We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Ice Hockey Medicine

From WikiSM
Jump to: navigation, search

Other Names

  • Ice Hockey
  • Hockey


  • This page focuses on medicine as it relates to Hockey


  • Ice hockey achieved its modern form in England in the 19th century[1]
  • From there it spread to the European continent and to North America

Epidemiology: Incidence

  • Estimates of incidence rates of injuries range from 2.3 to 79.2 per 1000 player hours
  • One study followed a professional team for 7 years and found an incidence of 5.93 injuries per 1000 hours/player and 2.14 with time lost per 1000 hours/player[2]
    • Note this included training time and games; if only including games the injury rate estimate is 60.0 injuries per 1000 hours/player
  • A study following the NHL over 7 seasons was performed by McKay et al[3]
    • They reported an injury rate of 49.4 injuries per 1000 player hours
    • The majority of injuries were during games (88.7%) vs practice (11.3%)
    • Reinjury rate was estimated to be 3.1% of injuries
  • Szukics et al narrative review[4]
    • Injury rate for all levels of play was 19.68 per 1000 AEs
    • Professional European players had the highest injury rate at 68.5 AE
    • Collegiate athletes had the lowest at 4.9 per 1000 AEs

Epidemiology: Injury Patterns

  • Most commonly injured body areas[3]
    • Head (16.8%), thigh (14.0%) and knee (13.0%)
    • These account for the most missed game time
  • Touminen et al 7 season study looking at international players[5]
    • By location: Head and face (39.8% of game injuries), lower body(30.7%), upper body(21.8%), spine/trunk (7.8%)
  • Jorgensen and Smasal[6]
    • Head is the most commonly injured followed by the lower extremity

Epidemiology: Missed Playing Time

  • ACL Injuries found to have the most game time missed in profesional hockey players[4]
  • 50.9% of NHL players missed at at least 1 game between 2009 and 2012[7]
    • Most sustaining leg/foot injuries
    • Salary loss of 68.2$ million


Mechanism of injury reported during regular season and postseason games between 2009 and 2012 (McKay, 2014)

Introduction to Ice Hockey

  • Ice hockey is played on a hockey rink
  • Each team typically consists of 22 players
    • There are 6 players on the ice for each team at a time; one of them is the goaltender
    • On ice: 2 wingers, 1 center, 2 defensemen, 1 goalie
  • Body contact is common, checking is permitted
  • Players use their stick to pass our shoot the hard rubber puck
  • The goal is to get the puck in the opposing teams goal
  • Professional ice hockey games include three 20 minute periods with an intermission between them
  • In the event the teams are tied at the end of regulation, over time can occur
  • Infraction of the rules can lead to penalties for the players


  • Collision sport with player speeds up to 40 km/h (24.8 m/h)[8]
  • The puck can travel up to 160 km/h (99 m/h)[3]
  • Despite protective gear, there is high energy trauma and collisions

Defining Exposure

  • Estimating and defining exposure is problematic across studies
  • This is compounded by the fact that the game is played in shifts, with varying participation by each player
    • It is uncommon for a single player to have more than 30 minutes of ice time
    • With the exception of the goalie who often plays the whole game

Time Loss

  • Historically, time loss has been used as a surrogate for injury severity
  • Many studies do not differentiate between time loss and non time loss injuries

Governing Bodies


Labeled image of some of the common hockey equipment[9]

Equipment: Regular Players

  • Helmet: strap, optional face cage or visor
  • Neck guard: nylon or ABS plates for puncture resistance, padding
  • Shoulder pads: padded vest with front and back panels
  • Elbow pads: provides forearm and sometimes tricep protection
  • Hockey jersey: covers the shoulder and elbow pads
  • Hockey gloves: worn on hands, very restrictive to protect fingers/thumb
  • Hockey pants: knee length oversized shorts with heavy padding
  • Jockstrap/ pelvic protector: protects the genitals
  • Garter: can be used to hold up hockey socks
  • Shin guards: hard plastic shell on front and outside of leg to protect leg
  • Hockey socks: covers the shin guard
  • Mouthguard: protects teeth and jaw
  • Ice skates: rigid shell with blade on plantar surface to enable player to skate on ice
  • Hockey puck: 3 inch diameter, 1 inch thick, 6 ounces (170 g) vulcanized rubber disk.
  • Hockey stick: made of wood or composite materials, L shaped to move puck around ice

Equipment: Goaltender

  • Goal stick: larger blade than typical stick, widened wooden shaft
  • Goal skates: thicker blade with less ankle support allowing for goalie to slide off skates more easily
  • Goalie mask: more protection designed to withstand high speed impact from pucks
  • Chest/Arm protector: more thickly padded than typical players shoulder pads
  • Blocker: Glove with rectangular pad, worn on side that holds the stick
  • Catch glove/trapper: Worn on opposite hand, used to gather puck or catch a flying shot
  • Goal jock/jill: more pelvic padding than regular players jock
  • Goal pants: thicker thigh padding with additional protection
  • Goal pads: thick padding for the legs covering shins and knees
  • Socks: cover from leg to foot

Risk Factors

Timing of Injury

  • Risk of injury in games is significantly higher than in practice
    • Estimates range from 2 to 8 times[2]
    • Asian Ice Hockey League estimated 6.6 times increased risk in game[10]
  • More injuries are reported at home than on the road (51.5% vs 48.5%)
  • Period
    • Injuries are more common in the first period than the second or third period[3]
    • The second period had the highest percentage of injuries at 34.6%[5]

Player Position

  • McKay et al study [3]
    • Defenseman: more likely to report an injury involving missed game time [IDR=1.21; 95% CI 1.14 to 1.28)]
    • No difference between defense and goalies or forward and goalies
  • Touminen et al[5]
    • Injuries were equally distributed according to player position
    • Wing (37%) (two per team), Center (18.4%), Defense (36.8%) (two per team).
    • Goalkeeper: 3.5% of all injuries (despite being on the ice the entire game)

Predictors of Time Loss

  • McKay et al study [3]
    • Being a goalie (OR=1.68, 95% CI 1.18 to 2.38)
    • Being injured in a road game (OR=1.43, 95% CI 1.25 to 1.63)
    • Mechanism of injury being a body check (OR=2.21, 95% CI 1.86 to 2.62)

Contact with the Boards

  • Touminen et al[5]
    • Majority of injuries occur away from the boards (68.5%)
    • Shoulder injuries are the most common injury from contact with the boards (27.3%)
    • Majority of concussions occurred without board contact (55.8%)

Causes of Injury

  • Three most common causes: body checking (27.2%), and stick (21.1%) and puck (12.3%) contact.[5]
    • Majority of the injuries caused by stick were head injuries (76.9%).
  • Player collision
    • Body checking was the most common mechanism of injury (28.2%) and also responsible for the most missed game time
  • Board
  • Stick
  • Ice
  • Goal
  • Non-direct
  • Skate
  • Puck

Injury Severity

  • Majority of players returned from injury within 1 week (53.8%)
    • 14.5% of the injured players did not return for at least 3 weeks

Return From Injury

  • Lubbe et al NHL players in first season after returning from injury were significantly reduced following[11]
    • Hip arthroscopy (HA)
    • Noninstability shoulder arthroscopy
    • Knee arthroscopy
    • Core muscle injury repair


  • Hockey is one of the highest concussion risk sports
    • Pfister et al: #2 at 1.2 per 1000 athlete exposures (#1 is rugby, #3 is American football)[12]
    • Kontos et al: Second article: 1.58 concussions per 1000 athlete exposures[13]
  • Kontos et al study in pediatric hockey players[13]
    • Occur more frequently in games (2.46 per 1000 AE), when compared to practice (1.17 per 1000 AE)
    • Younger players are more likely to be concussed
    • Most common mechanism is player-to-player contact, half involve secondary contact with boards
    • Youth leagues that permit body checking have a higher incidence than those which do not
  • Ornon et al[2]
    • Risk of severe concussion is much higher in defensemen
    • Responsible for 14% of all time loss, 12% of injuries with time loss
  • Touminen et al[5]
    • Most common cause for concussion was check to the head (51.9%)
    • Estimated time loss was more than 3 weeks in 7.7% of the cases
    • Position risk: Center (25%), defense (20.2%), wing (17.3%)
    • Nearly half of concussions occur in the first period (42.3%)


Famous laceartion along the left side of Sebastican Courcelles
Frontal view of 17-year-old male who was hit in the face with a hockey stick. Teeth 31 and 41 are displaced lingually by approximately 6 mm[14]


  • Hit by stick is most common reason for dental or facial injuries[15]
    • Accounts for 54% of facial trauma

Facial Laceration

  • Touminen et al[5]
    • Represents 74.3% of the facial injuries
    • 59.3% of them caused by stick

Dental Trauma

  • Touminen et al: 9.5% of head injuries[5]
    • Nearly 50% of injuries occur from the stick (48.9%)[16]
  • General commentary
    • Dental injuries are permanent
    • Also cause complications later in life
  • Lahti et al looked at dental injuries in Finland (1991 to 1992)[16]
    • 650 dental injuries, 915 damaged teeth
    • Most common diagnosis was noncomplicated crown fracture
    • Approximately two thirds occurred during games (66.8%) as opposed to training
    • 6 players had maxillofacial fractures
    • 50% of injuries involved the upper central incisors
  • Late complications[17]
    • Root resorption
    • Periapical lesion
    • Pulpal obliteration
    • Loss of vitality

Eye Trauma

  • Touminen et al: 1.4% of head injuries[5]


Admission T2-weighted MRI of the cervical spine demonstrating posterior displacement of the upper cervical spinal column, at and above the C5 vertebra, with epidural hematoma noted in the region of C5[18]


  • Zupon looked at spinal injuries in NCAA athletes[19]
    • Most injuries occurred in competition
    • 65.9% resulted in no lost playing time
    • 40% of injuries were to the lumbar spine, 39.2% to the cervical spine
    • Most injuries were classified as pain or spasm
    • Most common mechanism in games: contact
    • Most common mechanism in training: noncontact (33.3%), overuse (21.9%)
  • Fett showed a higher prevalence of back pain in German hockey players compared to all German athletes[20]

Cervical Spine Injuries

  • Ice hockey has the highest incidence of c-spine injuries of any sport[21]
  • Common mechanism: hit from behind which pushes the player into the boards with a slightly flexed neck[22]
  • Mai looked at NHL players treated surgically for cervical disc herniation[23] ** No significant decrease in performance postoperatively
  • For patients undergoing ACDF (anterior cervical discectomy and fusion)[24]
    • Radiographic union occurred at an average of 7.3 months
  • Factors which have reduced cervical spine injuries[22]
    • Banning checking from behind
    • Stricter enforcement of the rules
    • Increased spine injury prevention
  • NATA recommendation for equipment[25]
    • Hockey helmet does not afford the same stability as the helmet, shoulder pads in football
    • Shoulder pads should be removed, injured player transferred to a backboard with a log roll technique.
  • Return to play criteria[25]
    • Not standardized
    • Minimum requirements: full stable, pain-free range of motion, normal symmetric strength, absent neuro deficits

Lumbar Spondylolysis

  • Donaldson 44% of junior hockey players with low back pain had lumbar spondylolysis[26]
    • L5 (55%) followed by L4 (36%)
    • 73% of cases occurred on the players shooting side, 67% occurred in forwards
    • Average return to play was 8 weeks, 96% of athletes continued to play at an elite level

Lumbar Disc Herniation

  • Hsu et al[27]
    • >80% return-to-play rate at an average of 2.9 years after diagnosis
    • Significant decrease in games played and performance .
    • Nonoperative treatment returned to sport at a greater rate, played more games
    • Operative treatment had less of a drop off in performance

Upper Extremity

Rockwood classification of acromioclavicular joint injuries[28]
(A) Rockwood type III acromioclavicular (AC) joint injury in an ice hockey player treated with AC ligament reconstruction. (B) After sufficient postoperative recovery and graduated return to play, the same player reported shoulder pain after a separate incident just over 1 year after surgical intervention, resulting from a collision into the boards. A distal clavicle fracture about one of the bone tunnels from the reconstruction is demonstrated. A decision was made for nonoperative management. (C) At 1 year after injury, the player had successful return to play.[29]


  • Hostetler et al[30]
    • Most common site of youth hockey injuries (44%)
    • Sprains, strains, lacerations are the most commonly reported injuries
  • Shoulder is most commonly injured (49.6%) followed by fingers (14.2%), wrist (10.8%) and hand (10.8%)
  • Touminen et al: 40.4% of shoulder injuries are to the glenohumeral joint[5]
  • Gil reported an incidence of 0.60 per 10,000 AEs for operative UE injuries in collegiate athletes[31]
  • Melvin et al looked at upper extremity injuries among NCAA athletes[32]
    • The shoulder was most common (54.4%), followed hand (18.9%), and wrist (13.8%)
    • Common injuries were sprains (40.4%), contusions (19.9%), and fractures (9.5%).
    • The most common injury was AC joint sprain


Asymptomatic Shoulder

  • Hacken et al obtained an MRI on 25 asymptomatic hockey players[33]
    • 25% had labral tears, 75% found in the nondominant stick hand
    • 8% had AC Joint abnormalities
    • 6% had rotator cuff tears
    • Shoulder pathology was more common in the dominant shoulder

Acromioclavicular Joint Injury

  • Most commonly injured joint in hockey players[34]
  • Touminen et al: 50.5% of shoulder injuries [5]
  • Hibberd examined AC joint sprains in college athletes[35]
    • most commonly injured positions were forwards (57.5%) and defenseman (29.1%)
    • 37.9% of these sprains resulting in no time lost
    • 11.1% of these sprains were diagnosed as severe (defined as >3 weeks time lost or season ending).

Anterior Shoulder Dislocation

  • Common in hockey
    • Direct blow to posterior shoulder or collision forcing extended shoulder into abduction, external rotation[36]
  • Dwyer reported on MRI findings among NHL athletes who experienced a shoulder subluxation or dislocation[37]
    • 75% of players had Bankart lesions
    • 54.2% had a Hill-Sachs lesion
    • Labral Tear: 20.8% had a Type 2 SLAP tear, 8.3% had isolated posterior labral tears
    • 12.5% of players had a glenoid bony defect, all of which were <25% of the anteroinferior glenoid
  • Shoulder Stability Brace can be considered in players, helps prevent:
    • Excessive range of motion
    • Prevent repeat dislocation
    • Aid in proprioception

Clavicle Fracture

  • Common upper extremity injury in hockey
  • Skeletal maturity
    • Clavicular physis open until age 21
    • Important to evaluate radiographically
  • Surgical management
    • Operative repair for displaced midshaft fractures lowers recurrence risk[38]
    • Fractures with significant shortening/displacement, surgery may lower rate of nonunion/malunion[39]
    • Surgical management of minimally displaced midshaft fractures improves cosmesis and long term results[40]
    • Return to play can occur at 10-12 weeks when strength and range of motion have returned
  • Hebert-Davies and Agel reported average time from injury to return to play data[41]
    • 65 days for operative management
    • 97.6 days for nonoperative management
  • Norfray anaylzed the clavicle radiographs of 77 NHL players in the 1970s[42]
    • Findings: 8 ligamentous injuries, 6 AC joint subluxations, 2 AC joint dislocations, 2 distal
    • Follow up radiographs: ligament calcification (2 players with dislocation), 1 distal clavicle surgical excision, 1 post traumatic AC joint arthritis

Glenohumeral Instability

  • Hovelius followed 63 Swedish hockey players following a sentinel dislocation[43]
    • All players were under 30 years of age at time of first dislocation
    • Recurrence rate was 90% in players under 20, 50% in players > 25
  • Rangavajjula reported on 11 NHL players who returned after arthroscopic labral repair[44]
    • Return to play average was 4.3 months
    • No difference in hand dominance, performance after return to play


Olecranon Bursitis

  • Can be seen in hockey players, incidence unknown

Hand and Wrist


  • Gotlin et al looked at hand, wrist and forearm fractures among NHL players[45]
    • 30.8% Finger
    • 38.5% Hand
    • 13.8% Thumb
    • 14.6% Wrist
    • 2.4% Forearm

Metacarpal Fractures

  • Etiology
    • Occur most commonly in leagues which allow fighting
    • Can result from contact with pucks, sticks or collisions with boards
  • Fifth Metacarpal Fracture likely most common (need citation)

Os Styloideum

  • One study found a prevalence of 81% which is significantly higher than the general population[46]

Gamekeepers Thumb

  • Rovere study from minor league players between 1973 and 1975[47]
    • All players successful treated with thumb spica cast
    • No residual index pinch instability, time lost to secondary injury

Dorsal Ulnotriquetral Ligament Injury

  • Often termed "Hockey Wrist"
  • Ulnar sided wrist pain at the dorsal proximal triquetrum
    • Especially during wrist pronation, flexion and radial deviation
  • Likely occurs in the proximal hand on the hockey stick held in flexion-pronation
    • When combined with the torque to thew wrist in radial deviation
  • Not well characterized in the literature
    • Hard to distinguish from other causes of ulnar sided wrist pain


Adductor strains are particularly common in goalies[48]

Groin and Abdominal Strains

  • Can include: Abdominal Strain, Adductor Strain
  • Among NHL players, the rate increased from 12.99 per 100 player years (1991 season) to 19.87 per 100 player years (1997)[49]
    • Majority were noncontact adductor strains
    • 23.5% recurrence rate
    • Time lost greater in abdominal injuries than groin injuries
  • Groin Injury risk increases
    • Player completed <18 offseason training sessions
    • Adductor strength <80% of their abductor strength
  • Eckard et al NCAA Injury Surveillance Program[50]
    • Both hip flexor and adductor strains were often from noncontact injuries
    • Resulted in <24 hours of gametime loss
    • Hip flexor strains more likely to be recurrent

Hockey Groin Syndrome

  • Small tear in external oblique aponeurosis
    • Contains branches of ilioinguinal or iliohypogastric nerves

Core Muscle Injuries

  • NHL players returning to play following repair of external oblique aponeurosis[51]
    • No complications
    • Most had decreased assists, games played compared to control

Athletica Pubalgia

  • Consider in hockey players with groin pain exacerbated by valsalva maneuver or situps

Lower Extremity


  • Lower extremity injuries represent 30-45% of all hockey injuries[3][5]
  • Knee is most commonly injured part of the lower body (46.9%), followed by ankle and thigh injuries
  • Donaldson et al[52]
    • Thigh and knee injuries account for #2 and #3 cause of missed playing time
    • Injuries to the leg and foot resulting in the highest percentage of lost salary
  • Intra-articular Hip Injuries[53]
    • Incidence is 2.63 per 1000 AEs, most occur in game
    • Goal keepers, older players more likely to have intra-articular hip disease
    • Frequency in order: labral tearing, osteoarthritis, loose body, and femoroacetabular impingement (FAI)


Asymptomatic Hip Screening

  • Multiple NHL studies: high rates of asymptomatic hip labral tears, acetabular retroversion, cam-type morphology
  • Cam-type morphology correlating with decreased hip range of motion, positive anterior impingement
  • Goalkeepers had the highest prevalence of cam-type deformity, the least acetabular coverage
  • Wornet et al: one-half of Swedish professional hockey players reported hip and groin problems[54]
  • Silvis et al: 64% of asymptomatic American Hockey League players had magnetic resonance imaging (MRI) findings of hip pathology[55]
  • Ayeni et al: junior hockey athletes more likely to have radiographic findings of cam but not pincer impingement (compared with nonathletes)[56]

Hip Arthroscopy

  • Schallmo looking at NHL players following hip arthroscopy[57]
    • NHL players returned to sport at a significantly greater rate compared with National Basketball Association, National Football League, and Major League Baseball (MLB)
    • NHL players had a significant decrease in performance 1 season after surgery compared with their baseline
Anteroposterior radiograph of the pelvis (preoperative) demonstrating bilateral cam-type impingement[58]

Femoroacetabular Impingement (FAI)

  • Cam impingement is the most common type observed in ice hockey athletes
  • Youth and elite hockey players have shown a significantly higher prevalence of radiographic cam impingement compared with other athletes and the general population[59][60]
  • Proposed etiology in hockey players
    • Repetitive loading of the hip when skating can cause subclinical microtrauma, subsequent pathological remodeling of the femoral head
  • Sochaki studied 70 NHL players who underwent HA for FAI (2000 to 2016)[61]
    • 90% of athletes returned to sport at an average of 6.8 months
    • There was an 84.4% 1-year NHL career survival rate
    • Matched control players had significantly longer careers compared with those who had surgery
  • Menge followed 60 NHL players undergoing HA for FAI[62]
    • 67% continued to play professionally a minimum of 5 years after HA
    • Career length correlated with age at time of surgery.
  • Philippon studied 24 professional hockey players who underwent HA for FAI[63]
    • Average time to return to training was 3.4 months
    • The average modified Harris Hip Score improving from 70 to 95
  • 17 NHL athletes underwent arthroscopic microfracture of the hip, 82% of athletes returned to play with no change in performance[64]
  • Bizzini followed 5 Swiss national athletes who underwent open surgery for FAI[65]
    • Average return to gameplay was 9.6 months
    • 2 athletes unable to return to their previous level of play

Iliac Crest Contusion

  • Often called a 'Hip Pointer'
  • Occur when the hip abductor musculature is compressed against the ilium[40]
    • Often as a result of being checked into the boards

Quadriceps Contusions

  • Occur in defenseman trying to block a shot
  • Once identified, ice in a flexed position to minimize hematoma, decrease swelling


Medial Collateral Ligament Injury

  • Most commonly reported knee injury in hockey players
    • Second most common cause of missed games at the National Collegiate Athletic Association (NCAA) level[66]
  • Touminen et al[5]
    • MCL Strain represents 56.6% of knee injuries
    • Grade 1 strain is most common
  • Etiology
    • Most injuries are sustained as a result of player on player contact producing a valgus stress on the knee[66]
  • Risk is higher in forwards than defensemen[2]
  • Return to play[40]
    • Most isolated grade I and II return same month
    • Isolated grade III take 6-8 weeks

ACL Tear

  • Relatively uncommon injury in hockey
    • More common in female hockey players than males[67]
  • Touminen et al: 10.5% of knee injuries[5]
  • Longestaffe reviewed the NHL database from 2006 to 2016[68]
    • Identified 67 ACL tears, forwards were most susceptible
    • Compared to controls, athletes with ACL tear had decreased performance, no decrease in games or seasons played following the injury
  • Erickson reviewed 37 NHL players undergoing ACL recon (1990-2013)[69]
    • 97% returned at a mean of 7.8 months
    • Length of career was a mean of 4.47 with a 2.5% revision rate
    • No significant difference in performance pre- and post injury
  • Sikka examined ACL injuries among 47 NHL players (2006 to 2010)[70]
    • Significant decrease in postop performance and career compared to controls
    • 8.5% of players had a failure with a 20% reoperation rate
    • 10.6% of players did not return at al
    • 8.5% of players were unable to return to play for a full season
  • Mai et al compared NHL players to NFL, NBA and MLB undergoing ACL reconstruction[71]
    • NHL players had a higher return to play (95.8% vs 83.4%)
    • Shorter average recovery time (258 days vs 367 days)
    • Smallest decrease in performance the season after ACLR
  • Delayed reconstruction?[34]
    • Ice provides a low friction environment
    • Some players can continue the season with torn ACL in isolation, postpone reconstruction to postseason
    • Avoid if significant laxity, instability or meniscal injury
  • Return to play[72]
    • Most return to play within 6-12 months
    • Approx 80% can continue to play for 1 or more seasons
    • Less likely to RTP/ achieve same level of success if concomitant meniscus injury

Meniscus Tear

  • Touminen et al: 14.5% of knee injuries[5]

Osteochondral Defect of the Knee

  • NHL players had 100% return to play rates following microfracture surgery[73]

Patellar Tendonitis

  • There was a 13% prevalence among Norwegian hockey players[74]
    • Hockey players were the least symptomatic due to lack of jumping in Hockey

Foot and Ankle

Skate bite aka lace bit[75]
Widening of the mortise view consistent with complete disruption of the syndesmosis[76]


  • Crowley examined foot and ankle injuries among NCAA athletes[77]
    • 87% occurred during the regular season
    • The most common injury being foot contusions
    • High ankle sprains accounted for the most severe time loss (>14 days)
    • Foot contusions accounted for the most moderate time lost (<14 days).

Skate Bite (aka Lace Bite)

  • Manifests as anterior ankle pain
  • Results from stiff, poorly broken in new skates or older skates whos tongue has become inflexible[40]
  • Repeated pressure on the ankle against the stiff surface results in inflammation of tendons responsible for dorsiflexion
  • The tibialis anterior is most commonly implicated
  • Treatment/Prevention
    • "Breaking in" the skate with repeated, manual tongue flexion
    • placing a piece of foam on the interior of the tongue as a cushion
    • NSAIDS

Ankle Fracture

  • Relatively uncommon in hockey players
  • Baker et al obtained MRI in 31 NHL athletes, identifying 27 bony injuries[78]
    • 10 were occult fractures
    • Direct impact injury was more likely to cause a bony injury
    • Typically, seen in the medial foot or ankle

Lateral Ankle Sprain

  • Most occur during gametime due to contact[79]

High Ankle Sprain (Syndesmotic Sprain)

  • Tends to occur at higher frequency than lateral ankle sprains
    • Atypical compared to most other sports
  • 69% of high ankle sprains in college athletes occurred during competition[80]
  • Syndesmotic sprains can take a long time to heal in hockey
    • Primarily due to frequent twisting and change in direction
  • Wright et al: average of 45 days of recovery time[81]
    • Up to 12 weeks of recovery time has been observed
    • Lateral ankle sprain often only miss a few days
  • Mollon prospectively evaluated high ankle sprains in NHL athletes (2006 - 2012)[82]
    • 81% of these injuries caused an average of 8 games missed


Flexible Boards and Glass

  • Touminen et al[5]
    • 29% lowr risk of injury where flexible boards/glass were used (compared to traditional boards/glass)
    • Shoulder injury rate went from 2.2/1000 player-games to 0.9/1000 player-games
    • There was an approximately 57% reduction in concussions
    • Trend towards decrease in all other types of injuries


  • Mandated by NHL in 1979[83]
  • Decreases the rate of fatal and catastrophic head injuries
  • Paradoxical increase in concussions[84]
    • Thought to be the result of players feeling more invincible, increased awareness of concussions
  • Evidence that helmets protect against concussion is inconclusive[84]

Face Shields

  • The introduction of full facial shields has dramatically decreased the incidence of ocular, dental, and facial injuries[85]

Mouth Guards

  • Ineffective at reducing the severity of concussion[12]

Rule Enforcement

  • Illegal play is estimated to account for between 26.3% and 66% of total injuries
  • Checking and pushing from behind were made illegal
    • Primary mechanism of cervical spine injury is an axial load on a flexed neck

Strength and Conditioning Programs

  • Increasing the strength and endurance of joints and muscles is important in preventing musculoskeletal injuries
  • Unknown if there is any hockey centric research looking at strength and conditioning and injury prevention

Case Reports


  • Commotio Cordis: A 15 year old hockey player died after being struck in the chest by a puck[86]


  • Sports Hernia: A processional ice hockey player sustained an abdominal injury, was diagnosed with a sports hernia, treated conservatively, made a full recovery 7 weeks post injury and continued to compete professionally in the NHL[87]

Upper Extremity

  • Carpal Boss: An elite teenage hockey player was treated and able to return to play after two weeks without restriction or need for surgical consultation[88]

Lower Extremity

  • Meniscus Tear: Processional ice hockey goal tender was treated surgically for an arthroscopically repaired isolated lateral meniscus and was able to return to sport 103 days later and was still competing professionally up to 5 years later[89]
  • Lisfranc Injury: A NHL player sustained a lisfranc injury requiring surgical stabilization but was able to return to professional play[90]

See Also


  1.  Kenth Hansen, International Society of Olympic Historians, "The Birth of Swedish Ice Hockey – Antwerp 1920", Journal of Olympic History (JOH, formerly Citius, Altius, Fortius)
  2. 2.0 2.1 2.2 2.3 Ornon, Gregory, et al. "Epidemiology of injuries in professional ice hockey: a prospective study over seven years." Journal of experimental orthopaedics 7 (2020): 1-8.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 McKay CD, Tufts RJ, Shaffer B, Meeuwisse WH (2014) The epidemiology of professional ice hockey injuries: a prospective report of six NHL seasons. Br J Sports Med 48(1):57–62
  4. 4.0 4.1 Szukics, Patrick F., et al. "A scoping review of injuries in amateur and professional men’s ice hockey." Orthopaedic journal of sports medicine 10.4 (2022): 23259671221085968.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 Tuominen, Markku, et al. "Injuries in men's international ice hockey: a 7-year study of the International Ice Hockey Federation Adult World Championship Tournaments and Olympic Winter Games." British journal of sports medicine 49.1 (2015): 30-36.
  6. Pfo¨ rringer W, Smasal V. Aspects of traumatology in ice hockey. J Sports Sci. 1987;5(3):327-336.
  7. Donaldson L, Li B, Cusimano MD. Economic burden of time lost due to injury in NHL hockey players. Inj Prev. 2014;20(5):347-349.
  8. Flik K, Lyman S, Marx RG (2005) American collegiate men's ice hockey: an analysis of injuries. Am J Sports Med 33(2):183–187
  9. Image courtesy of https://spmha.ab.ca/, "hockey equipment"
  10. Kuzuhara K, Shimamoto H, Mase T. Ice hockey injuries in a Japanese elite team: a 3- year prospective study. J Athl Train. 2009;44(2): 208-214.
  11. Lubbe RJ, Freshman RD, Singh G, et al. Performance outcomes and return-to-sport rate of National Hockey League athletes vary after common orthopedic surgical procedures. Clin J Sport Med. 2021; 31(1):57-62. doi:10.1097/JSM.0000000000000696
  12. 12.0 12.1 Pfister T, Pfister K, Hagel B, et al. The incidence of concussion in youth sports: a systematic review and meta-analysis. Br. J. Sports Med. 2016; 50:292Y7.
  13. 13.0 13.1 Kontos AP, Elbin RJ, Sufrinko A, et al. Incidence of concussion in youth ice hockey players. Pediatrics. 2016; 137:e20151633.
  14. Afrashtehfar, Cyrus DM, Annie Marleau, and Kelvin I. Afrashtehfar. "HOW DO I MANAGE A PATIENT WITH LATERAL LUXATION OF A PERMANENT INCISOR?." Journal of the Canadian Dental Association 82.g21 (2016): g21.
  15. Sane, Juha, P. E. K. K. A. Ylipaavalniemi, and H. E. I. K. K. I. Leppänen. "Maxillofacial and dental ice hockey injuries." Medicine and science in sports and exercise 20.2 (1988): 202-207.
  16. 16.0 16.1 Lahti, Harri, Juha Sane, and Pekka Ylipaavalniemi. "Dental injuries in ice hockey games and training." Medicine and science in sports and exercise 34.3 (2002): 400-402.
  17. Häyrinen‐Immonen, Ritva, et al. "A six‐year follow‐up study of sports‐related dental injuries in children and adolescents." Dental Traumatology 6.5 (1990): 208-212.
  18. Yue, James J., Paul C. Ivancic, and David L. Scott. "Teardrop fracture following head-first impact in an ice hockey player: Case report and analysis of injury mechanisms." International journal of spine surgery 10 (2016).
  19. Zupon AB, Kerr ZY, Dalton SL, Dompier TP, Gardner EC. The epidemiology of back/neck/spine injuries in National Collegiate Athletic Association men’s and women’s ice hockey, 2009/2010 to 2014/ 2015. Res Sports Med. 2018;26(1):13-26. doi:10.1080/15438627. 2017.1365295
  20. Fett D, Trompeter K, Platen P. Back pain in elite sports: a crosssectional study on 1114 athletes. PLoS One. 2017;12(6):e0180130.
  21. Banerjee R, Palumbo MA, Fadale PD. Catastrophic cervical spine injuries in the collision sport athlete, part 1: epidemiology, functional anatomy, and diagnosis. Am. J. Sports Med. 2004; 32:1077Y87.
  22. 22.0 22.1 Tator CH, Provvidenza C, Cassidy JD. Update and overview of spinal injuries in Canadian Ice Hockey, 1943 to 2011: the continuing need for injury prevention and education. Clin. J. Sport Med. 2016. doi:10.1097/JSM.
  23. Mai HT, Chun DS, Schneider AD, Hecht AC, Maroon JC, Hsu WK. The difference in clinical outcomes after anterior cervical fusion, disk replacement, and foraminotomy in professional athletes. Clin Spine Surg. 2018;31(1):E80-E84.
  24. Watkins RG IV, Chang D, Watkins RG III. Return to play after anterior cervical discectomy and fusion in professional athletes. Orthop J Sports Med. 2018;6(6):2325967118779672.
  25. 25.0 25.1 NATA. Executive Summary of Appropriate Care of the Spine Injured Athlete Inter-Association Consensus. St Louis, Missouri. 2015. http://www.nata.org/ sites/default/files/Executive-Summary-Spine-Injury611 updated.pdf.
  26. Donaldson LD. Spondylolysis in elite junior-level ice hockey players. Sports Health. 2014;6(4):356-359.
  27. Hsu WK, McCarthy KJ, Savage JW. The professional athlete spine initiative: outcomes after lumbar disc herniation in 342 elite professional athletes. Spine J. 2011;11(3):180-186.
  28. Popkin, Charles A., et al. "Head, neck, and shoulder injuries in ice hockey: current concepts." American Journal of Orthopedics 46.3 (2017): 123-134.
  29. Jang, Eugene S., et al. "A current concepts review of clavicle injuries in ice hockey from sternoclavicular to acromioclavicular joint." Orthopaedic journal of sports medicine 8.9 (2020): 2325967120951413.
  30. Hostetler S, Xuang H, Smith G. Characteristics of ice hockey injuries treated in US emergency departments 2001Y2002. Pediatrics. 2004; 114:6.
  31. Gil JA, Goodman AD, DeFroda SF, Owens BD. Characteristics of operative shoulder injuries in the National Collegiate Athletic Association, 2009-2010 through 2013-2014. Orthop J Sports Med. 2018; 6(8):2325967118790764
  32. Melvin PR, Souza S, Nelson Mead R, Smith C, Mulcahey MK. Epidemiology of upper extremity injuries in NCAA men’s and women’s ice hockey. Am J Sports Med. 2018;46(10):2521-2529. doi:10.1177/0363546518781338
  33. Hacken B, Onks C, Flemming D. Prevalence of MRI shoulder abnormalities in asymptomatic professional and collegiate ice hockey athletes. Orthop J Sports Med. 2019;7(10):2325967119876865
  34. 34.0 34.1 Moslener MD, Wadsworth LT. Ice hockey: a team physician’s perspective. Curr. Sports Med. Rep. 2010; 9:134Y8.
  35. Hibberd EE, Kerr ZY, Roos KG, Djoko A, Dompier TP. Epidemiology of acromioclavicular joint sprains in 25 National Collegiate Athletic Association sports: 2009-2010 to 2014-2015 academic years. Am J Sports Med. 2016;44(10):2667-2674
  36. Youm T, Takemoto R, Park BK. Acute management of shoulder dislocations. J. Am. Acad. Orthop. Surg. 2014; 22:761Y71.
  37. Dwyer T, Petrera M, Bleakney R, Theodoropoulos JS. Shoulder instability in ice hockey players: incidence, mechanism, and MRI findings. Clin J Sport Med. 2013;32(4):803-813.
  38. Canadian Orthopaedic Trauma Society. Non operative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicentre randomised clinical trial. J. Bone Joint Surg. Am. 2007; 89<A:1Y10.
  39. Mckee RC, Whelan DB, Schemitsch EH, Mckee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J. Bone Joint Surg. Am. 2012; 94:675Y84.
  40. 40.0 40.1 40.2 40.3 Laprade RF, Surowiec RK, Sochanska AN, et al. Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries. Br. J. Sports Med. 2014; 48:4Y10.
  41. Hebert-Davies J, Agel J. Return to elite-level sport after clavicle fractures. BMJ Open Sport Exerc Med. 2018;4(1):e000371.
  42. Norfray JF, Tremaine MJ, Groves HC, Bachman DC. The clavicle in hockey. Am J Sports Med. 1977;5(6):275-280. doi:10.1177/03635465 7700500616
  43. Hovelius L. Shoulder dislocation in Swedish ice hockey players. Am J Sports Med. 1978;6(6):373-377.
  44. Rangavajjula A, Hyatt A, Raneses E, McCrossin J, Cohen S, DeLuca P. Return to play after treatment of shoulder labral tears in professional hockey players. Phys Sportsmed. 2016;44(2):119-125.
  45. Gotlin, Matthew J., et al. "Performance and return to sport after hand, wrist, and forearm fractures in the national hockey league." Arthroscopy, sports medicine, and rehabilitation 2.5 (2020): e505-e510.
  46. Greditzer HG IV, Hutchinson ID, Geannette CS, Hotchkiss RN, Kelly BT, Potter HG. Prevalence of os styloideum in National Hockey League players. Sports Health. 2017;9(5):469-473.
  47. Rovere GD, Gristina AG, Stolzer WA, Garver EM. Treatment of “gamekeeper’s thumb” in hockey players. Am J Sports Med. 1975; 3(4):147-151.
  48. Image courtesy of next-level-athletics.com, "quick groin strain cure"
  49. Emery CA, Meeuwisse WH, Powell JW. Groin and abdominal strain injuries in the National Hockey League. Clin J Sport Med. 1999;9(3): 151-156.
  50. Eckard TG, Padua DA, Dompier TP, Dalton SL, Thorborg K, Kerr ZY. Epidemiology of hip flexor and hip adductor strains in National Collegiate Athletic Association athletes, 2009/2010-2014/2015. Am J Sports Med. 2017;45(12):2713-2722.
  51. Jakoi A, O’Neill C, Damsgaard C, Fehring K, Tom J. Sports hernia in National Hockey League players: does surgery affect performance? Am J Sports Med. 2013;41(1):107-110.
  52. Donaldson L, Li B, Cusimano MD. Economic burden of time lost due to injury in NHL hockey players. Inj. Prev. 2014; 20:347Y9.
  53. Epstein DM, McHugh M, Yorio M, Neri B. Intra-articular hip injuries in National Hockey League players. Am J Sports Med. 2013;41(2): 343-348. doi:10.1177/0363546512467612
  54. Wo¨ rner T, Thorborg K, Eek F. High prevalence of hip and groin problems in professional ice hockey players, regardless of playing position. Knee Surg Sports Traumatol Arthrosc. 2020;28(7):2302-2308.
  55. Silvis ML, Mosher TJ, Smetana BS. High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players. Am J Sports Med. 2011;39(4):715-721.
  56. Ayeni OR, Banga K, Bhandari M. Femoroacetabular impingement in elite ice hockey players. Knee Surg Sports Traumatol Arthrosc. 2014; 22(4):920-925.
  57. Schallmo M, Fitzpatrick T, Yancey H, Marquez-Lara A, David Luo T, Stubbs AJ. Return- to-play and performance-based outcomes following hip arthroscopy for American professional athletes in different sports. Arthroscopy.2018;34(12):e15.doi:10.1016/j.arthro.2018.10.051
  58. Royston, Eric, and Lisabeth Bush. "Femoroacetabular impingement: A classic case of cam-type impingement in a 21-year-old soldier." Radiology Case Reports 9.3 (2014): 781. at the femoral head-neck junctions.
  59. Dalton SL, Zupon AB, Gardner EC, et al. The epidemiology of hip/groin injuries in National Collegiate Athletic Association men’s and women’s ice hockey: 2009Y2010 through 2014Y2015 academic years. Orthop. J. Sports Med. 2016; 4:2325967116632692.
  60. Lerebours F, Robertson W, Neri B, et al. Prevalence of cam-type morphology in elite ice hockey players. Am. J. Sports Med. 2016; 44:1024Y30.
  61. Sochacki KR, Jack RA, Hirase T, Vickery J, Harris JD. Performance and return to sport after hip arthroscopy for femoracetabular impingement syndrome in National Hockey League players. J Hip Preserv Surg. 2019;6(3):234-240. doi:10.1093/jhps/hnz030
  62. Menge TJ, Briggs KK, Philippon MJ. Predictors of length of career after hip arthroscopy for femoroacetabular impingement in professional hockey players. Am J Sports Med. 2016;44(9):2286-2291.
  63. Philippon M, Schenker M, Briggs K, Kuppersmith D. Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):908-914.
  64. McDonald JE, Herzog MM, Philippon MJ. Return to play after hip arthroscopy with microfracture in elite athletes. Arthroscopy. 2013; 29(2):330-335.
  65. Bizzini M, Notzli HP, Maffiuletti NA. Femoroacetabular impingement in professional ice hockey players: a case series of 5 athletes after open surgical decompression of the hip. Am J Sports Med. 2007;35(11): 1955-1959.
  66. 66.0 66.1 Grant JA, Bedi A, Kurz J, et al. Incidence and injury characteristics of medial collateral ligament injuries in male collegiate ice hockey players. Sports Health. 2013; 5:270Y2.
  67. Stanley LE, Kerr ZY, Dompier TP, Padua DA. Sex differences in the incidence of anterior cruciate ligament, medial collateral ligament, and meniscal injuries in collegiate and high school sports: 2009Y2010 through 2013Y2014. Am. J. Sports Med. 2016; 3.
  68. Longstaffe R, Leiter J, MacDonald P. Anterior cruciate ligament injuries in the National Hockey League: epidemiology and performance impact. Clin J Sport Med. 2020;30(3):224-230.
  69. Erickson BJ, Harris JD, Cole BJ. Performance and return to sport after anterior cruciate ligament reconstruction in National Hockey League players. Orthop J Sports Med. 2014;2(9):2325967114548831.
  70. Sikka R, Kurtenbach C, Steubs JT, Boyd JL, Nelson BJ. Anterior cruciate ligament injuries in professional hockey players. Am J Sports Med. 2016;44(2):378-383.
  71. Mai HT, Chun DS, Schneider AD. Performance-based outcomes after anterior cruciate ligament reconstruction in professional athletes differ between sports. Am J Sports Med. 2017;45(10):2226-2232.
  72. Sikka R, Kurtenbach C, Steubs JT, et al. Anterior cruciate ligament injuries in professional hockey players. Am. J. Sports Med. 2016; 44:378Y83.
  73. Schallmo MS, Singh SK, Barth KA, Freshman RD, Mai HT, Hsu WK. A cross-sport comparison of performance-based outcomes of professional athletes following primary microfracture of the knee. Knee. 2018;25(4):692-698.
  74. Lian ØB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med. 2005;33(4):561-567. doi:10.1177/0363546504270454
  75. Image courtesy of lacebitenerd.com, "spending a year testing lace bite treatments for hockey"
  76. Molinari, A., M. Stolley, and A. Amendola. "High ankle sprains (syndesmotic) in athletes: diagnostic challenges and review of the literature." The Iowa Orthopaedic Journal 29 (2009): 130.
  77. Crowley SG, Trofa DP, Turner Vosseller J. Epidemiology of foot and ankle injuries in National Collegiate Athletic Association men’s and women’s ice hockey. Orthop J Sports Med. 2019;7(8):232596711 986590. doi:10.1177/2325967119865908
  78. Baker JC, Hoover EG, Hillen TJ, Smith MV, Wright RW, Rubin DA. Subradiographic foot and ankle fractures and bone contusions detected by MRI in elite ice hockey players. Am J Sports Med. 2016;44(5):1317-1323.
  79. Roos KG, Kerr ZY, Mauntel TC, Djoko A, Dompier TP, Wikstrom EA. The epidemiology of lateral ligament complex ankle sprains in National Collegiate Athletic Association sports. Am J Sports Med. 2017;45(1):201-209.
  80. Mauntel TC, Wikstrom EA, Roos KG, Djoko A, Dompier TP, Kerr ZY. The epidemiology of high ankle sprains in National Collegiate Athletic Association sports. Am J Sports Med. 2017;45(9):2156-2163.
  81. Wright RW, Barile RJ, Surprenant DA,MatavaMJ. Ankle syndesmosis sprains in National Hockey League players. Am. J. Sports Med. 2004; 32:1941Y5.
  82. Mollon B, Wasserstein D, Murphy GM, White LM, Theodoropoulos J. High ankle sprains in professional ice hockey players: prognosis and correlation between magnetic resonance imaging patterns of injury and return to play. Orthop J Sports Med. 2019;7(9):2325967119871578.
  83. Biasca N, Wirth S, Tegner Y. The avoidability of head and neck injuries in ice hockey: an historical review. Br. J. Sports Med. 2002; 36:410Y27.
  84. 84.0 84.1 Daneshvar DH, Baugh CM, Nowinski CJ, et al. Helmets and mouth guards: the role of personal equipment in preventing sport-related concussions. Clin. Sports Med. 2011; 30:145Y63.
  85. Benson B, MeeuwisseW. Ice Hockey Injuries. Med. Sport Sci. 2005; 49:86Y119.
  86. Deady, Brian, and Grant Innes. "Sudden death of a young hockey player: case report of commotio cordis." The Journal of emergency medicine 17.3 (1999): 459-462.
  87. Woodward, J. Scott, Andrew Parker, and Robert M. MacDonald. "Non-surgical treatment of a professional hockey player with the signs and symptoms of sports hernia: a case report." International Journal of Sports Physical Therapy 7.1 (2012): 85.
  88. Kissel, Peter. "Conservative management of symptomatic carpal bossing in an elite hockey player: a case report." The Journal of the Canadian Chiropractic Association 53.4 (2009): 282.
  89. Bizzini, Mario, Mark Gorelick, and Thomas Drobny. "Lateral meniscus repair in a professional ice hockey goaltender: a case report with a 5-year follow-up." Journal of Orthopaedic & Sports Physical Therapy 36.2 (2006): 89-100.
  90. Patillo, D., et al. "Lisfranc injury in a national hockey league player: a case report." International journal of sports medicine (2007): 980-984.
Created by:
John Kiel on 10 October 2023 15:35:59
Last edited:
29 October 2023 18:25:19