Head, neck, and facial injuries in ice hockey: the effect of protective equipment

Chasing the Cup: A Comprehensive Review of Spinal Cord Injuries in Hockey

Ice hockey is a high-speed sport with a high rate of associated injury, including spinal cord injury (SCI). The incidence of hockey-related SCI has increased significantly in more recent years. A comprehensive literature search was conducted with the PubMed, Medline, Google Scholar, and Web of Science databases using the phrases “hockey AND spinal cord injuries” to identify relevant studies pertaining to hockey-related SCIs, equipment use, anatomy, and biomechanics of SCI, injury recognition, and return-to-play guidelines.

Fifty-three abstracts and full texts were reviewed and included, ranging from 1983 to 2021. The proportion of catastrophic SCIs is high when compared to other sports. SCIs in hockey occur most commonly from a collision with the boards due to intentional contact resulting in axial compression, as well as flexion-related teardrop fractures that lead to spinal canal compromise and neurologic injury. Public awareness programs, improvements in equipment, and rule changes can all serve to minimize the risk of SCI.

Hockey has a relatively high rate of associated SCIs occurring most commonly due to flexion-distraction injuries from intentional contact. Further investigation into equipment and hockey arena characteristics as well as future research into injury recognition and removal from and return to play is necessary.

Risk Factors Based on Analysis of Injury Mechanism and Protective Equipment for Ice Hockey Amateur Players

Considering the increasing popularity of ice hockey in South Korea, types of injuries and protective equipment for amateur club members need to be further studied. The purpose of the study is to investigate various injuries and protective equipment used by amateur players and to analyze different risk factors by collecting information on areas of injury and their mechanisms. The online survey for 102 participants was designed to address the general information of participants, types of injuries, information about ice hockey equipment, and open-ended questions about injuries and equipment. We conducted in-depth face-to-face interviews with five players about their experiences with injury and opinions about the protective equipment. In total, 60% of the survey participants had experienced injuries, including to the knee (22.6%), shoulder (21.6%), ankle (20.6%), and wrist (14.7%), in order of frequency. Types of injury included sprain (33.3%), contusion (31.4%), fracture (17.7%), abrasion (10.8%), and concussion (0.9%). Injury mechanisms included instances in which those with less proficiency in skating would be injured initially from player-to-player contact, and from landing on the ice or crashing into the fence afterward. We acknowledged how important wearing correctly sized equipment is for protection, and we highlighted the need to develop protective gear that accommodates Asian body measurements.

The Role of Mouthguards in Preventing and Reducing Sports-related Trauma

a mouthguard, also known as a gumshield, mouth protector or sports guard is an appliance that covers the teeth and surrounding mucosa with the aim of preventing or reducing trauma to the teeth, gingival tissue, lips and jaws. The device is usually worn on the maxillary arch and works by separating the maxillary and mandibular dentition, protecting the teeth from the surrounding soft tissue, absorbing or redistributing shock and/or stabilising the mandible during traumatic jaw closure. They may also play a role in preventing and reducing concussion by absorbing impact forces that would otherwise be transmitted through the base of the skull to the brain, although the evidence for this is less conclusive. A mouthguard will usually fall into one of three categories: stock mouthguards (which are made ready to use and are believed to give the least protection), the mouth-formed or 'boil and bite' type (which are heated in hot water, placed in the mouth and moulded to the teeth) and custom-made mouthguards (which are usually made on a stone model of the maxillary teeth and surrounding tissue and are thought to give the most protection). These devices can be made from various materials but ethylene-vinyl acetate is by far the most popular material, probably because of the ease with which it can be used for the production of custom-made mouthguards. This paper gives a review of the role of mouthguards in preventing and reducing sports-related trauma and examines the materials that are used to fabricate them.

Facial Trauma in Sports

Injuries resulting from facial trauma are common in all sports. Athlete-to-athlete contact, falls, and blows from equipment account for the majority of these events. Appropriate knowledge of basic science, relevant anatomy, and clinical skills is required to provide the correct medical care. While true medical emergencies are infrequent, a prompt accurate diagnosis is essential in developing targeted management and return to play options.

Attitudes towards the use of mouth and face guards in Swedish ice hockey: part 2. Results

BACKGROUND/AIM

The yearly cost of sports injuries, which affects Swedish society, is estimated to 3 billion SEK (460 million USD). Injuries in ice hockey represent at least 270 million SEK (42 million USD). Despite the high number of injuries, mouth and face guards are rarely used in Swedish ice hockey. The major aim of this study was to examine the attitudes of mouth and face guards in two ice hockey clubs in Sweden (one elite and one division 3 club). A second purpose was to determine why some players use mouth and face guards, while others do not. A third goal was to present a material that ice hockey clubs could use for further discussions.

MATERIALS AND METHOD

A phenomenographic analysis of focus groups interviews.

RESULTS

The phenomenographic analysis of the data resulted in 12 categories. Within each category, issues, activities and engagement of the participants were described. Further, similarities and differences in the discussions between the elite club and the division 3 club were described. The following categories were found to engage the participants the most: 'Ice hockey is a high-velocity collision sport in which injuries are expected', 'Attitudes towards personal protection guards' and 'Suggested measures'.

CONCLUSIONS

The participants were aware of the risk of playing ice hockey, but they know little about the consequences of a dental injury. Although ice hockey players wish to protect themselves, they refuse to accept just any mouth or face guard. Through the discussions about reducing dental and jaw injuries by routine use of protection devices, many reform proposals were presented that could be useful in future discussions.

Changing the Face of Hockey: A Study of the Half-Visor's Ability to Reduce the Severity of Facial Injuries of the Upper-Half of the Face among East Coast Hockey League Players

OBJECTIVE

The purpose of the study was to identify the effectiveness of half-visors by qualitatively comparing the severity, location, and mechanism of facial injuries involving the upper-half of the face among an equal number of East Coast Hockey League (ECHL) players with and without half-visors. Full visors were not included in the study because ECHL players do not wear full visors.

DESIGN

A stratified sample was retrospectively collected from 5 seasons of ECHL players who suffered facial injuries to the upper-half of the face with and without half-visors. The upper-half of the face is the region purported to be protected by the half-visor. A total of 186 injuries were identified to the upper-half of the face (93 wore half-visors and 93 wore no protection).

SETTING

Johnstown Cambria County War Memorial Arena, Johnstown, PA.

RESULTS

High-sticking was the most common mechanism of injury. Injury severity scores for lacerations with standard deviations by injury location (ie, forehead, cheek) were statistically significant in the half-visor group when compared with the no-visor group. The injury severity scores for contusions due to collisions were statistically higher in the no-visor group compared with the half-visor group.

CONCLUSIONS

Most injury mechanisms occur from an upward trajectory, which could easily slip under the half-visor and strike the upper-half of the face and eye region. The half-visor may not adequately protect the upper-half of the face from common injury mechanisms.

KEYWORDS

facial protection in hockey; half-visor; hockey facial injuries; facial injury mechanisms.

Community football players' attitudes towards protective equipment--a pre-season measure

BACKGROUND

The Australian football injury prevention project (AFIPP) was a randomised controlled trial examining the effects of protective equipment on injury rates in Australian Football.

OBJECTIVE

To present the results of the AFIPP baseline survey of community football players' attitudes towards protective equipment.

METHODS

Teams of players were recruited from the largest community football league in Victoria, Australia, during the 2001 playing season; 301 players were enrolled in the study and all were surveyed before the season began about their attitudes towards protective headgear and mouthguards.

RESULTS

Almost three quarters of the players (73.6%) reported wearing mouthguards during the previous playing season (year 2000) compared with only 2.1% wearing headgear. The most common reasons for not wearing headgear and mouthguards (in non-users) were: "I don't like wearing it" (headgear: 44.8%; mouthguards: 30.6%), and "It is too uncomfortable" (headgear: 40.7%; mouthguards: 45.8%).

CONCLUSIONS

The higher mouthguard usage reflects the favourable attitudes towards mouthguards by Australian football players generally. Similarly, the low headgear usage reflects the low acceptance of this form of protection in this sport. Further research should be directed towards establishing the reasons why players seem to believe that headgear plays a role in injury prevention yet few wear it.

Characteristics of ice hockey-related injuries treated in US emergency departments, 2001-2002

OBJECTIVE

Ice hockey, a popular sport in some regions, has potential for injury due to the velocities of players, pucks, and sticks. Previous studies conducted worldwide have shown that the rate of injury increases as the size and the speed of players increase, as well as when checking is allowed. However, national data about the annual number and types of injuries among ice hockey players are lacking. Data from previous studies were collected from regional tournaments, collegiate teams, local emergency departments (EDs), and different countries. The purpose of this article is to examine ice hockey injuries using a national US database to determine the age distribution of total injuries, injury types, and body regions injured, with a particular focus on ice hockey players <18 years old.

METHODS

Data regarding ice hockey-related injuries treated in US EDs between January 1, 2001, and December 31, 2002, were extracted from the National Electronic Injury Surveillance System (NEISS). Data considered included age, gender, race, injury diagnosis, and body region injured. Ice hockey-related injury cases were identified using the consumer product code for ice hockey and the narrative description of the incident in NEISS.

RESULTS

An estimated 32,750 individuals with ice hockey-related injuries were treated in US EDs in 2001-2002, including >18,000 youths <18 years old. The number of injuries peak through adolescence (ages 12-17; 47% of all injuries). Males experienced 90% of all injuries. A very small percentage of individuals were hospitalized after injury (1.2% of individuals <18 years old; 0.5% of individuals > or =18 years old). The incidence of head injuries increased as age decreased, although the trend was not statistically significant. The upper extremity (44%) accounted for the highest total percentages of body regions injured for youths <18 years old, and trunk (14%) and facial injuries (10%) represented the smallest total percentages. Players > or =18 years old had significantly more lacerations than younger players (38% of injuries for 18- to 24-year-olds; 25% for 25- to 34-year-olds; 50% for 35- to 44-year-olds compared with 19% for 6- to 11-year-olds and 14% for 12- to 17-year-olds).

CONCLUSIONS

Adolescents had the greatest number of ice hockey-related injuries treated in NEISS hospital EDs in 2001-2002; thus, ongoing efforts to develop injury prevention strategies should focus on this age group. Players < or =17 years old had a lower percentage of lacerations compared with all older players and a higher percentage of upper extremity injuries. The percentage of individuals hospitalized after injury was very low, yet youths <18 years old had twice the percentage of hospitalization after injury compared with individuals > or =18 years old. Males experienced the vast majority of all ice hockey-related injuries, with females representing a higher percentage of injuries among youths than among adults. Children and adults alike can reap the physical fitness and social benefits from ice hockey, when they are able to avoid predictable and preventable injuries.

The avoidability of head and neck injuries in ice hockey: an historical review

The number of minor traumatic brain injury (mTBI), cerebral concussions, is increasing and cannot be eliminated by any kind of equipment. Prevention strategies, such as the introduction of "checking from behind" rules have become effective in decreasing the number of severe spinal injuries. A new "head checking" rule should reduce mTBI in the same way in the following years. Mouthguards should be mandatory as an effective device for the prevention of dental and orofacial injuries, as well as reducing the incidence and severity of mTBI. A new internet database system, the International Sports Injury System (ISIS) should improve epidemiological analysis of head, face, and spinal injuries worldwide. ISIS should provide an internationally compatible system for continuous monitoring of risk factors, protective effects of equipment, and protective effects of equipment and effects of changes in rules through the years.

The effect of a hockey visor and sports goggles on visual function

BACKGROUND

Despite the potential for eye injury, most hockey players in the National Hockey League do not use a protective face shield. We examined the effect of a hockey visor and sports goggle on visual function to see whether visual impediment is a substantial factor in the resistance to use of protective eyewear.

METHODS

We measured Snellen visual acuity, Ishihara colour vision and contrast sensitivity and performed Humphrey central 30 degrees and peripheral 30 degrees to 60 degrees threshold perimetry in eight volunteers (10 eyes) with and without a sports goggle and a hockey visor (half face shield). Subjects with normal acuity and normal confrontation fields who did not require presbyopic correction at near were enrolled. Five subjects (10 eyes) had further testing with threshold perimetry of the temporal crescent. The order in which the tests were performed (no mask first, visor first or goggle first) was alternated between subjects.

RESULTS

There was no difference in Snellen acuity or Ishihara colour vision, and no statistically significant difference in contrast sensitivity or foveal threshold with or without protective eyewear. The visor caused a statistically significant decrease in the central 30 degrees mean deviation index compared to no mask (p = 0.001), but the goggle did not. Each of the peripheral quadrant threshold totals was significantly decreased with the visor compared with no mask (p < 0.05). The 30 degrees to 60 degrees temporal field was better preserved with the goggle than with the visor, but the nasal peripheral field was worse with the goggle than with the visor. Both the visor and the goggle caused a statistically significant decrease of more than 4 decibels in the temporal crescent threshold (p = 0.000).

INTERPRETATION

Protective eyewear does not adversely affect Snellen acuity, contrast sensitivity, Ishihara colour vision or foveal threshold. The central 30 degrees field of vision is not affected by the sports goggle and is minimally depressed by the hockey visor. The goggle better preserves the temporal midperipheral field, but, unlike the visor, the goggle caused a monocular nasal lens rim scotoma. Both devices caused a depression of more than 4 dB of the far temporal field beyond 60 degrees (temporal crescent).

The impact of face shield use on concussions in ice hockey: a multivariate analysis

OBJECTIVE

To identify specific risk factors for concussion severity among ice hockey players wearing full face shields compared with half face shields (visors).

METHODS

A prospective cohort study was conducted during one varsity hockey season (1997-1998) with 642 male ice hockey players (median age 22 years) from 22 teams participating in the Canadian Inter-University Athletics Union. Half of the teams wore full face shields, and half wore half shields (visors) for every practice and game throughout the season. Team therapists and doctors recorded on structured forms daily injury, participation, and information on face shield use for each athlete. The main outcome measure was any traumatic brain injury requiring assessment or treatment by a team therapist or doctor, categorised by time lost from subsequent participation and compared by type of face shield worn.

RESULTS

Players who wore half face shields missed significantly more practices and games per concussion (2.4 times) than players who wore full face shields (4.07 sessions (95% confidence interval (CI) 3.48 to 4.74) v 1.71 sessions (95% CI 1.32 to 2.18) respectively). Significantly more playing time was lost by players wearing half shields during practices and games, and did not depend on whether the athletes were forwards or defence, rookies or veterans, or whether the concussions were new or recurrent. In addition, players who wore half face shields and no mouthguards at the time of concussion missed significantly more playing time (5.57 sessions per concussion; 95% CI 4.40 to 6.95) than players who wore half shields and mouthguards (2.76 sessions per concussion; 95% CI 2.14 to 3.55). Players who wore full face shields and mouthguards at the time of concussion lost no playing time compared with 1.80 sessions lost per concussion (95% CI 1.38 to 2.34) for players wearing full face shields and no mouthguards.

CONCLUSIONS

The use of a full face shield compared with half face shield by intercollegiate ice hockey players significantly reduced the playing time lost because of concussion, suggesting that concussion severity may be reduced by the use of a full face shield.

Position Statement. Violence and injury in ice hockey

Ice hockey is a sport enjoyed by many men and women at the spectator and participant level. It is played with high intensity and often involves body contact. Although the women's games is far from injury free, it is the men's game that has drawn criticism for excessive violence. Much attention has been drawn to the serious injuries that have occurred in ice hockey, specifically spinal injuries, concussions, and eye injuries. Many such injuries are the result of illegal and violent acts such as checking from behind or a deliberate high stick. Because of this, some medical organizations have called for changes in the sport, such as minimum age requirements for body-checking. As a practical matter such changes are unlikely to be accepted by hockey governing boards. Many of those involved in the sport consider body-checking a fundamental component of the game. Furthermore, a distinction needs to be made between any kind of injury and a serious, catastrophic injury. For example, although a recent study found that body-checking accounted for up to 38% of ice hockey injuries, none were of the catastrophic type. With respect to catastrophic injuries such as spinal cord trauma or a blinded eye, legal body-checking accounts for significantly less than illegal body-checking (e.g., checking from behind) or violent stick work. To reduce serious injury in ice hockey, we offer 10 recommendations, key among them automatic game suspensions for certain rules violations, and recognition of the coach as the most important figure in promoting a clean, safe game.

An operational model to investigate contact sports injuries

PURPOSE

A cyclical operational model is proposed to examine the interrelationship of a number of factors that are involved in sports injury epidemiology. In sports injury research, investigations often attempt to identify a unique risk factor that distinguishes an injured player. However, a wide variety of factors can contribute to a sports injury occurring, and an understanding of the cause of injury is important to advance knowledge.

METHODS

The proposed model identifies a healthy/fit player initially, although the player may exhibit a number of intrinsic risk factors for sports injury. Before exposure to extrinsic risk factors, there is the opportunity for implementation of prevention strategies by coaching personnel and the sports medicine team. These strategies might include, among others, appropriate warm-up, adequate hydration, wearing protective equipment, and prophylactic taping. Additionally, preventative screening could take place to assess the various intrinsic and extrinsic risk factors that could lead to sports injury.

DISCUSSION

Two examples of how the operational model relates to contact sports injury cases are presented. Participating in sport inevitably exposes the player to external risk factors that predispose toward injury. The treatment of the injured player aims to restore the player to preinjury playing status and to prevent the injury from becoming chronic.

CONCLUSIONS

It is suggested that the application of this proposed cyclical model may lead to greater success in understanding the multifaceted nature of sports injuries and furthermore help minimize injury risk and support the rehabilitation of injured contact sports participants.

Personal risk factors associated with injury among female recreational ice hockey players

INTRODUCTION

Women's ice hockey is a rapidly growing sport, however little is known about the injuries sustained by this group of athletes.

PURPOSE

The objective of this research was to identify risk factors associated with injury among female recreational ice hockey players.

METHODS

This prospective study followed players from two women's ice hockey leagues in Edmonton, Canada during the 1997-98 hockey season. The occurrence of injuries was monitored during the season through standardized telephone follow-up. Risk factors were determined using multiple logistic regression.

RESULTS

The initial study sample consisted of 314 players, however as the season progressed 19 (6%) were lost to follow-up. The results of the study are based on 295 (94%) participants. A total of 125 injuries were reported; the injury rate was 7.5 injuries/1,000 player-exposures. Risk factors found to be significantly related to the occurrence of injury were: injury in the past year (OR= 1.57), more than 5 years of hockey experience (OR=1.49), and high exposure level (OR=1.41).

CONCLUSION

This research is the first to quantify personal risk factors associated with injury among female recreational ice hockey players. A sports injury in the previous 12 months appears to be highly associated with injury and further research is required to more fully understand this relationship. The importance of controlling for level of exposure when investigating risk factors for sports injury was demonstrated.

In neck to neck competition are women more fragile?

Recent studies indicate numerous differences between female and male athletes regarding injuries of the upper and lower extremities. Studies have been much less clear concerning a gender differential regarding injuries of the cervical spine. For the purposes of the current review, injuries have been divided into three categories. The first category is cervical strain injury. It has been reported that strain injuries are more prevalent in female athletes than male athletes. The second category is cervical disc injury and cervical disc herniation. It has been reported that the male to female incidence is approximately equal in this category. In the third category, which is referred to as major structural injury, studies to date have almost entirely reported on injuries in males showing a significant male preponderance. With increasing participation of women in contact sports that cause major structural injury, a greater incidence of these injuries may be seen in women.