Fast Movers

Ice hockey is a game of breakneck speed and fierce collisions. How do PTs keep players safe?

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Ice hockey is one of the fastest-growing sports, with more than 3.8 million players in North America alone. The increase in participants has brought an increasing awareness of various injuries within the sport.
For example, approximately 20,000 patients with ice hockey injuries present to emergency departments annually.1 Lower-extremity injuries account for about 27% of all hockey injuries, and foot injuries account for another 11%.2

Several factors contribute to injuries among ice hockey players, including the high speed of the sport, the frozen rubber puck, flailing sticks, rigid boards, and legal body-checking. Amateur hockey players can reach speeds of 20 mph on their skates, while professionals can exceed 30 mph.3 Hockey pucks have been clocked at over 100 mph.1

Daly et al suggested that athletes who participate in ice hockey could anticipate an injury after playing for as little as seven hours. This, of course, depends on age and athletic performance level.4 Not surprisingly, the majority of injuries occur during the pressure of the actual game, rather than during practice.5

While the ankle is the most commonly injured joint for all athletes, hockey players most frequently suffer from syndesmosis sprain, commonly known as a high ankle sprain. Incidence of syndesmosis sprains is estimated from only one percent to as much as 20% of all ankle sprains.3 However, in a study of hockey players, Wright et al demonstrated that syndesmosis sprains represented 74% of all ankle sprains. National Hockey League data suggests that league-wide, syndesmosis sprains represent 50% of all ankle sprains.3

Syndesmosis Injury

The distal syndesmotic articulation between the tibia and fibula is composed of three major ligaments: the anterior inferior tibiofibular ligament, the posterior inferior tibiofibular ligament, and the interosseous ligament. The ligaments stabilize the distal articulation of the tibia and fibula, and allow the ankle to perform dynamic joint motions. Syndesmosis injuries involve a disruption of the ligamentous structures between the distal fibula and the tibia.6

In ice hockey, there are two common etiologies of a syndesmosis sprain. The first occurs when a player catches a blade in an ice rut, thus forcefully rotating the ankle. The second occurs when a player hits something, and then falls over the front of his skates, forcing the ankle into external rotation and extreme dorsiflexion.2

Three mechanisms take place during a syndesmosis injury: external rotation of the foot, eversion of the talus within the ankle, and excessive foot dorsiflexion. These cause the distal fibula to be pushed laterally away from articulating with the distal tibia. The forced widening at this distal segment can cause the ligamentous structures that stabilize the distal syndesmotic articulation to rupture.6

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While syndesmosis injuries may be unpreventable, the need for proper diagnosis is critical. Typical symptoms of a syndesmosis sprain include localized pain and tenderness to the anterior inferior tibiofibular ligament, pain with passive or active external rotation, pain with passive or active dorsiflexion, and a heel-raise gait pattern to avoid ankle dorsiflexion during push-off. Since severe swelling is usually not present, a syndesmosis injury may be frequently misdiagnosed as a less severe injury.6

Conservative treatment is recommended following a syndesmosis sprain, as long as there is no ligamentous tear or bone fracture. Immediate non-weight bearing with crutches is highly recommended to decrease further injury to the distal tibiofibular syndesmotic junction. Various types of splints immobilize and protect the distal area during acute healing. Pain and acute inflammation can be controlled with cryotherapy and electrical stimulation.6

After the pain has decreased and the athlete can tolerate full weight bearing, it may be safe to begin a light exercise program including range of motion, strength training, and balance. In severe cases, surgical intervention in the form of an open reduction internal fixation may be necessary to regain distal tibiofibular stability.6

Common Fractures

In addition to ankle sprains, fractures of the foot account for many lower-extremity injuries in hockey players.

How does a hockey player fracture a foot or ankle while laced up in a secure hockey skate? The answer typically is a one-inch by three-inch hard disk of vulcanized rubber that's frozen before the game and launched off the blade of a hockey stick at speeds near 100 mph. Fractures can also result from being struck directly by a hockey stick.

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The most commonly fractured bones in the foot are the navicular and the base of the fifth metatarsal. This is because the leather of the boot is the only protection in the medial and lateral aspect of the ankle. These fractures are usually oblique, but they can be comminuted or spiral.2

Many players try to play through the pain as long as the fracture is not displaced.2 Ferrara et al demonstrated that players with lower-extremity fractures and dislocations missed an average of 22 days.7 Depending on the severity of the fracture, treatment can require four to eight weeks of immobilization.

If the fracture is displaced and cannot be reduced, it may warrant surgical intervention with a type of open reduction internal fixation.2 This will ultimately lengthen the athlete's recovery time, including time off the ice.

Protect and Play

In any sport, injury prevention is key to the health and success of the athlete and team. This is why hockey players are covered in full-body protective gear, including helmet, facemask, mouth guard, shoulder pads, gloves, elbow pads, protective cup, padded hockey pants, and shin guards.

Should hockey skates be classified as protective gear for the foot and ankle? Deits et al demonstrated that from 1990 to 2006, more than 300,000 hockey-related injuries reported to the emergency department. Injuries to the lower leg, ankle and foot accounted for 11% of that number.1

Contact with the puck showed the highest means as a mechanism of injury for the lower leg, ankle, and foot at 20.1%, while contact from a stick accounted for 3.5%.1

The hockey skate is a solid boot made from plastic and leather. While it does add a protective layer, the foot and ankle are still susceptible to injury. Importantly, the necessary immobilization of the foot and ankle in the hockey boot is what increases the incidence for syndesmosis sprains.

Education and use of protective equipment designed specifically for the foot and ankle can prevent many injuries to those areas. Increasingly, hockey players at all levels are choosing to protect themselves with foot and ankle guards that fit over their hockey skates.

These lightweight protective guards are molded from a transparent polycarbonate that has exceptional impact resistance. The products deflect and dissipate the severe shock from high-impact blows without slowing or hindering a player's performance. They also protect against less-common injuries, such as skate blade cuts.

Simply stated, ice hockey skates do not appear to provide as much protection from ankle injuries as we might want to believe. The foot and ankle within the hockey skate are still very much at risk for syndesmosis sprains and fractures.3 The rigidity of the skate can give the player a false sense of security in regard to ankle injury prevention.

Knowing the signs and symptoms of syndesmosis injury and foot fracture is crucial in assigning a correct diagnosis. In addition, complete awareness of all possible risk factors and appropriate healing time associated with each of these specific injuries is essential.

Athletes, coaches, physicians and certified athletic trainers all need to be aware of protective equipment available, and encourage its use. Accurate and thorough physical examination is imperative to achieving a correct diagnosis, which is key to establishing appropriate interventions that will ultimately return the ice hockey athlete to practice and games in the timeliest manner. 

References for the cover story and sidebar are available at www.advanceweb.com/pt under the Toolbox tab.

Michael Smerek is a licensed physical therapist and certified strength and conditioning specialist at Crystal Lake Orthopedics, a division of Rockford Orthopedic Associates, Crystal Lake, Ill. He specializes in evaluating and treating the throwing shoulder and has extensive experience with rehabilitation of ACL repairs, total knee replacements, and total hip replacements.


Bench Time

Time lost or sitting on the bench waiting for an injury to heal can be frustrating for any athlete and team. Unlike the common lateral ankle sprain, syndesmosis sprains seem to heal superficially very quickly, with a quick resolve of edema and ecchymosis. However, when an athlete recovering from a syndesmosis sprain returns to the ice, he may find that sport-specific movements such as cutting, turning, twisting, jumping and pushing off are quite painful.

Wright et al found that mean recovery time for a syndesmosis sprain was 45 days.1Lin et al reported that the average recovery time for patients with syndesmosis sprains was 55 days. Note that this is almost twice as much recovery time as required by patients with third-degree lateral ankle sprains that are very common among athletes, but rare among hockey players.2 Surgical cases can require up to 18 weeks until full functional recovery.3

-Michael Smerek


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