ice hockey include acromioclavicular joint separations, clavicle fractures and glenohumeral dislocations. ▸ Ice hockey has unique injury patterns. ▸ There remains a need for additional scientific information with regard to external risk factors of injury.
Treatment It is generally accepted that almost all low ankle sprains in ice hockey players can be treated through non-operative and functional measures.47–49 The RICE therapy should begin immediately to limit bruising and swelling.48 Lace-up ankle supports and taping have also been reported to be effective in reducing swelling and injury prevention.47 External support has shown to be beneficial to aid with earlier mobilisation due to continuous weight bearing support within the ankle (figure 6).47 Functional rehabilitation through balance exercises is recommended to decrease time until recovery, focusing on improving ankle motion.48 50 Ankle sprains do not usually require surgical treatment.47 However, with chronic instability, severe injuries or concurrent injuries, surgical ligament repair or reconstruction maintains the advantage of less common recurrence when compared with non-operative treatments.47
Return to play Most low ankle sprains are managed non-operatively and with a functional rehabilitation programme. This is because the ice hockey boot provides excellent support and protection for low ankle sprains. Return to play usually occurs within a few days to a week, although complete ligament healing may take from 6–12 weeks.51 LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
How might it impact on clinical practice in the near future? ▸ Valuable information on the identification, treatment and return-to-play is presented for common musculoskeletal ice hockey injuries. ▸ This work will give all shareholders in the athlete a resource to guide treatment and recovery. ▸ As care of high-level athletes continues to evolve, more work should be performed to optimise return to play in ice hockey specific injuries.
Acknowledgements The authors would like to thank Luke O’Brien, PT for his assistance in the descriptions of proper physical examination of injuries and rehabilitation protocol. In memory of Scott Winkler, former Colorado College Division I ice hockey player, who passed away unexpectedly on 12 June 2013. Contributors RFL, RKS, ANS, BSH, BMM, LE and CAW involved in substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; and were responsible for drafting the work or revising it critically for important intellectual content, and final approval of the version to be published; agreement to be accountable for all the aspects of the work 7 of 8
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Review in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding This study was funded by the Steadman Philippon Research Institute. Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed. 28
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LaPrade RF, et al. Br J Sports Med 2014;48:4–10. doi:10.1136/bjsports-2013-093020
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Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries Robert F LaPrade, Rachel K Surowiec, Ada N Sochanska, Brandon S Hentkowski, Brandie M Martin, Lars Engebretsen and Coen A Wijdicks Br J Sports Med 2014 48: 4-10 originally published online November 27, 2013
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