PTs help hockey players stay on the ice

By Lauren Fritsky

Hockey is a high-impact sport with plenty of room for injury. It's also an up-and-coming activity attracting both children barely in kindergarten and adults, in addition to collegiate and professional players. ADVANCE spoke with several physical therapists about how to treat and prevent injuries for hockey players young and old, professional and recreational.

Overuse Vs. Contact

Hockey players suffer overuse injuries that come with the movements of the game. But contact injuries-head trauma and lacerations, for instance-also come with the high-impact sport. Hockey injuries also happen more often in games than in practices, according to Scott Hamersly, PT, MS, SCS, ATC, CSCS, a therapist at Methodist Sports Medicine/The Orthopedic Specialists in Indianapolis, IN, which treats both professional and recreational athletes.

"If you look at exposure hours of participating, the frequency and severity of injuries has usually proven to be greater in game situations," Hamersly said. "The intensity is greater."

Physical therapists treating hockey players mostly see upper-extremity injuries as opposed to lower, in areas such as the shoulder, wrist and spine, Hamersly said. Ankle injuries are rarer compared to other sports because of the way the skates are designed, and severe knee injuries are less common because the foot isn't planted in hockey since it's played on ice. Facial and neck injuries can also occur from contact.

Jennifer Day, PT, LAT, a therapist at Point Sports Medicine Center in Stevens Point, WI, sees mostly hip flexor and adductor strains in hockey players that come to her clinic. Non-contact related issues she has treated include groin strains, knee pain and other overuse injuries.

"We have also seen separated or dislocated shoulders, wrist sprains, LBP, or knee pain ranging from patellofemoral syndrome to MCL/ACL injuries in the clinic," she said. "On the ice, it may be more common to see wrist fractures, including scaphoid fractures from stick checks, skate cuts and facial lacerations or concussions. These injuries are more often seen by the LAT and referred to the MD without PT follow-up."

Steven R. Tippett, PT, PhD, SCS, ATC, chair and professor in the department of physical therapy and health science at Bradley University in Peoria, IL, said the more significant contact injuries are typically seen in older youth players and adults.

"The bodies are bigger and the speed of the game is greater," he explained. "Collisions with the boards can result in shoulder-SC joint and AC joint-injuries that result in a few days to a few weeks off of the ice. Fractures of the clavicle also occur from this mechanism. Head and neck injuries-muscle strain and concussion-can also result in collisions with players or with the boards. When the forces are absorbed by the lower body, knee injuries such as collateral ligament sprains, and ankle injuries can occur."

Youth Vs. Adult

Hamersly recently treated a 6-foot, 4-inch tall, 220-pound high school player after he underwent surgery to stabilize his dislocated shoulder. He was put in a mobilizer for months, then put through range of motion and strengthening exercises. It took four months to get him back to full range of motion with about 80 percent strength and another two to completely return him to hockey.

Hamersly says the injuries are similar for youth and adult hockey players-for now. Much remains to be seen, because hockey is just now becoming a widely played sport among youth.

"You're seeing kids starting at a younger age be solely devoted to that sport and play it year-round," he said. "You're seeing kids as young as 6 playing day in, day out."

Day agrees that the injuries are similar in different age populations. Fractures, for instance, may occur more in adults because of more aggressive stick play and checking, but they also can occur in youth players because they are not as skeletally mature. Dr. Tippett said youth players encounter overuse injuries, but their musculoskeletal system is different from that of a skeletally mature individual, so the specific injuries can vary.

"At the heart of many of their problems is a lack of muscle length and muscle balance," he said. "Treatment is geared toward prevention, and once an injury of this type occurs, treating the symptoms along with using an appropriate therapeutic exercise program and activity modification is key."

Professional Vs. Recreational

In addition to whether they are adult or adolescent, the type of injuries a hockey player experiences often depend on whether the player plays professionally or recreationally, Dr. Tippett said.

"At the professional level, as skill level increases and the amount of time spent on the ice and off-ice conditioning increases, overuse injuries do increase," he explained. "Injuries such as this often involve the low back, hips and possibly 'sports hernias' or 'sportsman's groin.' It is unclear as to whether or not these can always be prevented, but in order to keep all the bases covered, adequate core strength, hip flexibility and muscle balance are ­important.

"We try to walk the fine line of allowing activity at a level to be competitive without making things worse. Once the injury begins to impact performance, relative rest is a must. The non-professionals who participate in adult leagues also show overuse injuries due to inadequate strength, flexibility and ­endurance."

One of the most significant injuries Dr. Tippett has seen was a knee dislocation in a professional hockey player injured during the off-season. The player underwent rehabilitation for six months after surgery and was able to return to the NHL and play for years post-injury.

Other on-ice injuries he has treated include: concussion with loss of consciousness for two to three minutes; posterior SC joint dislocation that placed pressure on the trachea resulting in minimal air exchange issues; and eversion ankle sprains with fibular fracture, as well as various lower leg fractures.

Day has seen on-ice injuries such as concussions from checks or hits, neck/spinal cord injuries from sliding into the boards and skate cuts.

"The more severe injuries-concussions, AC or SC sprains, or fractures-are a result of contact," she said.

Recovery Time and Injury ­Prevention

The injury prevention tips Dr. Tippett recommends for hockey players are simple: wear the required protective equipment, don't underestimate the importance of off-ice conditioning, and take breaks between seasons to let the body recover. As with recovery time for any sport, the player should be able to perform all functions without deficit before return to play is allowed. 

At Day's facility, therapists work closely with coaches and athletic trainers to progress the athlete back to play. She and other therapists address ROM and pain first, adding strengthening exercises, endurance activities and functional patterns as able. Cross training is also added to the regimen. The recovery time varies based on the nature and severity of the injury.

"If the athlete is not at 100 percent and returns to play, the risk of re-injury is increased," she explained. "He may also be ineffective on the ice and hinder the team. Taking the time to fully recover can prevent them from playing the rest of the season at less than 100 percent. Education is often key in working with the athletes and the coaches to help them understand the importance of allowing the injury to repair."

Day has also found success with less common treatments.

"I have had good success clinically with microcurrent probes treating chronic and acute tendon injuries even though I have not seen as much research supporting this modality," she explained.

Lauren Fritsky is a freelance contributor to ADVANCE.

Exercise Strategies For Hockey Players

Mark Mortland, PT, ATC, team physical therapist of the 2009 NHL Champion Pittsburgh Penguins and spokesman for the American Physical Therapy Association (APTA), offers these tips for the proper exercise regimen for hockey ­players:

Dynamic warm-ups: Warming up should include a combination of dry floor and ice exercises. On the dry floor, running in place, lunges, high-knee exercises (high, fast marching movements), and static stretching (stretching while standing in place) can be used to prepare for the game. On the ice, players should combine warm-up laps and sprints.

Post-game/post-practice cool down: It is important to stretch the muscles while they are still warm. Focus on static stretches (stretching while standing in place) of large muscle groups such as the hamstrings, quadriceps, gluteus and hips.

Overall core strength: Developing strong abdominal muscles (i.e., crunches, sit-ups) can help stop low-back pain, a common injury often resulting from the crouched positions of the players. Core strength also helps players better handle the crushing impacts they can endure while playing hockey.

Information obtained from www.apta.org/AM/Template.cfm?Section=News_Archive&TEMPLATE=/CM/ContentDisplay.