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Lower Extremity Injuries in Ice Hockey: Current Concepts
ABSTRACT
Ice hockey is a fast-paced, collision sport requiring tremendous skill and finesse, yet ice hockey can be a harsh and violent game. It has one of the highest musculoskeletal injury rates in all of competitive sports. Razor sharp skates, aluminum sticks and boards made from high density polyethylene (HDPE), all contribute to the intrinsic hazards of the game. The objective of this article is to review evaluation, management, and return-to-the-rink guidelines after common lower extremity ice hockey injuries.
“Hockey is a fast body-contact game played by men with clubs in their hands and knives laced to their feet, since the skates are razor sharp, and before the evening is over it is almost a certainty that someone will be hurt and will fleck the ice with a generous contribution of gore before he is led away to be hemstitched together again.” —Paul Gallico in Farewell to Sport (1938)
Ice hockey is a collision sport with player speeds in excess of 30 miles/hour, on a sheet of ice surrounded by unforgiving boards, with a vulcanized rubber puck moving at speeds approaching 100 miles/hour.1-3 Understanding injuries specific to this fast-paced sport is an essential part of being a team physician at any level of competitive ice hockey. We are continuing to improve our ability to correctly identify and treat injuries in ice hockey players.2,4 On the prevention side, rule changes in hockey have been implemented, such as raising the age to allow checking and penalties for deliberate hits to the head and checking from behind, to make the game safer to play.3 Additionally, advancements in biomechanical research and 3D modeling are providing new insights into the pathoanatomy of the hip joint, which can be utilized for surgical planning in hockey players and goalies suffering from symptomatic femoroacetabular impingement (FAI) of the hip.5
During the 2010 Winter Olympics, more than 30% of ice hockey players were injured, which was the highest percentage amongst all competing sports.6 They also tallied the highest percentage of player-to-player injuries during the Olympics of any sport. Consequently, the team physician covering ice hockey should be prepared to manage upper and lower extremity musculoskeletal injuries, but also concussions, cervical spine injuries, and ocular and dental trauma.2
One of the earliest epidemiological studies of ice hockey injuries looked at elite Danish hockey players over 2 seasons and found that head trauma accounted for 28% of all injuries, followed by lower extremity injuries at 27% with upper extremity injuries accounting for 19%.7 More recent epidemiological studies have shown similar rates based on body region while further defining individual diagnoses and their incidence. This should help clinicians and researchers develop prevention strategies, as well as improve treatments to optimize player outcomes and return to sport.8,9 Our group recently reviewed the evaluation and management of common head, neck, and shoulder injuries at all competitive levels of ice hockey, and this article serves to complement the former by focusing on lower extremity injuries (Table).2
Continue to: Hip and groin...
EVALUATION AND MANAGEMENT OF COMMON LOWER EXTREMITY HOCKEY INJURIES
HIP INJURIES
Hip and groin injuries are very common amongst this group of athletes and account for approximately 9% of all ice hockey injuries.1 Unfortunately, they are also known for their high recurrence rates, which may be in part due to delayed diagnosis, inadequate rest and rehabilitation, as well as the extreme loads that are placed on the hip during competition.10,11 In hockey, the most commonly reported hip injuries include goaltender’s hip, FAI, sports hernia/hockey groin syndrome, adductor strains, hip pointer, and quadriceps contusions. Dalton and colleagues12 performed the largest epidemiological study to date on hip and groin injuries amongst National Collegiate Athletic Association ice hockey players and reported that the most common injury mechanism was noncontact in nature. Contact injuries accounted for 13% (55 of 421) in men’s ice hockey players while less than 4% (4 of 114) injuries in female ice hockey players, which is likely attributed to a no checking rule in the women’s division. Some of these hip and groin injuries are difficult to diagnose so it is important for the team physician to perform a thorough history and physical examination. Advanced imaging (magnetic resonance imaging [MRI] or a computed tomography (CT) scan with 3D reconstructions) may be necessary to make the correct diagnosis. This is important for providing proper treatment as well as setting player expectations for return to sport.12
Table 1. Return-to-Play Guidelines for Common Lower Extremity Ice Hockey Injuries | ||
Lower Extremity Injury | Treatment Options | Return-to-the-Rink Goal |
FAI | In-season: injection, physical therapy program, NSAIDS. Off-season or unable to play: requires arthroscopic surgery | Nonoperative can take up to 6 weeks. Surgical depends on what is fixed but goal is 4 months to return to ice24,26
|
Sports hernia/athletic pubalgia
| In-season: physical therapy program, NSAIDS Off-season or unable to play requiring surgery. Essential to make sure no other pathology (eg, FAI, osteitis pubis, adductor strain) to maximize success
| Nonoperative 6-8 wk trial of physical therapy Operative: depends if concomitant FAI but in isolation goal is 3-4 mo33,54
|
Adductor strains | Ice, NSAIDS, physical therapy, use of Hypervolt Hyperice | Depends on position (goalie vs skater) and severity; can take up to 4-8 wk to return to ice. Want 70% strength and painless ROM to skate successfully;55 in chronic cases, may take up to 6 mo35
|
Quadriceps contusion
| Hinged knee brace to maintain 120° of flexion, ice, compression wrap.
| When player regains motion and strength, return to ice can be as fast a couple of days or as long as 3 wk8,46
|
MCL | Hinged knee brace, shin pad modification, ice, NSAIDs | Depends on Grade; if Grade I, 1-2 wk; Grade II, 2-4 wk; Grade III, 4-6 wk8
|
ACL | Surgery autograft BTB autograft soft tissue
| 9-10 mo41 |
Meniscus tear | Depends on type of tear and seasonal timing (in-season or off-season) | If surgical, 3-4 mo; if repair, 4-6 wk if partial menisectomy
|
High ankle sprain
| Cam boot, NSAIDS, ice and physical therapy
| 6 wk49 |
Boot top laceration | Repair of cut structures, depends on depth and what is injured; best treatment is prevention with Kevlar socks | If laceration is deep and severs any medial tendons/vascular structures, return to ice can be ≥6 mo
|
Lace bite
| Bunga pad, ice, diclofenac gel
| Couple of days to up to 2 wk in recalcitrant cases3 |
Abbreviations: ACL, anterior cruciate ligament; BTB, bone-patellar tendon-bone; Cam, controlled ankle motion boot; MCL, medial collateral ligament; FAI, femoroacetabular impingement; NSAIDS, nonsteroidal anti-inflammatory drugs; ROM, range of motion.
Throughout the hockey community, FAI is being examined as a possible source of symptomatic hip pain amongst players at all levels. A recent study, which utilized the National Hockey League (NHL) injury surveillance database, reported that FAI accounted for 5.3% of all hip and groin injuries.13 The etiology of FAI is thought to arise from a combination of genetic predisposition coupled with repetitive axial loading/hip flexion. This causes a bony overgrowth of the proximal femoral physes resulting in a cam deformity (Figure 1).5,14 The abnormal bony anatomy allows for impingement between the acetabulum and proximal femur, which can injure the labrum and articular cartilage of the hip joint.
In the recent study by Ross and colleagues,15 the authors focused on symptomatic hip impingement in ice hockey goalies.15 Goaltender’s hip may be the result of the “butterfly style,” which is a technique of goaltending that emphasizes guarding the lower part of the goal. The goalie drops to his/her knees and internally rotates the hips to allow the leg pads to be parallel to the ice. This style acquired the name butterfly because of the resemblance of the spread goalie pads to a butterfly’s wings. Bedi and associates16 have evaluated hip biomechanics using 3D-generated bone models and showed in their study that arthroscopic treatment can improve hip kinematics and range of motion.
Plain radiographs showed that 90% (61 of 68) of hockey goalies had an elevated alpha angle signifying a femoral cam-type deformity.15 Goalies had a significantly lower mean lateral center-edge angle (27.3° vs 29.6°; P = .03) and 13.2% of them were found to have acetabular dysplasia (lateral center-edge angle<20°) compared to only 3% of positional players. The CT scan measurements demonstrated that hockey goalies have a unique cam-type deformity that is located more lateral (1:00 o’clock vs 1:45 o’clock; P < .0001) along the proximal femur, an elevated maximum alpha angle (80.9° vs 68.6°; P < .0001) and loss of offset, when compared to positional players. These findings provide an anatomical basis in support of reports that goaltenders are more likely to experience intra-articular hip injuries compared to other positional players.13
Regardless of position, symptomatic FAI in a hockey player is generally a problem that slowly builds and is made worse with activity.17 On examination, the player may have limited hip flexion and internal rotation, as well as weakness compared to the contralateral side when testing hip flexion and abduction.18,19 Plain radiographs plus MRI or CT allow for proper characterization and diagnosis (to include underlying chondrolabral pathology).20,21
In the young athlete, initial management includes physical therapy, which focuses on core strengthening. Emphasis is placed on hip flexion and extension, as well as abduction and external rotation with the goal of reducing symptoms and avoiding injuries.22 A similar approach may be applied to the elite athlete, but failure of nonoperative management may necessitate surgical intervention. Hip arthroscopy continues to grow in popularity over open surgical dislocation with low complication rate and high return-to-play rate.23-25
For the in-season athlete, attempts to continue to play can be assisted with the role of an intra-articular corticosteroid injection, which can help calm inflammation within the hip joint and mitigate pain, while rehabilitation focuses on core stabilization, postural retraining and focusing on any muscle imbalances that might be present. For positional players, ice time and shift duration can be adjusted to give the player’s hip a period of rest; meanwhile, for goaltenders, shot volumes in practice can be decreased.
Continue to: For athletes who...
For athletes who fail nonoperative care, surgical treatment varies depending on underlying hip pathology and may include femoroplasty, acetabuloplasty, and microfracture as well as labral repair or debridement. Though data are limited, Philippon and colleagues26 have published promising results in a case series of 28 NHL players after surgical intervention for FAI. All players returned to sport at an average of 3.8 months and players who had surgery within 1 year of injury returned on average 1.1 months sooner than those who waited more than 1 year. Rehabilitation protocol varies between goaltenders compared to defensemen and offensive players due to the different demands required for blocking shots on goal.27
One of the most challenging injuries to correctly identify in the hip area is athletic pubalgia (also referred to as sports hernia or core muscle injury) because pain in the groin may be referred from the lumbar spine, hip joint, urologic, or perineal etiologies.28 Sports hernias involve dilatation of the external ring of the inguinal canal and thinning of the posterior wall. Players may report to the athletic trainer or team physician with a complaint of groin pain that is worse when pushing off with their skate or taking a slap shot.29 On exam, pain can be reproduced by hip extension, contralateral torso rotation, or with a resisted sit-up with palpation of the inferolateral edge of the distal rectus abdominus.30 An MRI with specific sequences centered over the pubic symphysis is usually warranted to aid in the workup of sports hernia. An MRI in these cases may also demonstrate avulsions of the rectus abdominus.31
Most of these injuries are managed conservatively but can warrant surgical intervention if the symptoms persist. In the study by Jakoi and colleagues,32 they identified 43 ice hockey players over an 8-year period (2001-2008) who had repairs of their sports hernias and assessed the statistics during the 2 years prior and 2 years after surgery. The authors found that 80% of these players were able to return to the ice for 2 or more full seasons. The return-to-sport rate was comparable to other sports after sports hernia repair, but players who had played in ≥7 seasons demonstrated a greater decrease in number of games played, goals, assists and time on ice compared to those who had played in ≤6 seasons prior to the time of injury. Between 1989 and 2000, 22 NHL players who failed to respond to nonoperative management of their groin injuries underwent surgical exploration.29 At the time of surgical exploration, their hockey groin syndrome, consisted of small tears in the external oblique aponeurosis through which branches of the ilioinguinal or iliohypogastric could be identified. These surgical procedures were all through a standard inguinal approach and the perforating neurovascular structures were excised, while the main trunk of the ilioinguinal nerve was ablated and the external oblique aponeurosis was repaired and reinforced with Goretex (W.L. Gore & Associates Inc, Flagstaff, AZ). At follow-up, 18 of the 22 players (82%) had no pain and 19 (86%) were able to resume their careers in the NHL.29 Ice hockey players with sports hernias or hockey groin syndrome often return to the sport, but it is important to identify these problems early so that surgical options can be discussed if the player fails conservative management. It is also critical to make sure that all pathology is identified, because in players with mixed sports hernia and FAI, return-to-play results improve when both issues are addressed. In a study of athletes (some of whom were ice hockey players), who had both FAI and sports hernia, and only hernia/pubalgia surgery was performed, 25% of these athletes returned to sport. If only FAI was addressed, 50% of the athletes returned to sport; however, when hernia and FAI were treated, 89% returned to play.33
Adductor strains includes injury to the adductor muscles, pectineus, obturator externus and gracilis, and are prevalent in ice hockey players. A study of elite Swedish ice hockey players published in 1988 reported that adductor strains accounted for 10% (10 of 95) of all injuries.34 Given the prevalence of these injuries, considerable research has been dedicated to understanding their mechanism and prevention.35 Adductor strains within the ice hockey population have been attributed to the eccentric forces on the adductors when players attempt to decelerate the leg during a stride.36 A study of NHL players revealed that a ratio <80% of adductor-to-abductor muscle is the best predictor of a groin strain.37
These injuries are also well known for their recurrence rates, as was the case in an NHL study where 4 of the 9 adductor strains (44%) were recurrent injuries.37 The authors attributed the recurrence to an incomplete rehabilitation program and an accelerated return to sport. This was followed by an NHL prevention program that spanned 2 seasons and analyzed 58 players whose adductor-to-abductor ratio was <80% and placed them into a 6-week intervention program during the preseason.37 Only 3 players sustained an adductor strain in the 2 subsequent seasons after the intervention, compared to 11 strains in the previous 2 seasons. Thus, early identification of muscle strength imbalance coupled with an appropriate intervention program has proven to be an effective means of reducing adductor strains in this at-risk population.
Continue to: Contact injuries may...
Contact injuries may vary with checking into the boards being unique to men’s ice hockey. Hip pointers occur as a result of a direct compression injury to the iliac crest, which causes trauma to the bone but also to the overlying hip abductor musculature, and represent roughly 2.4% of ice hockey injuries.23 The resulting contusion may cause a local hematoma formation. Early identification of the injury plus treatment with RICE (rest, ice, compression, elevation) coupled with crutches to limit weight-bearing status may minimize soft tissue trauma and swelling, and ultimately aid in pain control and return to sport.38 Hip abductor strengthening, added padding over the injured area, as well as a compressive hip spica wrapping, have all been suggested to expedite return to play and help prevent recurrence of the hip pointer.8
KNEE INJURIES
Injury to the medial collateral ligament (MCL) is the most commonly reported knee injury (Figure 2) and second only to concussion amongst all injuries in National Collegiate Athletic Association ice hockey players.8,39 The mechanism of injury typically involves a valgus force on the knee, which is often caused by collision into another player.39 Valgus stress testing with the knee in 30° of flexion is used to grade the severity of injury (Grade I: 0-5 mm of medial opening; Grade II: 5-10 mm of medial opening; Grade III: >10 mm of medial opening).39 One study that followed a single college hockey team for 8 seasons reported that 77% of injuries (10 of 13) occurred during player-to-player collision,39 with 5 being Grade 1 injuries, 6 Grade 2 injuries, 1 Grade 3; information was missing for 1 player. Nonoperative management of incomplete injuries, grade 1 and 2 sprains, with RICE and early physical therapy intervention to work on knee range of motion and quadriceps strengthening typically helps the player return to sport within days for grade 1 and 2 injuries to 3 weeks for grade 2 injuries. Complete tears have been managed both operatively and nonoperatively with evidence to suggest better outcomes after surgical intervention if there is a concomitant ACL injury requiring reconstruction.8,9
Anterior cruciate ligament (ACL) tears occur less frequently in hockey players compared to the players in other sports such as football and basketball.38,40 Between 2006 and 2010, 47 players were identified by the NHL Injury Surveillance System as having sustained an ACL injury, which equates to an incidence of 9.4 ACL injuries per NHL season over this time span.41 The mechanism of ACL tears in ice hockey players appears to be different from other sports players based on a recent MRI study that evaluated players for concomitant injuries following ACL tear and noted significantly fewer bone bruises on the lateral femoral condyle compared to players in other sports.42 Early evaluation after injury with Lachman and/or pivot shift tests aids the diagnosis. Data from the NHL study identified 32 players (68%) with concomitant meniscal injuries and 32 (68%) had MCL injuries in conjunction with their ACL tears.41 Average length in the league prior to injury was 5.65 seasons. Twenty-nine of the injured players (61.7%) underwent reconstruction with a patellar tendon autograft, 13 (27.7%) had a hamstring autograft, and 5 (10.6%) had either a patellar tendon or hamstring allograft.41 Meniscus and ACL injuries were associated with a decreased length of career compared to age-matched controls and, notably, players >30 years at the time of injury had only a 67% rate of return to sport whereas those <30 years had a return-to-sport rate of 80%. Players who were able to return did so at an average of 9.8 months (range, 6-21 months) and had a significant reduction in total number of goals, assists, and points scored compared to controls. Decline in performance was typically associated with forwards and wings, while defensemen did not demonstrate the same decrease in performance following return to ice hockey.41
Meniscal tears are a well-documented concomitant injury with ruptures of the ACL, and the combination is a known pattern associated with shorter careers compared to isolated ACL tears in ice hockey players.41 The lateral meniscus is known for increased mobility compared to the medial meniscus and is more commonly injured (39% vs 8.5%) in ACL tears that occur in contact sports and downhill skiing.42 Ice hockey presents a scenario that is different from other contact sports because of the near frictionless interaction between the player’s ice skates and playing surface. This likely equates to a different injury mechanism and dissipation of energy after contact as well as non-contact injuries.38 A recent study reviewed knee MRI findings associated with ACL tears in collegiate ice hockey players and compared to other sports known for their high rates of concomitant meniscal pathology. The authors reported a statistically significant decrease in lateral meniscus tears and bone-bruising patterns in ice hockey players with ACL injuries compared to athletes with ACL tears in other sports.43 In contrast, an NHL study of ACL tears in professional ice hockey players found that 68% of players had concomitant meniscal tears (32 out of 47 players).41
Continue to: The presence of...
The presence of a meniscal tear on MRI is typically a surgical problem, especially if it occurred with an ACL injury. Meniscal repair is preferable, if possible, because there is a known association of increased cartilage contact pressures associated with meniscal debridement. Return to sport following meniscus injury hinges upon whether it is an isolated injury and how it is treated. If the meniscus injury occurs in isolation and can be treated with a debridement and partial resection alone, there is obviously a quicker return to sport as the player can be weight-bearing immediately following surgery. Return to skating after meniscal debridement and partial resection is usually 4 to 6 weeks, whereas meniscal repair protocols vary depending on surgeon; players may need 3 months to 4 months to return to the ice.
Quadriceps contusions are contact injuries that are not unique to ice hockey (Figure 3). They may result from player collision but also from direct blows from a hockey puck. A high velocity puck is known to cause immense trauma to the quadriceps muscles, which may result in localized bleeding and hematoma formation. If the player is able to anticipate the event, active contraction of the quadriceps muscle has been shown to absorb some of the energy and result in a less traumatic injury, but in a fast paced ice hockey game, the player’s anticipation is less likely than in other sports such as baseball.44Interestingly, the degree of knee flexion after injury is predictive of injury severity with milder injuries associated with angles >90 and more severe injuries resulting in knee flexion angles <45° and typically an antalgic gait.45 It is important to treat these injuries during the first 24 hours with the knee maintained in 120°of flexion, plus ice and compression, which can be achieved using a locked knee brace or elastic compression wrap. Quadriceps stretching and isometric strengthening should immediately follow the period of immobilization. The addition of NSAIDs may help prevent the formation of myositis ossificans. A study from West Point suggests that the average return to sport or activity ranges from 13 days (mild contusion) to 21 days (severe contusions), while others8 have indicated that if the injury is treated acutely and a player is able to regain motion and strength, return to ice hockey within a few days is possible.
FOOT AND ANKLE
Ice hockey has some unique injuries that can be attributed to the use of ice skates for play. One such injury is boot-top lacerations, which are fortunately rare as they can be a career-ending injury.47 The spectrum of injury ranges from superficial abrasions to more severe soft tissue disruption, including the extensor tendons and neurovascular structures. The actual mechanism of injury involves an opponent’s skate blade cutting across the anterior ankle. One early case report described a protective method of having players place their skate tongues deep to their protective shin pads, instead of turning the tongues down.47 Kevlar socks have also been shown to help prevent or minimize the damage from a skate blade.48
Injury to the lateral ankle ligaments, anterior talofibular ligament or calcaneofibular ligament, are usually more common than the higher ankle sprains involving the syndesmosis. However, this is not the case in ice hockey. The rigidity of the ice skate at the level of the lateral ligaments seems to impart a protective mechanism to the lower ligaments, but this results in a higher incidence of syndesmotic injuries. These high ankle injuries are unfortunately more debilitating and often require a longer recovery period. In a study of these injuries in NHL players, syndesmotic sprains made up 74% of all ankle sprains, whereas only 18.4% of ankle sprains involved the syndesmosis in American football players..49,50 The average number of days between injury and return to play is 45 days, and some authors believe that defensemen may have a harder time recovering because of the demands on their ankles by having to switch continuously between forward and backward skating.49
Most patients are treated conservatively when their ankle plain radiographs show a congruent mortise and no evidence of syndesmotic widening. If the player expresses pain when squeezing the syndesmosis, it is helpful to obtain stress radiographs to further evaluate for syndesmotic injury. Nonoperative management includes RICE, immobilization in a rigid boot with crutches to protect weight-bearing with gradual advancements and eventually physical therapy to address any ankle stiffness, followed by dynamic functional activities. Treatment options for syndesmotic widening and failed conservative management includes both screw and plate options as well as suture buttons.49,51,52
Ankle and foot fractures were historically a rare injury in ice hockey players based on radiograph evaluation; however, the recent study by Baker and colleagues4 demonstrated that MRI can be helpful in detecting subradiographic fractures. Most of the injuries detected after MRI were from being hit by a hockey puck; this was a novel mechanism that had not been previously reported in the literature.4 Of the injuries that resulted from a direct blow, 14 of 17 occurred on the medial aspect of the foot and ankle, which is believed to result another word? from a defender skating towards an offensive player and attempting to block shots on goal. In this study, all occult fractures involving the medial malleolus were eventually treated with open reduction and internal fixation and underwent routine healing.4 The navicular bone and base of the first metatarsal accounted for the remaining medial-sided fractures. In a recent analysis of risk factors for reoperation following operative fixation of foot fractures across the National Basketball Association, the National Football Leagues, Major League Baseball, and the National Hockey League only a total of 3 fractures involving the foot (1 navicular and 2 first metatarsal) were identified in NHL players over a 30-year period.53 The study acknowledged a major limitation being a public source for identifying players with fractures.
Lace bite is another common ice hockey injury. It typically occurs at the beginning of a season or whenever a player is breaking in a new pair of skates. The cause of the lace bite is the rigid tongue in the skate that rubs against the anterior ankle. Skating causes inflammation in the area of the tibialis anterior tendon, and the player will complain of significant anterior ankle pain. First line treatment for lace bite is ice (Figure 4A), NSAID gel (eg, diclofenac 1%), and a Bunga lace-bite pad (Absolute Athletics). (Figure 4B).
SUMMARY
Lower extremity injuries are common in ice hockey players, and a covering physician should be comfortable managing these injuries from breezers to skate. Proper evaluation and work-up is critical for early diagnosis and identification of pathology, which can minimize the impact of the injury and expedite a treatment plan to return the player safely to the ice and in the game.
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35. Holmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999;353(9151):439-443.
36. Sim FH, Chao EY. Injury potential in modern ice hockey. Am J Sports Med. 1978;6(6):378-384.
37. Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. Am J Sports Med. 2001;29(2):124-128.
38. LaPrade RF, Wijdicks CA, Griffith CJ. Division I intercollegiate ice hockey team coverage. BrJ Sports Med. 2009;43(13):1000-1005.
39. Grant JA, Bedi A, Kurz J, Bancroft R, Miller BS. Incidence and injury characteristics of medial collateral ligament injuries in male collegiate ice hockey players. Sports Health. 2013;5(3):270-272.
40. Erickson BJ, Harris JD, Cole BJ, et al. Performance and return to sport after anterior cruciate ligament reconstruction in National Hockey League players. Orthop J Sports Med. 2014;2(9):2325967114548831.
41. 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.
42. Friden T, Erlandsson T, Zatterstrom R, Lindstrand A, Moritz U. Compression or distraction of the anterior cruciate injured knee: variations in injury pattern in contact sports and downhill skiing. Knee Surg Sports Traumatol Arthrosc. 1995;3(3):144-147.
43. Kluczynski MA, Kang JV, Marzo JM, Bisson LJ. Magnetic resonance imaging and intra-articular findings after anterior cruciate ligament injuries in ice hockey versus other sports. Orthop J Sports Med. 2016;4(5):2325967116646534. 44. Beiner JM, Jokl P. Muscle contusion injuries: current treatment options. J Am Acad Orthop Surg. 2001;9(4):227-237.
45. Jackson DW, Feagin JA. Quadriceps contusions in young athletes. Relation of severity of injury to treatment and prognosis. J Bone Joint Surg Am. 1973;55(1):95-105.
46. Ryan JB, Wheeler JH, Hopkinson WJ, Arciero RA, Kolakowski KR. Quadriceps contusions. West Point update. Am J Sports Med. 1991;19(3):299-304.
47. Johnson PN, Mark; Green, Eric. Boot-top lacerations in ice hockey players: a new injury. Clin J Sports Med. 1991:205-208.
48. Nauth A, Aziz M, Tsuji M, Whalen DB, Theodoropoulos JS, Zdero R. The protective effect of Kevlar socks against hockey skate blade injuries: a biomechanical study. Orthop J Sports Med. 2014;2(Suppl 2):7.
49. Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med. 2004;32(8):1941-1945.
50. Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med. 1991;19(3):294-298.
51. Marymont JV, Lynch MA, Henning CE. Acute ligamentous diastasis of the ankle without fracture. Evaluation by radionuclide imaging. Am J Sports Med. 1986;14(5):407-409.
52. Miller CD, Shelton WR, Barrett GR, Savoie FH, Dukes AD. Deltoid and syndesmosis ligament injury of the ankle without fracture. Am J Sports Med. 1995;23(6):746-750.
53. Singh SK, Larkin KE, Kadakia AR, Hsu WK. Risk factors for reoperation and performance-based outcomes after operative fixation of foot fractures in the professional athlete: a cross-sport analysis. Sports Health. 2018;10(1):70-74.
54. Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014;6(2):139-144.
55. Elattar O, Choi HR, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports Health. 2016;8(4):313-323.
ABSTRACT
Ice hockey is a fast-paced, collision sport requiring tremendous skill and finesse, yet ice hockey can be a harsh and violent game. It has one of the highest musculoskeletal injury rates in all of competitive sports. Razor sharp skates, aluminum sticks and boards made from high density polyethylene (HDPE), all contribute to the intrinsic hazards of the game. The objective of this article is to review evaluation, management, and return-to-the-rink guidelines after common lower extremity ice hockey injuries.
“Hockey is a fast body-contact game played by men with clubs in their hands and knives laced to their feet, since the skates are razor sharp, and before the evening is over it is almost a certainty that someone will be hurt and will fleck the ice with a generous contribution of gore before he is led away to be hemstitched together again.” —Paul Gallico in Farewell to Sport (1938)
Ice hockey is a collision sport with player speeds in excess of 30 miles/hour, on a sheet of ice surrounded by unforgiving boards, with a vulcanized rubber puck moving at speeds approaching 100 miles/hour.1-3 Understanding injuries specific to this fast-paced sport is an essential part of being a team physician at any level of competitive ice hockey. We are continuing to improve our ability to correctly identify and treat injuries in ice hockey players.2,4 On the prevention side, rule changes in hockey have been implemented, such as raising the age to allow checking and penalties for deliberate hits to the head and checking from behind, to make the game safer to play.3 Additionally, advancements in biomechanical research and 3D modeling are providing new insights into the pathoanatomy of the hip joint, which can be utilized for surgical planning in hockey players and goalies suffering from symptomatic femoroacetabular impingement (FAI) of the hip.5
During the 2010 Winter Olympics, more than 30% of ice hockey players were injured, which was the highest percentage amongst all competing sports.6 They also tallied the highest percentage of player-to-player injuries during the Olympics of any sport. Consequently, the team physician covering ice hockey should be prepared to manage upper and lower extremity musculoskeletal injuries, but also concussions, cervical spine injuries, and ocular and dental trauma.2
One of the earliest epidemiological studies of ice hockey injuries looked at elite Danish hockey players over 2 seasons and found that head trauma accounted for 28% of all injuries, followed by lower extremity injuries at 27% with upper extremity injuries accounting for 19%.7 More recent epidemiological studies have shown similar rates based on body region while further defining individual diagnoses and their incidence. This should help clinicians and researchers develop prevention strategies, as well as improve treatments to optimize player outcomes and return to sport.8,9 Our group recently reviewed the evaluation and management of common head, neck, and shoulder injuries at all competitive levels of ice hockey, and this article serves to complement the former by focusing on lower extremity injuries (Table).2
Continue to: Hip and groin...
EVALUATION AND MANAGEMENT OF COMMON LOWER EXTREMITY HOCKEY INJURIES
HIP INJURIES
Hip and groin injuries are very common amongst this group of athletes and account for approximately 9% of all ice hockey injuries.1 Unfortunately, they are also known for their high recurrence rates, which may be in part due to delayed diagnosis, inadequate rest and rehabilitation, as well as the extreme loads that are placed on the hip during competition.10,11 In hockey, the most commonly reported hip injuries include goaltender’s hip, FAI, sports hernia/hockey groin syndrome, adductor strains, hip pointer, and quadriceps contusions. Dalton and colleagues12 performed the largest epidemiological study to date on hip and groin injuries amongst National Collegiate Athletic Association ice hockey players and reported that the most common injury mechanism was noncontact in nature. Contact injuries accounted for 13% (55 of 421) in men’s ice hockey players while less than 4% (4 of 114) injuries in female ice hockey players, which is likely attributed to a no checking rule in the women’s division. Some of these hip and groin injuries are difficult to diagnose so it is important for the team physician to perform a thorough history and physical examination. Advanced imaging (magnetic resonance imaging [MRI] or a computed tomography (CT) scan with 3D reconstructions) may be necessary to make the correct diagnosis. This is important for providing proper treatment as well as setting player expectations for return to sport.12
Table 1. Return-to-Play Guidelines for Common Lower Extremity Ice Hockey Injuries | ||
Lower Extremity Injury | Treatment Options | Return-to-the-Rink Goal |
FAI | In-season: injection, physical therapy program, NSAIDS. Off-season or unable to play: requires arthroscopic surgery | Nonoperative can take up to 6 weeks. Surgical depends on what is fixed but goal is 4 months to return to ice24,26
|
Sports hernia/athletic pubalgia
| In-season: physical therapy program, NSAIDS Off-season or unable to play requiring surgery. Essential to make sure no other pathology (eg, FAI, osteitis pubis, adductor strain) to maximize success
| Nonoperative 6-8 wk trial of physical therapy Operative: depends if concomitant FAI but in isolation goal is 3-4 mo33,54
|
Adductor strains | Ice, NSAIDS, physical therapy, use of Hypervolt Hyperice | Depends on position (goalie vs skater) and severity; can take up to 4-8 wk to return to ice. Want 70% strength and painless ROM to skate successfully;55 in chronic cases, may take up to 6 mo35
|
Quadriceps contusion
| Hinged knee brace to maintain 120° of flexion, ice, compression wrap.
| When player regains motion and strength, return to ice can be as fast a couple of days or as long as 3 wk8,46
|
MCL | Hinged knee brace, shin pad modification, ice, NSAIDs | Depends on Grade; if Grade I, 1-2 wk; Grade II, 2-4 wk; Grade III, 4-6 wk8
|
ACL | Surgery autograft BTB autograft soft tissue
| 9-10 mo41 |
Meniscus tear | Depends on type of tear and seasonal timing (in-season or off-season) | If surgical, 3-4 mo; if repair, 4-6 wk if partial menisectomy
|
High ankle sprain
| Cam boot, NSAIDS, ice and physical therapy
| 6 wk49 |
Boot top laceration | Repair of cut structures, depends on depth and what is injured; best treatment is prevention with Kevlar socks | If laceration is deep and severs any medial tendons/vascular structures, return to ice can be ≥6 mo
|
Lace bite
| Bunga pad, ice, diclofenac gel
| Couple of days to up to 2 wk in recalcitrant cases3 |
Abbreviations: ACL, anterior cruciate ligament; BTB, bone-patellar tendon-bone; Cam, controlled ankle motion boot; MCL, medial collateral ligament; FAI, femoroacetabular impingement; NSAIDS, nonsteroidal anti-inflammatory drugs; ROM, range of motion.
Throughout the hockey community, FAI is being examined as a possible source of symptomatic hip pain amongst players at all levels. A recent study, which utilized the National Hockey League (NHL) injury surveillance database, reported that FAI accounted for 5.3% of all hip and groin injuries.13 The etiology of FAI is thought to arise from a combination of genetic predisposition coupled with repetitive axial loading/hip flexion. This causes a bony overgrowth of the proximal femoral physes resulting in a cam deformity (Figure 1).5,14 The abnormal bony anatomy allows for impingement between the acetabulum and proximal femur, which can injure the labrum and articular cartilage of the hip joint.
In the recent study by Ross and colleagues,15 the authors focused on symptomatic hip impingement in ice hockey goalies.15 Goaltender’s hip may be the result of the “butterfly style,” which is a technique of goaltending that emphasizes guarding the lower part of the goal. The goalie drops to his/her knees and internally rotates the hips to allow the leg pads to be parallel to the ice. This style acquired the name butterfly because of the resemblance of the spread goalie pads to a butterfly’s wings. Bedi and associates16 have evaluated hip biomechanics using 3D-generated bone models and showed in their study that arthroscopic treatment can improve hip kinematics and range of motion.
Plain radiographs showed that 90% (61 of 68) of hockey goalies had an elevated alpha angle signifying a femoral cam-type deformity.15 Goalies had a significantly lower mean lateral center-edge angle (27.3° vs 29.6°; P = .03) and 13.2% of them were found to have acetabular dysplasia (lateral center-edge angle<20°) compared to only 3% of positional players. The CT scan measurements demonstrated that hockey goalies have a unique cam-type deformity that is located more lateral (1:00 o’clock vs 1:45 o’clock; P < .0001) along the proximal femur, an elevated maximum alpha angle (80.9° vs 68.6°; P < .0001) and loss of offset, when compared to positional players. These findings provide an anatomical basis in support of reports that goaltenders are more likely to experience intra-articular hip injuries compared to other positional players.13
Regardless of position, symptomatic FAI in a hockey player is generally a problem that slowly builds and is made worse with activity.17 On examination, the player may have limited hip flexion and internal rotation, as well as weakness compared to the contralateral side when testing hip flexion and abduction.18,19 Plain radiographs plus MRI or CT allow for proper characterization and diagnosis (to include underlying chondrolabral pathology).20,21
In the young athlete, initial management includes physical therapy, which focuses on core strengthening. Emphasis is placed on hip flexion and extension, as well as abduction and external rotation with the goal of reducing symptoms and avoiding injuries.22 A similar approach may be applied to the elite athlete, but failure of nonoperative management may necessitate surgical intervention. Hip arthroscopy continues to grow in popularity over open surgical dislocation with low complication rate and high return-to-play rate.23-25
For the in-season athlete, attempts to continue to play can be assisted with the role of an intra-articular corticosteroid injection, which can help calm inflammation within the hip joint and mitigate pain, while rehabilitation focuses on core stabilization, postural retraining and focusing on any muscle imbalances that might be present. For positional players, ice time and shift duration can be adjusted to give the player’s hip a period of rest; meanwhile, for goaltenders, shot volumes in practice can be decreased.
Continue to: For athletes who...
For athletes who fail nonoperative care, surgical treatment varies depending on underlying hip pathology and may include femoroplasty, acetabuloplasty, and microfracture as well as labral repair or debridement. Though data are limited, Philippon and colleagues26 have published promising results in a case series of 28 NHL players after surgical intervention for FAI. All players returned to sport at an average of 3.8 months and players who had surgery within 1 year of injury returned on average 1.1 months sooner than those who waited more than 1 year. Rehabilitation protocol varies between goaltenders compared to defensemen and offensive players due to the different demands required for blocking shots on goal.27
One of the most challenging injuries to correctly identify in the hip area is athletic pubalgia (also referred to as sports hernia or core muscle injury) because pain in the groin may be referred from the lumbar spine, hip joint, urologic, or perineal etiologies.28 Sports hernias involve dilatation of the external ring of the inguinal canal and thinning of the posterior wall. Players may report to the athletic trainer or team physician with a complaint of groin pain that is worse when pushing off with their skate or taking a slap shot.29 On exam, pain can be reproduced by hip extension, contralateral torso rotation, or with a resisted sit-up with palpation of the inferolateral edge of the distal rectus abdominus.30 An MRI with specific sequences centered over the pubic symphysis is usually warranted to aid in the workup of sports hernia. An MRI in these cases may also demonstrate avulsions of the rectus abdominus.31
Most of these injuries are managed conservatively but can warrant surgical intervention if the symptoms persist. In the study by Jakoi and colleagues,32 they identified 43 ice hockey players over an 8-year period (2001-2008) who had repairs of their sports hernias and assessed the statistics during the 2 years prior and 2 years after surgery. The authors found that 80% of these players were able to return to the ice for 2 or more full seasons. The return-to-sport rate was comparable to other sports after sports hernia repair, but players who had played in ≥7 seasons demonstrated a greater decrease in number of games played, goals, assists and time on ice compared to those who had played in ≤6 seasons prior to the time of injury. Between 1989 and 2000, 22 NHL players who failed to respond to nonoperative management of their groin injuries underwent surgical exploration.29 At the time of surgical exploration, their hockey groin syndrome, consisted of small tears in the external oblique aponeurosis through which branches of the ilioinguinal or iliohypogastric could be identified. These surgical procedures were all through a standard inguinal approach and the perforating neurovascular structures were excised, while the main trunk of the ilioinguinal nerve was ablated and the external oblique aponeurosis was repaired and reinforced with Goretex (W.L. Gore & Associates Inc, Flagstaff, AZ). At follow-up, 18 of the 22 players (82%) had no pain and 19 (86%) were able to resume their careers in the NHL.29 Ice hockey players with sports hernias or hockey groin syndrome often return to the sport, but it is important to identify these problems early so that surgical options can be discussed if the player fails conservative management. It is also critical to make sure that all pathology is identified, because in players with mixed sports hernia and FAI, return-to-play results improve when both issues are addressed. In a study of athletes (some of whom were ice hockey players), who had both FAI and sports hernia, and only hernia/pubalgia surgery was performed, 25% of these athletes returned to sport. If only FAI was addressed, 50% of the athletes returned to sport; however, when hernia and FAI were treated, 89% returned to play.33
Adductor strains includes injury to the adductor muscles, pectineus, obturator externus and gracilis, and are prevalent in ice hockey players. A study of elite Swedish ice hockey players published in 1988 reported that adductor strains accounted for 10% (10 of 95) of all injuries.34 Given the prevalence of these injuries, considerable research has been dedicated to understanding their mechanism and prevention.35 Adductor strains within the ice hockey population have been attributed to the eccentric forces on the adductors when players attempt to decelerate the leg during a stride.36 A study of NHL players revealed that a ratio <80% of adductor-to-abductor muscle is the best predictor of a groin strain.37
These injuries are also well known for their recurrence rates, as was the case in an NHL study where 4 of the 9 adductor strains (44%) were recurrent injuries.37 The authors attributed the recurrence to an incomplete rehabilitation program and an accelerated return to sport. This was followed by an NHL prevention program that spanned 2 seasons and analyzed 58 players whose adductor-to-abductor ratio was <80% and placed them into a 6-week intervention program during the preseason.37 Only 3 players sustained an adductor strain in the 2 subsequent seasons after the intervention, compared to 11 strains in the previous 2 seasons. Thus, early identification of muscle strength imbalance coupled with an appropriate intervention program has proven to be an effective means of reducing adductor strains in this at-risk population.
Continue to: Contact injuries may...
Contact injuries may vary with checking into the boards being unique to men’s ice hockey. Hip pointers occur as a result of a direct compression injury to the iliac crest, which causes trauma to the bone but also to the overlying hip abductor musculature, and represent roughly 2.4% of ice hockey injuries.23 The resulting contusion may cause a local hematoma formation. Early identification of the injury plus treatment with RICE (rest, ice, compression, elevation) coupled with crutches to limit weight-bearing status may minimize soft tissue trauma and swelling, and ultimately aid in pain control and return to sport.38 Hip abductor strengthening, added padding over the injured area, as well as a compressive hip spica wrapping, have all been suggested to expedite return to play and help prevent recurrence of the hip pointer.8
KNEE INJURIES
Injury to the medial collateral ligament (MCL) is the most commonly reported knee injury (Figure 2) and second only to concussion amongst all injuries in National Collegiate Athletic Association ice hockey players.8,39 The mechanism of injury typically involves a valgus force on the knee, which is often caused by collision into another player.39 Valgus stress testing with the knee in 30° of flexion is used to grade the severity of injury (Grade I: 0-5 mm of medial opening; Grade II: 5-10 mm of medial opening; Grade III: >10 mm of medial opening).39 One study that followed a single college hockey team for 8 seasons reported that 77% of injuries (10 of 13) occurred during player-to-player collision,39 with 5 being Grade 1 injuries, 6 Grade 2 injuries, 1 Grade 3; information was missing for 1 player. Nonoperative management of incomplete injuries, grade 1 and 2 sprains, with RICE and early physical therapy intervention to work on knee range of motion and quadriceps strengthening typically helps the player return to sport within days for grade 1 and 2 injuries to 3 weeks for grade 2 injuries. Complete tears have been managed both operatively and nonoperatively with evidence to suggest better outcomes after surgical intervention if there is a concomitant ACL injury requiring reconstruction.8,9
Anterior cruciate ligament (ACL) tears occur less frequently in hockey players compared to the players in other sports such as football and basketball.38,40 Between 2006 and 2010, 47 players were identified by the NHL Injury Surveillance System as having sustained an ACL injury, which equates to an incidence of 9.4 ACL injuries per NHL season over this time span.41 The mechanism of ACL tears in ice hockey players appears to be different from other sports players based on a recent MRI study that evaluated players for concomitant injuries following ACL tear and noted significantly fewer bone bruises on the lateral femoral condyle compared to players in other sports.42 Early evaluation after injury with Lachman and/or pivot shift tests aids the diagnosis. Data from the NHL study identified 32 players (68%) with concomitant meniscal injuries and 32 (68%) had MCL injuries in conjunction with their ACL tears.41 Average length in the league prior to injury was 5.65 seasons. Twenty-nine of the injured players (61.7%) underwent reconstruction with a patellar tendon autograft, 13 (27.7%) had a hamstring autograft, and 5 (10.6%) had either a patellar tendon or hamstring allograft.41 Meniscus and ACL injuries were associated with a decreased length of career compared to age-matched controls and, notably, players >30 years at the time of injury had only a 67% rate of return to sport whereas those <30 years had a return-to-sport rate of 80%. Players who were able to return did so at an average of 9.8 months (range, 6-21 months) and had a significant reduction in total number of goals, assists, and points scored compared to controls. Decline in performance was typically associated with forwards and wings, while defensemen did not demonstrate the same decrease in performance following return to ice hockey.41
Meniscal tears are a well-documented concomitant injury with ruptures of the ACL, and the combination is a known pattern associated with shorter careers compared to isolated ACL tears in ice hockey players.41 The lateral meniscus is known for increased mobility compared to the medial meniscus and is more commonly injured (39% vs 8.5%) in ACL tears that occur in contact sports and downhill skiing.42 Ice hockey presents a scenario that is different from other contact sports because of the near frictionless interaction between the player’s ice skates and playing surface. This likely equates to a different injury mechanism and dissipation of energy after contact as well as non-contact injuries.38 A recent study reviewed knee MRI findings associated with ACL tears in collegiate ice hockey players and compared to other sports known for their high rates of concomitant meniscal pathology. The authors reported a statistically significant decrease in lateral meniscus tears and bone-bruising patterns in ice hockey players with ACL injuries compared to athletes with ACL tears in other sports.43 In contrast, an NHL study of ACL tears in professional ice hockey players found that 68% of players had concomitant meniscal tears (32 out of 47 players).41
Continue to: The presence of...
The presence of a meniscal tear on MRI is typically a surgical problem, especially if it occurred with an ACL injury. Meniscal repair is preferable, if possible, because there is a known association of increased cartilage contact pressures associated with meniscal debridement. Return to sport following meniscus injury hinges upon whether it is an isolated injury and how it is treated. If the meniscus injury occurs in isolation and can be treated with a debridement and partial resection alone, there is obviously a quicker return to sport as the player can be weight-bearing immediately following surgery. Return to skating after meniscal debridement and partial resection is usually 4 to 6 weeks, whereas meniscal repair protocols vary depending on surgeon; players may need 3 months to 4 months to return to the ice.
Quadriceps contusions are contact injuries that are not unique to ice hockey (Figure 3). They may result from player collision but also from direct blows from a hockey puck. A high velocity puck is known to cause immense trauma to the quadriceps muscles, which may result in localized bleeding and hematoma formation. If the player is able to anticipate the event, active contraction of the quadriceps muscle has been shown to absorb some of the energy and result in a less traumatic injury, but in a fast paced ice hockey game, the player’s anticipation is less likely than in other sports such as baseball.44Interestingly, the degree of knee flexion after injury is predictive of injury severity with milder injuries associated with angles >90 and more severe injuries resulting in knee flexion angles <45° and typically an antalgic gait.45 It is important to treat these injuries during the first 24 hours with the knee maintained in 120°of flexion, plus ice and compression, which can be achieved using a locked knee brace or elastic compression wrap. Quadriceps stretching and isometric strengthening should immediately follow the period of immobilization. The addition of NSAIDs may help prevent the formation of myositis ossificans. A study from West Point suggests that the average return to sport or activity ranges from 13 days (mild contusion) to 21 days (severe contusions), while others8 have indicated that if the injury is treated acutely and a player is able to regain motion and strength, return to ice hockey within a few days is possible.
FOOT AND ANKLE
Ice hockey has some unique injuries that can be attributed to the use of ice skates for play. One such injury is boot-top lacerations, which are fortunately rare as they can be a career-ending injury.47 The spectrum of injury ranges from superficial abrasions to more severe soft tissue disruption, including the extensor tendons and neurovascular structures. The actual mechanism of injury involves an opponent’s skate blade cutting across the anterior ankle. One early case report described a protective method of having players place their skate tongues deep to their protective shin pads, instead of turning the tongues down.47 Kevlar socks have also been shown to help prevent or minimize the damage from a skate blade.48
Injury to the lateral ankle ligaments, anterior talofibular ligament or calcaneofibular ligament, are usually more common than the higher ankle sprains involving the syndesmosis. However, this is not the case in ice hockey. The rigidity of the ice skate at the level of the lateral ligaments seems to impart a protective mechanism to the lower ligaments, but this results in a higher incidence of syndesmotic injuries. These high ankle injuries are unfortunately more debilitating and often require a longer recovery period. In a study of these injuries in NHL players, syndesmotic sprains made up 74% of all ankle sprains, whereas only 18.4% of ankle sprains involved the syndesmosis in American football players..49,50 The average number of days between injury and return to play is 45 days, and some authors believe that defensemen may have a harder time recovering because of the demands on their ankles by having to switch continuously between forward and backward skating.49
Most patients are treated conservatively when their ankle plain radiographs show a congruent mortise and no evidence of syndesmotic widening. If the player expresses pain when squeezing the syndesmosis, it is helpful to obtain stress radiographs to further evaluate for syndesmotic injury. Nonoperative management includes RICE, immobilization in a rigid boot with crutches to protect weight-bearing with gradual advancements and eventually physical therapy to address any ankle stiffness, followed by dynamic functional activities. Treatment options for syndesmotic widening and failed conservative management includes both screw and plate options as well as suture buttons.49,51,52
Ankle and foot fractures were historically a rare injury in ice hockey players based on radiograph evaluation; however, the recent study by Baker and colleagues4 demonstrated that MRI can be helpful in detecting subradiographic fractures. Most of the injuries detected after MRI were from being hit by a hockey puck; this was a novel mechanism that had not been previously reported in the literature.4 Of the injuries that resulted from a direct blow, 14 of 17 occurred on the medial aspect of the foot and ankle, which is believed to result another word? from a defender skating towards an offensive player and attempting to block shots on goal. In this study, all occult fractures involving the medial malleolus were eventually treated with open reduction and internal fixation and underwent routine healing.4 The navicular bone and base of the first metatarsal accounted for the remaining medial-sided fractures. In a recent analysis of risk factors for reoperation following operative fixation of foot fractures across the National Basketball Association, the National Football Leagues, Major League Baseball, and the National Hockey League only a total of 3 fractures involving the foot (1 navicular and 2 first metatarsal) were identified in NHL players over a 30-year period.53 The study acknowledged a major limitation being a public source for identifying players with fractures.
Lace bite is another common ice hockey injury. It typically occurs at the beginning of a season or whenever a player is breaking in a new pair of skates. The cause of the lace bite is the rigid tongue in the skate that rubs against the anterior ankle. Skating causes inflammation in the area of the tibialis anterior tendon, and the player will complain of significant anterior ankle pain. First line treatment for lace bite is ice (Figure 4A), NSAID gel (eg, diclofenac 1%), and a Bunga lace-bite pad (Absolute Athletics). (Figure 4B).
SUMMARY
Lower extremity injuries are common in ice hockey players, and a covering physician should be comfortable managing these injuries from breezers to skate. Proper evaluation and work-up is critical for early diagnosis and identification of pathology, which can minimize the impact of the injury and expedite a treatment plan to return the player safely to the ice and in the game.
ABSTRACT
Ice hockey is a fast-paced, collision sport requiring tremendous skill and finesse, yet ice hockey can be a harsh and violent game. It has one of the highest musculoskeletal injury rates in all of competitive sports. Razor sharp skates, aluminum sticks and boards made from high density polyethylene (HDPE), all contribute to the intrinsic hazards of the game. The objective of this article is to review evaluation, management, and return-to-the-rink guidelines after common lower extremity ice hockey injuries.
“Hockey is a fast body-contact game played by men with clubs in their hands and knives laced to their feet, since the skates are razor sharp, and before the evening is over it is almost a certainty that someone will be hurt and will fleck the ice with a generous contribution of gore before he is led away to be hemstitched together again.” —Paul Gallico in Farewell to Sport (1938)
Ice hockey is a collision sport with player speeds in excess of 30 miles/hour, on a sheet of ice surrounded by unforgiving boards, with a vulcanized rubber puck moving at speeds approaching 100 miles/hour.1-3 Understanding injuries specific to this fast-paced sport is an essential part of being a team physician at any level of competitive ice hockey. We are continuing to improve our ability to correctly identify and treat injuries in ice hockey players.2,4 On the prevention side, rule changes in hockey have been implemented, such as raising the age to allow checking and penalties for deliberate hits to the head and checking from behind, to make the game safer to play.3 Additionally, advancements in biomechanical research and 3D modeling are providing new insights into the pathoanatomy of the hip joint, which can be utilized for surgical planning in hockey players and goalies suffering from symptomatic femoroacetabular impingement (FAI) of the hip.5
During the 2010 Winter Olympics, more than 30% of ice hockey players were injured, which was the highest percentage amongst all competing sports.6 They also tallied the highest percentage of player-to-player injuries during the Olympics of any sport. Consequently, the team physician covering ice hockey should be prepared to manage upper and lower extremity musculoskeletal injuries, but also concussions, cervical spine injuries, and ocular and dental trauma.2
One of the earliest epidemiological studies of ice hockey injuries looked at elite Danish hockey players over 2 seasons and found that head trauma accounted for 28% of all injuries, followed by lower extremity injuries at 27% with upper extremity injuries accounting for 19%.7 More recent epidemiological studies have shown similar rates based on body region while further defining individual diagnoses and their incidence. This should help clinicians and researchers develop prevention strategies, as well as improve treatments to optimize player outcomes and return to sport.8,9 Our group recently reviewed the evaluation and management of common head, neck, and shoulder injuries at all competitive levels of ice hockey, and this article serves to complement the former by focusing on lower extremity injuries (Table).2
Continue to: Hip and groin...
EVALUATION AND MANAGEMENT OF COMMON LOWER EXTREMITY HOCKEY INJURIES
HIP INJURIES
Hip and groin injuries are very common amongst this group of athletes and account for approximately 9% of all ice hockey injuries.1 Unfortunately, they are also known for their high recurrence rates, which may be in part due to delayed diagnosis, inadequate rest and rehabilitation, as well as the extreme loads that are placed on the hip during competition.10,11 In hockey, the most commonly reported hip injuries include goaltender’s hip, FAI, sports hernia/hockey groin syndrome, adductor strains, hip pointer, and quadriceps contusions. Dalton and colleagues12 performed the largest epidemiological study to date on hip and groin injuries amongst National Collegiate Athletic Association ice hockey players and reported that the most common injury mechanism was noncontact in nature. Contact injuries accounted for 13% (55 of 421) in men’s ice hockey players while less than 4% (4 of 114) injuries in female ice hockey players, which is likely attributed to a no checking rule in the women’s division. Some of these hip and groin injuries are difficult to diagnose so it is important for the team physician to perform a thorough history and physical examination. Advanced imaging (magnetic resonance imaging [MRI] or a computed tomography (CT) scan with 3D reconstructions) may be necessary to make the correct diagnosis. This is important for providing proper treatment as well as setting player expectations for return to sport.12
Table 1. Return-to-Play Guidelines for Common Lower Extremity Ice Hockey Injuries | ||
Lower Extremity Injury | Treatment Options | Return-to-the-Rink Goal |
FAI | In-season: injection, physical therapy program, NSAIDS. Off-season or unable to play: requires arthroscopic surgery | Nonoperative can take up to 6 weeks. Surgical depends on what is fixed but goal is 4 months to return to ice24,26
|
Sports hernia/athletic pubalgia
| In-season: physical therapy program, NSAIDS Off-season or unable to play requiring surgery. Essential to make sure no other pathology (eg, FAI, osteitis pubis, adductor strain) to maximize success
| Nonoperative 6-8 wk trial of physical therapy Operative: depends if concomitant FAI but in isolation goal is 3-4 mo33,54
|
Adductor strains | Ice, NSAIDS, physical therapy, use of Hypervolt Hyperice | Depends on position (goalie vs skater) and severity; can take up to 4-8 wk to return to ice. Want 70% strength and painless ROM to skate successfully;55 in chronic cases, may take up to 6 mo35
|
Quadriceps contusion
| Hinged knee brace to maintain 120° of flexion, ice, compression wrap.
| When player regains motion and strength, return to ice can be as fast a couple of days or as long as 3 wk8,46
|
MCL | Hinged knee brace, shin pad modification, ice, NSAIDs | Depends on Grade; if Grade I, 1-2 wk; Grade II, 2-4 wk; Grade III, 4-6 wk8
|
ACL | Surgery autograft BTB autograft soft tissue
| 9-10 mo41 |
Meniscus tear | Depends on type of tear and seasonal timing (in-season or off-season) | If surgical, 3-4 mo; if repair, 4-6 wk if partial menisectomy
|
High ankle sprain
| Cam boot, NSAIDS, ice and physical therapy
| 6 wk49 |
Boot top laceration | Repair of cut structures, depends on depth and what is injured; best treatment is prevention with Kevlar socks | If laceration is deep and severs any medial tendons/vascular structures, return to ice can be ≥6 mo
|
Lace bite
| Bunga pad, ice, diclofenac gel
| Couple of days to up to 2 wk in recalcitrant cases3 |
Abbreviations: ACL, anterior cruciate ligament; BTB, bone-patellar tendon-bone; Cam, controlled ankle motion boot; MCL, medial collateral ligament; FAI, femoroacetabular impingement; NSAIDS, nonsteroidal anti-inflammatory drugs; ROM, range of motion.
Throughout the hockey community, FAI is being examined as a possible source of symptomatic hip pain amongst players at all levels. A recent study, which utilized the National Hockey League (NHL) injury surveillance database, reported that FAI accounted for 5.3% of all hip and groin injuries.13 The etiology of FAI is thought to arise from a combination of genetic predisposition coupled with repetitive axial loading/hip flexion. This causes a bony overgrowth of the proximal femoral physes resulting in a cam deformity (Figure 1).5,14 The abnormal bony anatomy allows for impingement between the acetabulum and proximal femur, which can injure the labrum and articular cartilage of the hip joint.
In the recent study by Ross and colleagues,15 the authors focused on symptomatic hip impingement in ice hockey goalies.15 Goaltender’s hip may be the result of the “butterfly style,” which is a technique of goaltending that emphasizes guarding the lower part of the goal. The goalie drops to his/her knees and internally rotates the hips to allow the leg pads to be parallel to the ice. This style acquired the name butterfly because of the resemblance of the spread goalie pads to a butterfly’s wings. Bedi and associates16 have evaluated hip biomechanics using 3D-generated bone models and showed in their study that arthroscopic treatment can improve hip kinematics and range of motion.
Plain radiographs showed that 90% (61 of 68) of hockey goalies had an elevated alpha angle signifying a femoral cam-type deformity.15 Goalies had a significantly lower mean lateral center-edge angle (27.3° vs 29.6°; P = .03) and 13.2% of them were found to have acetabular dysplasia (lateral center-edge angle<20°) compared to only 3% of positional players. The CT scan measurements demonstrated that hockey goalies have a unique cam-type deformity that is located more lateral (1:00 o’clock vs 1:45 o’clock; P < .0001) along the proximal femur, an elevated maximum alpha angle (80.9° vs 68.6°; P < .0001) and loss of offset, when compared to positional players. These findings provide an anatomical basis in support of reports that goaltenders are more likely to experience intra-articular hip injuries compared to other positional players.13
Regardless of position, symptomatic FAI in a hockey player is generally a problem that slowly builds and is made worse with activity.17 On examination, the player may have limited hip flexion and internal rotation, as well as weakness compared to the contralateral side when testing hip flexion and abduction.18,19 Plain radiographs plus MRI or CT allow for proper characterization and diagnosis (to include underlying chondrolabral pathology).20,21
In the young athlete, initial management includes physical therapy, which focuses on core strengthening. Emphasis is placed on hip flexion and extension, as well as abduction and external rotation with the goal of reducing symptoms and avoiding injuries.22 A similar approach may be applied to the elite athlete, but failure of nonoperative management may necessitate surgical intervention. Hip arthroscopy continues to grow in popularity over open surgical dislocation with low complication rate and high return-to-play rate.23-25
For the in-season athlete, attempts to continue to play can be assisted with the role of an intra-articular corticosteroid injection, which can help calm inflammation within the hip joint and mitigate pain, while rehabilitation focuses on core stabilization, postural retraining and focusing on any muscle imbalances that might be present. For positional players, ice time and shift duration can be adjusted to give the player’s hip a period of rest; meanwhile, for goaltenders, shot volumes in practice can be decreased.
Continue to: For athletes who...
For athletes who fail nonoperative care, surgical treatment varies depending on underlying hip pathology and may include femoroplasty, acetabuloplasty, and microfracture as well as labral repair or debridement. Though data are limited, Philippon and colleagues26 have published promising results in a case series of 28 NHL players after surgical intervention for FAI. All players returned to sport at an average of 3.8 months and players who had surgery within 1 year of injury returned on average 1.1 months sooner than those who waited more than 1 year. Rehabilitation protocol varies between goaltenders compared to defensemen and offensive players due to the different demands required for blocking shots on goal.27
One of the most challenging injuries to correctly identify in the hip area is athletic pubalgia (also referred to as sports hernia or core muscle injury) because pain in the groin may be referred from the lumbar spine, hip joint, urologic, or perineal etiologies.28 Sports hernias involve dilatation of the external ring of the inguinal canal and thinning of the posterior wall. Players may report to the athletic trainer or team physician with a complaint of groin pain that is worse when pushing off with their skate or taking a slap shot.29 On exam, pain can be reproduced by hip extension, contralateral torso rotation, or with a resisted sit-up with palpation of the inferolateral edge of the distal rectus abdominus.30 An MRI with specific sequences centered over the pubic symphysis is usually warranted to aid in the workup of sports hernia. An MRI in these cases may also demonstrate avulsions of the rectus abdominus.31
Most of these injuries are managed conservatively but can warrant surgical intervention if the symptoms persist. In the study by Jakoi and colleagues,32 they identified 43 ice hockey players over an 8-year period (2001-2008) who had repairs of their sports hernias and assessed the statistics during the 2 years prior and 2 years after surgery. The authors found that 80% of these players were able to return to the ice for 2 or more full seasons. The return-to-sport rate was comparable to other sports after sports hernia repair, but players who had played in ≥7 seasons demonstrated a greater decrease in number of games played, goals, assists and time on ice compared to those who had played in ≤6 seasons prior to the time of injury. Between 1989 and 2000, 22 NHL players who failed to respond to nonoperative management of their groin injuries underwent surgical exploration.29 At the time of surgical exploration, their hockey groin syndrome, consisted of small tears in the external oblique aponeurosis through which branches of the ilioinguinal or iliohypogastric could be identified. These surgical procedures were all through a standard inguinal approach and the perforating neurovascular structures were excised, while the main trunk of the ilioinguinal nerve was ablated and the external oblique aponeurosis was repaired and reinforced with Goretex (W.L. Gore & Associates Inc, Flagstaff, AZ). At follow-up, 18 of the 22 players (82%) had no pain and 19 (86%) were able to resume their careers in the NHL.29 Ice hockey players with sports hernias or hockey groin syndrome often return to the sport, but it is important to identify these problems early so that surgical options can be discussed if the player fails conservative management. It is also critical to make sure that all pathology is identified, because in players with mixed sports hernia and FAI, return-to-play results improve when both issues are addressed. In a study of athletes (some of whom were ice hockey players), who had both FAI and sports hernia, and only hernia/pubalgia surgery was performed, 25% of these athletes returned to sport. If only FAI was addressed, 50% of the athletes returned to sport; however, when hernia and FAI were treated, 89% returned to play.33
Adductor strains includes injury to the adductor muscles, pectineus, obturator externus and gracilis, and are prevalent in ice hockey players. A study of elite Swedish ice hockey players published in 1988 reported that adductor strains accounted for 10% (10 of 95) of all injuries.34 Given the prevalence of these injuries, considerable research has been dedicated to understanding their mechanism and prevention.35 Adductor strains within the ice hockey population have been attributed to the eccentric forces on the adductors when players attempt to decelerate the leg during a stride.36 A study of NHL players revealed that a ratio <80% of adductor-to-abductor muscle is the best predictor of a groin strain.37
These injuries are also well known for their recurrence rates, as was the case in an NHL study where 4 of the 9 adductor strains (44%) were recurrent injuries.37 The authors attributed the recurrence to an incomplete rehabilitation program and an accelerated return to sport. This was followed by an NHL prevention program that spanned 2 seasons and analyzed 58 players whose adductor-to-abductor ratio was <80% and placed them into a 6-week intervention program during the preseason.37 Only 3 players sustained an adductor strain in the 2 subsequent seasons after the intervention, compared to 11 strains in the previous 2 seasons. Thus, early identification of muscle strength imbalance coupled with an appropriate intervention program has proven to be an effective means of reducing adductor strains in this at-risk population.
Continue to: Contact injuries may...
Contact injuries may vary with checking into the boards being unique to men’s ice hockey. Hip pointers occur as a result of a direct compression injury to the iliac crest, which causes trauma to the bone but also to the overlying hip abductor musculature, and represent roughly 2.4% of ice hockey injuries.23 The resulting contusion may cause a local hematoma formation. Early identification of the injury plus treatment with RICE (rest, ice, compression, elevation) coupled with crutches to limit weight-bearing status may minimize soft tissue trauma and swelling, and ultimately aid in pain control and return to sport.38 Hip abductor strengthening, added padding over the injured area, as well as a compressive hip spica wrapping, have all been suggested to expedite return to play and help prevent recurrence of the hip pointer.8
KNEE INJURIES
Injury to the medial collateral ligament (MCL) is the most commonly reported knee injury (Figure 2) and second only to concussion amongst all injuries in National Collegiate Athletic Association ice hockey players.8,39 The mechanism of injury typically involves a valgus force on the knee, which is often caused by collision into another player.39 Valgus stress testing with the knee in 30° of flexion is used to grade the severity of injury (Grade I: 0-5 mm of medial opening; Grade II: 5-10 mm of medial opening; Grade III: >10 mm of medial opening).39 One study that followed a single college hockey team for 8 seasons reported that 77% of injuries (10 of 13) occurred during player-to-player collision,39 with 5 being Grade 1 injuries, 6 Grade 2 injuries, 1 Grade 3; information was missing for 1 player. Nonoperative management of incomplete injuries, grade 1 and 2 sprains, with RICE and early physical therapy intervention to work on knee range of motion and quadriceps strengthening typically helps the player return to sport within days for grade 1 and 2 injuries to 3 weeks for grade 2 injuries. Complete tears have been managed both operatively and nonoperatively with evidence to suggest better outcomes after surgical intervention if there is a concomitant ACL injury requiring reconstruction.8,9
Anterior cruciate ligament (ACL) tears occur less frequently in hockey players compared to the players in other sports such as football and basketball.38,40 Between 2006 and 2010, 47 players were identified by the NHL Injury Surveillance System as having sustained an ACL injury, which equates to an incidence of 9.4 ACL injuries per NHL season over this time span.41 The mechanism of ACL tears in ice hockey players appears to be different from other sports players based on a recent MRI study that evaluated players for concomitant injuries following ACL tear and noted significantly fewer bone bruises on the lateral femoral condyle compared to players in other sports.42 Early evaluation after injury with Lachman and/or pivot shift tests aids the diagnosis. Data from the NHL study identified 32 players (68%) with concomitant meniscal injuries and 32 (68%) had MCL injuries in conjunction with their ACL tears.41 Average length in the league prior to injury was 5.65 seasons. Twenty-nine of the injured players (61.7%) underwent reconstruction with a patellar tendon autograft, 13 (27.7%) had a hamstring autograft, and 5 (10.6%) had either a patellar tendon or hamstring allograft.41 Meniscus and ACL injuries were associated with a decreased length of career compared to age-matched controls and, notably, players >30 years at the time of injury had only a 67% rate of return to sport whereas those <30 years had a return-to-sport rate of 80%. Players who were able to return did so at an average of 9.8 months (range, 6-21 months) and had a significant reduction in total number of goals, assists, and points scored compared to controls. Decline in performance was typically associated with forwards and wings, while defensemen did not demonstrate the same decrease in performance following return to ice hockey.41
Meniscal tears are a well-documented concomitant injury with ruptures of the ACL, and the combination is a known pattern associated with shorter careers compared to isolated ACL tears in ice hockey players.41 The lateral meniscus is known for increased mobility compared to the medial meniscus and is more commonly injured (39% vs 8.5%) in ACL tears that occur in contact sports and downhill skiing.42 Ice hockey presents a scenario that is different from other contact sports because of the near frictionless interaction between the player’s ice skates and playing surface. This likely equates to a different injury mechanism and dissipation of energy after contact as well as non-contact injuries.38 A recent study reviewed knee MRI findings associated with ACL tears in collegiate ice hockey players and compared to other sports known for their high rates of concomitant meniscal pathology. The authors reported a statistically significant decrease in lateral meniscus tears and bone-bruising patterns in ice hockey players with ACL injuries compared to athletes with ACL tears in other sports.43 In contrast, an NHL study of ACL tears in professional ice hockey players found that 68% of players had concomitant meniscal tears (32 out of 47 players).41
Continue to: The presence of...
The presence of a meniscal tear on MRI is typically a surgical problem, especially if it occurred with an ACL injury. Meniscal repair is preferable, if possible, because there is a known association of increased cartilage contact pressures associated with meniscal debridement. Return to sport following meniscus injury hinges upon whether it is an isolated injury and how it is treated. If the meniscus injury occurs in isolation and can be treated with a debridement and partial resection alone, there is obviously a quicker return to sport as the player can be weight-bearing immediately following surgery. Return to skating after meniscal debridement and partial resection is usually 4 to 6 weeks, whereas meniscal repair protocols vary depending on surgeon; players may need 3 months to 4 months to return to the ice.
Quadriceps contusions are contact injuries that are not unique to ice hockey (Figure 3). They may result from player collision but also from direct blows from a hockey puck. A high velocity puck is known to cause immense trauma to the quadriceps muscles, which may result in localized bleeding and hematoma formation. If the player is able to anticipate the event, active contraction of the quadriceps muscle has been shown to absorb some of the energy and result in a less traumatic injury, but in a fast paced ice hockey game, the player’s anticipation is less likely than in other sports such as baseball.44Interestingly, the degree of knee flexion after injury is predictive of injury severity with milder injuries associated with angles >90 and more severe injuries resulting in knee flexion angles <45° and typically an antalgic gait.45 It is important to treat these injuries during the first 24 hours with the knee maintained in 120°of flexion, plus ice and compression, which can be achieved using a locked knee brace or elastic compression wrap. Quadriceps stretching and isometric strengthening should immediately follow the period of immobilization. The addition of NSAIDs may help prevent the formation of myositis ossificans. A study from West Point suggests that the average return to sport or activity ranges from 13 days (mild contusion) to 21 days (severe contusions), while others8 have indicated that if the injury is treated acutely and a player is able to regain motion and strength, return to ice hockey within a few days is possible.
FOOT AND ANKLE
Ice hockey has some unique injuries that can be attributed to the use of ice skates for play. One such injury is boot-top lacerations, which are fortunately rare as they can be a career-ending injury.47 The spectrum of injury ranges from superficial abrasions to more severe soft tissue disruption, including the extensor tendons and neurovascular structures. The actual mechanism of injury involves an opponent’s skate blade cutting across the anterior ankle. One early case report described a protective method of having players place their skate tongues deep to their protective shin pads, instead of turning the tongues down.47 Kevlar socks have also been shown to help prevent or minimize the damage from a skate blade.48
Injury to the lateral ankle ligaments, anterior talofibular ligament or calcaneofibular ligament, are usually more common than the higher ankle sprains involving the syndesmosis. However, this is not the case in ice hockey. The rigidity of the ice skate at the level of the lateral ligaments seems to impart a protective mechanism to the lower ligaments, but this results in a higher incidence of syndesmotic injuries. These high ankle injuries are unfortunately more debilitating and often require a longer recovery period. In a study of these injuries in NHL players, syndesmotic sprains made up 74% of all ankle sprains, whereas only 18.4% of ankle sprains involved the syndesmosis in American football players..49,50 The average number of days between injury and return to play is 45 days, and some authors believe that defensemen may have a harder time recovering because of the demands on their ankles by having to switch continuously between forward and backward skating.49
Most patients are treated conservatively when their ankle plain radiographs show a congruent mortise and no evidence of syndesmotic widening. If the player expresses pain when squeezing the syndesmosis, it is helpful to obtain stress radiographs to further evaluate for syndesmotic injury. Nonoperative management includes RICE, immobilization in a rigid boot with crutches to protect weight-bearing with gradual advancements and eventually physical therapy to address any ankle stiffness, followed by dynamic functional activities. Treatment options for syndesmotic widening and failed conservative management includes both screw and plate options as well as suture buttons.49,51,52
Ankle and foot fractures were historically a rare injury in ice hockey players based on radiograph evaluation; however, the recent study by Baker and colleagues4 demonstrated that MRI can be helpful in detecting subradiographic fractures. Most of the injuries detected after MRI were from being hit by a hockey puck; this was a novel mechanism that had not been previously reported in the literature.4 Of the injuries that resulted from a direct blow, 14 of 17 occurred on the medial aspect of the foot and ankle, which is believed to result another word? from a defender skating towards an offensive player and attempting to block shots on goal. In this study, all occult fractures involving the medial malleolus were eventually treated with open reduction and internal fixation and underwent routine healing.4 The navicular bone and base of the first metatarsal accounted for the remaining medial-sided fractures. In a recent analysis of risk factors for reoperation following operative fixation of foot fractures across the National Basketball Association, the National Football Leagues, Major League Baseball, and the National Hockey League only a total of 3 fractures involving the foot (1 navicular and 2 first metatarsal) were identified in NHL players over a 30-year period.53 The study acknowledged a major limitation being a public source for identifying players with fractures.
Lace bite is another common ice hockey injury. It typically occurs at the beginning of a season or whenever a player is breaking in a new pair of skates. The cause of the lace bite is the rigid tongue in the skate that rubs against the anterior ankle. Skating causes inflammation in the area of the tibialis anterior tendon, and the player will complain of significant anterior ankle pain. First line treatment for lace bite is ice (Figure 4A), NSAID gel (eg, diclofenac 1%), and a Bunga lace-bite pad (Absolute Athletics). (Figure 4B).
SUMMARY
Lower extremity injuries are common in ice hockey players, and a covering physician should be comfortable managing these injuries from breezers to skate. Proper evaluation and work-up is critical for early diagnosis and identification of pathology, which can minimize the impact of the injury and expedite a treatment plan to return the player safely to the ice and in the game.
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48. Nauth A, Aziz M, Tsuji M, Whalen DB, Theodoropoulos JS, Zdero R. The protective effect of Kevlar socks against hockey skate blade injuries: a biomechanical study. Orthop J Sports Med. 2014;2(Suppl 2):7.
49. Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med. 2004;32(8):1941-1945.
50. Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med. 1991;19(3):294-298.
51. Marymont JV, Lynch MA, Henning CE. Acute ligamentous diastasis of the ankle without fracture. Evaluation by radionuclide imaging. Am J Sports Med. 1986;14(5):407-409.
52. Miller CD, Shelton WR, Barrett GR, Savoie FH, Dukes AD. Deltoid and syndesmosis ligament injury of the ankle without fracture. Am J Sports Med. 1995;23(6):746-750.
53. Singh SK, Larkin KE, Kadakia AR, Hsu WK. Risk factors for reoperation and performance-based outcomes after operative fixation of foot fractures in the professional athlete: a cross-sport analysis. Sports Health. 2018;10(1):70-74.
54. Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014;6(2):139-144.
55. Elattar O, Choi HR, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports Health. 2016;8(4):313-323.
1. Flik K, Lyman S, Marx RG. American collegiate men's ice hockey: an analysis of injuries. Am J Sports Med. 2005;33(2):183-187.
2. Popkin CA, Nelson BJ, Park CN, et al. Head, neck, and shoulder injuries in ice hockey: current concepts. Am J Orthop (Belle Mead NJ). 2017;46(3):123-134.
3. Popkin CA, Schulz BM, Park CN, Bottiglieri TS, Lynch TS. Evaluation, management and prevention of lower extremity youth ice hockey injuries. Open Access J Sports Med. 534 2016;7:167-176.
4. 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.
5. Philippon MJ, Ho CP, Briggs KK, Stull J, LaPrade RF. Prevalence of increased alpha angles as a measure of cam-type femoroacetabular impingement in youth ice hockey players. Am J Sports Med. 2013;41(6):1357-1362.
6. Engebretsen L, Steffen K, Alonso JM, et al. Sports injuries and illnesses during the Winter Olympic Games 2010. Br J Sports Med. 2010;44(11):772-780.
7. Jorgensen U, Schmidt-Olsen S. The epidemiology of ice hockey injuries. Br J Sports Med. 1986;20(1):7-9.
8. Laprade RF, Surowiec RK, Sochanska AN, et al. Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries. BrJ Sports Med. 2014;48(1):4-10.
9. Mosenthal W, Kim M, Holzshu R, Hanypsiak B, Athiviraham A. Common ice hockey injuries and treatment: a current concepts review. Curr Sports Med Rep. 2017;16(5):357-362.
10. Tyler TF, Silvers HJ, Gerhardt MB, Nicholas SJ. Groin injuries in sports medicine. Sports Health. 2010;2(3):231-236.
11. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29(4):521-533.
12. Dalton SL, Zupon AB, Gardner EC, Djoko A, Dompier TP, Kerr ZY. The epidemiology of hip/groin injuries in National Collegiate Athletic Association men's and women's ice hockey: 2009-2010 through 2014-2015 academic years. Orthop J Sports Med. 2016;4(3):2325967116632692.
13. Epstein DM, McHugh M, Yorio M, Neri B. Intra-articular hip injuries in national hockey league players: a descriptive epidemiological study. Am J Sports Med. 2013;41(2):343-348.
14. Nepple JJ, Vigdorchik JM, Clohisy JC. What is the association between sports participation and the development of proximal femoral cam deformity? A systematic review and meta-analysis. Am J Sports Med. 2015;43(11):2833-2840.
15. Ross JR, Bedi A, Stone RM, Sibilsky Enselman E, Kelly BT, Larson CM. Characterization of symptomatic hip impingement in butterfly ice hockey goalies. Arthroscopy. 2015;31(4):635-642.
16. Bedi A, Dolan M, Hetsroni I, et al. Surgical treatment of femoroacetabular impingement improves hip kinematics: a computer-assisted model. Am J Sports Med. 2011;39(Suppl):43S-49S.
17. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res. 2009;467(3):638-644.
18. Nepple JJ, Goljan P, Briggs KK, Garvey SE, Ryan M, Philippon MJ. Hip strength deficits in patients with symptomatic femoroacetabular impingement and labral ears. Arthroscopy. 2015;31(11):2106-2111.
19. Audenaert EA, Peeters I, Vigneron L, Baelde N, Pattyn C. Hip morphological characteristics and range of internal rotation in femoroacetabular impingement. Am J Sports Med. 2012;40(6):1329-1336.
20. Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84(4):556-560.
21. Kuhn AW, Ross JR, Bedi A. Three-dimensional imaging and computer navigation in planning for hip preservation surgery. Sports Med Arthrosc Rev. 2015;23(4):e31-e38.
22. Wall PD, Fernandez M, Griffin DR, Foster NE. Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. PM R. 2013;5(5):418-426.
23. Kuhn AW, Noonan BC, Kelly BT, Larson CM, Bedi A. The hip in ice hockey: a current concepts review. Arthroscopy. 2016;32(9):1928-1938.
24. O'Connor M, Minkara AA, Westermann RW, Rosneck J, Lynch TS. Return to play after hip arthroscopy: a systematic review and meta-analysis. Am J Sports Med. 2018:46(11):2780-2788.
25. Minkara AA, Westermann RW, Rosneck J, Lynch TS. Systematic review and meta-analysis of outcomes after hip arthroscopy in femoroacetabular impingement. Am J Sports Med. 2018:363546517749475.
26. Philippon MJ, Weiss DR, Kuppersmith DA, Briggs KK, Hay CJ. Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players. Am J Sports Med. 2010;38(1):99-104.
27. Pierce CM, Laprade RF, Wahoff M, O'Brien L, Philippon MJ. Ice hockey goaltender rehabilitation, including on-ice progression, after arthroscopic hip surgery for femoroacetabular impingement. J Orthop Sports Phys Ther. 2013;43(3):129-141.
28. MacLeod DA, Gibbon WW. The sportsman's groin. Br J Surg. 1999;86(7):849-850.
29. Irshad K, Feldman LS, Lavoie C, Lacroix VJ, Mulder DS, Brown RA. Operative management of "hockey groin syndrome": 12 years of experience in National Hockey League players. Surgery. 2001;130(4):759-764; discussion 764-756.
30. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. Management of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med. 2000;28(1):2-8.
31. Zoga AC, Kavanagh EC, Omar IM, et al. Athletic pubalgia and the "sports hernia": MR imaging findings. Radiology. 2008;247(3):797-807.
32. 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.
33. Larson CM, Pierce BR, Giveans MR. Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: a case series. Arthroscopy.2011;27(6):768-775.
34. Lorentzon R, Wedren H, Pietila T. Incidence, nature, and causes of ice hockey injuries. A three-year prospective study of a Swedish elite ice hockey team. Am J Sports Med. 1988;16(4):392-396.
35. Holmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999;353(9151):439-443.
36. Sim FH, Chao EY. Injury potential in modern ice hockey. Am J Sports Med. 1978;6(6):378-384.
37. Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. Am J Sports Med. 2001;29(2):124-128.
38. LaPrade RF, Wijdicks CA, Griffith CJ. Division I intercollegiate ice hockey team coverage. BrJ Sports Med. 2009;43(13):1000-1005.
39. Grant JA, Bedi A, Kurz J, Bancroft R, Miller BS. Incidence and injury characteristics of medial collateral ligament injuries in male collegiate ice hockey players. Sports Health. 2013;5(3):270-272.
40. Erickson BJ, Harris JD, Cole BJ, et al. Performance and return to sport after anterior cruciate ligament reconstruction in National Hockey League players. Orthop J Sports Med. 2014;2(9):2325967114548831.
41. 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.
42. Friden T, Erlandsson T, Zatterstrom R, Lindstrand A, Moritz U. Compression or distraction of the anterior cruciate injured knee: variations in injury pattern in contact sports and downhill skiing. Knee Surg Sports Traumatol Arthrosc. 1995;3(3):144-147.
43. Kluczynski MA, Kang JV, Marzo JM, Bisson LJ. Magnetic resonance imaging and intra-articular findings after anterior cruciate ligament injuries in ice hockey versus other sports. Orthop J Sports Med. 2016;4(5):2325967116646534. 44. Beiner JM, Jokl P. Muscle contusion injuries: current treatment options. J Am Acad Orthop Surg. 2001;9(4):227-237.
45. Jackson DW, Feagin JA. Quadriceps contusions in young athletes. Relation of severity of injury to treatment and prognosis. J Bone Joint Surg Am. 1973;55(1):95-105.
46. Ryan JB, Wheeler JH, Hopkinson WJ, Arciero RA, Kolakowski KR. Quadriceps contusions. West Point update. Am J Sports Med. 1991;19(3):299-304.
47. Johnson PN, Mark; Green, Eric. Boot-top lacerations in ice hockey players: a new injury. Clin J Sports Med. 1991:205-208.
48. Nauth A, Aziz M, Tsuji M, Whalen DB, Theodoropoulos JS, Zdero R. The protective effect of Kevlar socks against hockey skate blade injuries: a biomechanical study. Orthop J Sports Med. 2014;2(Suppl 2):7.
49. Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med. 2004;32(8):1941-1945.
50. Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med. 1991;19(3):294-298.
51. Marymont JV, Lynch MA, Henning CE. Acute ligamentous diastasis of the ankle without fracture. Evaluation by radionuclide imaging. Am J Sports Med. 1986;14(5):407-409.
52. Miller CD, Shelton WR, Barrett GR, Savoie FH, Dukes AD. Deltoid and syndesmosis ligament injury of the ankle without fracture. Am J Sports Med. 1995;23(6):746-750.
53. Singh SK, Larkin KE, Kadakia AR, Hsu WK. Risk factors for reoperation and performance-based outcomes after operative fixation of foot fractures in the professional athlete: a cross-sport analysis. Sports Health. 2018;10(1):70-74.
54. Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014;6(2):139-144.
55. Elattar O, Choi HR, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports Health. 2016;8(4):313-323.
TAKE-HOME POINTS:
Ice hockey is a high-speed, collision sport with one of the highest injury rates in all of sports.
Femoroacetabular impingement is a cause of hip pain at all levels of ice hockey; studies indicate goaltenders are at high risk—particularly those who utilize the butterfly, as opposed to hybrid or stand-up, goaltending style.
Medial collateral ligament (MCL) tears are common in ice hockey and are usually the result of a collision with another player.
Use of Kevlar socks and placement of skate tongues deep to the shin pads can help reduce the chance of a boot-top laceration.
High-ankle sprains are more prevalent in ice hockey because of the rigidity of hockey skates and can be a cause of significant loss of time away from the rink.
Outcomes After Peripheral Nerve Block in Hip Arthroscopy
ABSTRACT
Pain control following hip arthroscopy presents a significant clinical challenge, with postoperative pain requiring considerable opioid use. Peripheral nerve blocks (PNBs) have emerged as one option to improve pain and limit the consequences of opioid use. The purpose of this study is to provide a comprehensive review of outcomes associated with PNB in hip arthroscopy. We hypothesize that the use of PNB in hip arthroscopy leads to improved outcomes and is associated with few complications. A systematic review of PubMed, Medline, Scopus, and Embase databases was conducted through January 2015 for English-language articles reporting outcome data, with 2 reviewers independently reviewing studies for inclusion. When available, similar outcomes were combined to generate frequency-weighted means. Six studies met the inclusion criteria for this review, reporting on 710 patients undergoing hip arthroscopy. The mean ages were 37.0 and 37.7 years for the PNB and comparator groups, respectively, with a reported total of 281 (40.5%) male and 412 (59.5%) female patients. Postoperative post-anesthesia care unit (PACU) pain was consistently reduced in the PNB group, with the use of a lower morphine equivalent dose and lower rates of inpatient admission, compared with that in the control groups. Postoperative nausea and/or vomiting as well as PACU discharge time showed mixed results. High satisfaction and few complications were reported. In conclusion, PNB is associated with reductions in postoperative pain, analgesic use, and the rate of inpatient admissions, though similar rates of nausea/vomiting and time to discharge were reported. Current PNB techniques are varied, and future research efforts should focus on examining which of these methods provides the optimal risk-benefit profile in hip arthroscopy.
Continue to: Hip arthroscopy has emerged...
Hip arthroscopy has emerged as a useful procedure in the diagnosis and treatment of hip pathology,1-8 experiencing a substantial rise in popularity in recent years, with the number of procedures growing by a factor of 18 from 1999 to 20099 and 25 from 2006 to 2013.10 Though hip arthroscopy is beneficial in many cases, marked postoperative pain has presented a substantial challenge, with patients requiring considerable doses of opiate-based medications in the post-anesthesia care unit (PACU).11,12 Increased narcotic use carries increased side effects, including postoperative nausea and vomiting,13 and poorly managed pain leads to increased unplanned admissions.14 Furthermore, patients with chronic hip pain and long-term opioid use may experience heightened and prolonged pain following the procedure, owing to medication tolerance and reduced opioid efficacy in this setting.15
Several pain control strategies have been employed in patients undergoing hip arthroscopy. General anesthesia16,17 and combined spinal epidural (CSE)18 are commonly used. However, such techniques rely heavily on opioids for postoperative pain control,11 and epidural anesthesia commonly requires adjunctive treatments (eg, neuromuscular blockade) to ensure muscle relaxation for joint distraction.19 One technique that has been employed recently is peripheral nerve block (PNB), which has been associated with a significant decrease in postoperative opioid use and nausea and vomiting.13,20 This method has proven successful in other fields of arthroscopy, including shoulder arthroscopy, in which it resulted in faster recovery, reduced opioid consumption,21 and demonstrated cost-effectiveness22 compared with general anesthesia and knee arthroscopy.23-26 As it is a relatively new field, little is known about the use of PNB in hip arthroscopy.
The goal of this systematic review was to comprehensively review the studies reporting on PNB in hip arthroscopy. We specifically focused on outcomes, including postoperative pain; analgesic use; nausea, vomiting, and antiemetic use; discharge time; inpatient admission; and patient satisfaction, as well as the complications associated with the use of PNB. Our knowledge of outcomes associated with PNB in hip arthroscopy is based on a few individual studies that have reported on small groups of patients using a variety of outcome measures and other findings. Furthermore, each of these studies commonly reflects the experience of an individual surgeon at a single institution and, when taken alone, may not be an accurate representation of the more general outcomes associated with PNB. A comprehensive review of such studies will provide surgeons, anesthesiologists, and patients with a better understanding of the anticipated outcomes of using PNB in hip arthroscopy. We hypothesize that the use of PNB in hip arthroscopy leads to improved outcomes and is associated with few complications.
MATERIALS AND METHODS
A systematic review of outcomes associated with PNB in hip arthroscopy was performed using the available English-language literature in accordance with the guidelines laid out by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included studies retrieved from the PubMed, Medline, Scopus, and Embase computerized literature databases. Searches were executed comprising all years from database inception through January 2015. Articles were retrieved by an electronic search of medical subject headings and keyword terms and their respective combinations (Table 1). The inclusion criteria for studies in this systematic review were studies that (1) were written in the English language and (2) reported explicit outcome data. The exclusion criteria were (1) review articles, meta-analyses, case reports, abstracts/conference papers, comments/letters, or technique articles without reported patient data and (2) basic research, biomechanics, or animal/cadaveric studies without reported patient data.
Table 1. Search Terms Entered to Identify English-Language Studies Through January 2015
Database | Search terms |
PubMed, Scopus | Keyword: (hip AND arthroscopy) AND (pain control OR pain management OR pain regimen OR nerve block OR spinal anesthesia OR regional anesthesia OR general anesthesia) |
Medline | MeSH (includes both MeSH terms and keywords): (Hip) AND (Arthroscopy) AND (“Pain Management” OR “Anesthesia, General” OR “Anesthesia” OR “Anesthesia, Inhalation”, OR “Balanced Anesthesia” OR “Anesthesia, Local” OR “Anesthesia, Spinal” OR “Anesthesia, Conduction” OR “Nerve Block”) |
Embase | MeSH (includes both MeSH terms and keywords): (Hip) AND (Arthroscopy) AND (“Pain Management” OR “General Anesthesia” OR “Anesthesia” OR “Inhalation Anesthesia”, OR “Balanced Anesthesia” OR “Local Anesthesia” OR “Spinal Anesthesia” OR “Regional Anesthesia” OR “Nerve Block”) |
The literature search strategy is outlined in the Figure. The initial title search yielded a subset of possible articles that were then further included or excluded on the basis of the contents of the article’s abstract, wherein articles were again selected on the basis of the aforementioned inclusion and exclusion criteria. Articles selected in both the title and abstract phases underwent full-text review, during which the full text of each qualifying article was reviewed. In addition, the reference sections from articles undergoing full-text review were scanned to identify any additional studies that had not been identified in the original literature search. Appropriate studies for final inclusion were then selected at this stage. The title, abstract, and full-text selection process were performed by 2 of the study authors (Dr. Steinhaus and Dr. Lynch), with any discrepancies being discussed and resolved by mutual agreement.
Continue to: For all 6 included studies...
For all 6 included studies,16-18,27-29 data were collected regarding the study specifics, patients included, and outcomes measured in the study. The journal of publication, type of study, level of evidence, and type of PNB, as well as the presence of a comparator group were noted (Table 2). Patient information included the number of patients at baseline and follow-up, mean age, gender, weight, height, body mass index, American Society of Anesthesiologists (ASA) status, and the specific procedures performed. In addition, data were collected on outcomes, including postoperative pain, as well as secondary outcomes and additional findings reported by the studies (Table 3). Where possible, weighted averages were calculated across all studies to obtain aggregate data.
RESULTS
STUDY INCLUSION
Six studies, all published between 2012 and 2014, were included in this systematic review (Table 2). Three studies involved lumbar plexus block, 2 studies involved femoral nerve block, and 1 study evaluated fascia iliaca block. Two studies used a control group of patients who received only general anesthesia (compared with the treatment group who received both general anesthesia and PNB); another study compared intravenous morphine with PNB; and 1 study compared CSE alone with PNB in addition to epidural.
DEMOGRAPHIC DATA
Demographic data from the included studies are presented in Table 2. In total, 710 and 549 patients were evaluated at baseline and final follow-up, respectively, which represents a follow-up rate of 77%. The frequency-weighted mean age of patients receiving PNB was 37.0 years compared with 37.7 years in the comparison groups, and the studies reported a total of 281 (40.5%) male and 412 (59.5%) female patients. The procedures performed were heterogeneously reported; therefore, totals were not tabulated, although the reported procedures included osteochondroplasty, labral débridement, labral and/or capsular repair, gluteus minimus repair, and synovectomy.
POSTOPERATIVE PAIN
Four studies reported on postoperative pain, and these data are presented in Table 3. In a retrospective study of patients receiving femoral nerve block in addition to general anesthesia, Dold and colleagues16 noted postoperative pain at 0, 15, 30, 45, and 60 minutes following arrival in the PACU, and discovered a statistically significantly lower level of pain at 60 minutes compared with inpatients receiving general anesthesia alone. YaDeau and colleagues18 found a significantly lower level of pain at rest in the PACU for those receiving CSE and lumbar plexus blockade compared with those receiving CSE alone. This significant difference did not persist at 24 hours or 6 months after the procedure, nor did it exist for pain with movement at any time point. Similarly, Schroeder and colleagues17 examined patients receiving general anesthesia and lumbar plexus block and found a significant reduction in pain immediately postoperatively in the PACU, though these effects disappeared the day following the procedure. Krych and colleagues27 also reported on postoperative pain in patients undergoing fascia iliaca blockade, although they did not include a comparator group. Outcome comparison between patients who received PNB and controls in the PACU and 1 day following the procedure are presented in Table 4.
ANALGESIC USE
Four studies reported on analgesic use after PNB, and these data are presented in Table 3. Dold and colleagues16 noted analgesic use intraoperatively, in the PACU, and in the surgical day care unit (SDCU). These authors found a significant reduction in morphine equivalent dose given in the operating room and in the PACU in the group receiving PNB, with a nonsignificant trend toward lower use of oxycodone in the SDCU. Schroeder and colleagues17 similarly reported significant reductions in morphine equivalent dose intraoperatively and in Phase I recovery for patients receiving PNB, and these differences disappeared in Phase II recovery as well as intraoperatively if the block dose was considered. In addition, these authors found a significant reduction in the use of fentanyl and hydromorphone in the operating room in the PNB group, as well as a significant reduction in the proportion of patients receiving ketorolac in the operating room or PACU. Finally, YaDeau and colleagues18 reported total analgesic usage in the PACU among PNB patients compared with those receiving CSE alone and showed a strong trend toward reduced use in the PNB group, although this difference was not significant (P = .051). PACU analgesic use is presented in Table 4.
Continue to: Postoperative nausea...
POSTOPERATIVE NAUSEA/VOMITING AND ANTIEMETIC USE
Five studies presented data on nausea, vomiting, or antiemetic use following PNB and are shown in Table 3. YaDeau and colleagues18 reported nausea among 34% of patients in the PNB group, compared with 20% in the control group, vomiting in 2% and 7%, respectively, and antiemetic use in 12% of both groups. Dold and colleagues16 identified a similar trend, with 41.1% of patients in the PNB group and 32.5% of patients in the control group experiencing postoperative nausea or vomiting, while Krych and colleagues27 noted only 10% of PNB patients with mild nausea and none requiring antiemetic use. In their study of patients receiving PNB, Schroeder and colleagues17 found a significant reduction in antiemetic use among PNB patients compared with those receiving general anesthesia alone. Similarly, Ward and colleagues29 noted a significant difference in postoperative nausea, with 10% of patients in the PNB group experiencing postoperative nausea compared with 75% of those in the comparator group who received intravenous morphine. The mean percentage of patients experiencing postoperative nausea and/or vomiting is shown in Table 4.
DISCHARGE TIME
Four studies presented data on discharge time from the PACU and are summarized in Table 3. Three of these studies included a comparator group. Both Dold and colleagues16 and YaDeau and colleagues18 reported an increase in the time to discharge for patients receiving PNB, although these differences were not significant. The study by Ward and colleagues,29 on the other hand, noted a significant reduction in the time to discharge for the PNB group. In addition to these studies, Krych and colleagues27 examined the time from skin closure to discharge for patients receiving PNB, noting a mean 199 minutes for the patients in their study. Mean times to discharge for the PNB and control groups are presented in Table 4.
INPATIENT ADMISSION
Four studies presented data on the proportion of study participants who were admitted as inpatients, and these data are shown in Table 3. Dold and colleagues16 reported no inpatient admissions in their PNB group compared with 5.0% for the control group (both cases of pain control), while YaDeau and colleagues18 found that 3 admissions occurred, with 2 in the control group (1 for oxygen desaturation and the other for intractable pain and nausea) and 1 from the PNB group (epidural spread and urinary retention). Two additional studies reported data on PNB groups alone. Krych and colleagues27 observed no overnight admissions in their study, while Nye and colleagues28 reported 1 readmission for bilateral leg numbness and weakness due to epidural spread, which resolved following discontinuation of the block. The mean proportion of inpatient admissions is presented in Table 4.
SATISFACTION
A total of 3 studies examined patient satisfaction, and these data are presented in Table 3. In their study, Ward and colleagues29 reported a significantly greater rate of satisfaction at 1 day postoperatively among the patients in the PNB group (90%) than among patients who received intravenous morphine (25%) (P < .0001). Similarly, YaDeau and colleagues18 noted greater satisfaction among the PNB group than among the control group, with PNB patients rating their satisfaction at a mean of 8.6 and control patients at a mean of 7.9 on a 10-point scale (0-10) 24 hours postoperatively, although this difference was not significant. Finally, Krych and colleagues27 found that 67% of patients were “very satisfied” and 33% were “satisfied”, based on a Likert scale.
COMPLICATIONS
Four studies presented data on complications, and these findings are summarized in Table 3. In their work, Nye and colleagues28 reported most extensively on complications associated with PNB. Overall, the authors found a rate of significant complications of 3.8%. In terms of specific complications, they noted local anesthetic systemic toxicity (0.9%), epidural spread (0.5%), sensory or motor deficits (9.4%), falls (0.5%), and catheter issues. In their study of patients receiving PNB and CSE, YaDeau and colleagues18 identified 1 patient in the PNB group with epidural spread and urinary retention, while they noted 1 case of oxygen desaturation and another case of intractable pain and nausea in the group receiving CSE alone, all 3 of which required inpatient admission. They found no permanent adverse events attributable to the PNB. In another study, Dold and colleagues16 observed no complications in patients receiving PNB compared with those in 2 admissions in the control group for inadequate pain control. Similarly, Krych and colleagues27 identified no complications in patients who received PNB in their study.
DISCUSSION
Hip arthroscopy has experienced a substantial gain in popularity in recent years, emerging as a beneficial technique for both the diagnosis and treatment of diverse hip pathologies in patients spanning a variety of demographics. Nevertheless, postoperative pain control, as well as medication side effects and unwanted patient admissions, present major challenges to the treating surgeon. As an adjuvant measure, peripheral nerve block represents one option to improve postoperative pain management, while at the same time addressing the adverse effects of considerable opioid use, which is commonly seen in these patients. Early experience with this method in hip arthroscopy was reported in a case series by Lee and colleagues.12 In an attempt to reduce postoperative pain, as well as limit the adverse effects and delay in discharge associated with considerable opioid use in the PACU, the authors used preoperative paravertebral blocks of L1 and L2 in 2 patients requiring hip arthroscopy with encouraging results. Since then, a number of studies have attempted the use of PNB in hip arthroscopy.16-18,27-29 However, we were unable to identify any prior reviews reporting on peripheral nerve blockade in hip arthroscopy, and thus this study is unique in providing a greater understanding of the outcomes associated with PNB use.
In general, we found that PNB was associated with improved outcomes. Based on the studies included in this review, there was a statistically significantly lower level of pain in the PACU for femoral nerve block (compared with general anesthesia alone)16 and lumbar plexus blockade (compared with general anesthesia17 and CSE18 alone). Nevertheless, these effects are likely short-lived, with differences disappearing the day following the procedure. In terms of analgesic use, 2 studies report significant reductions in analgesic use intraoperatively and in the PACU/Phase I recovery,16,17 with a third reporting a strong trend toward reduced analgesic use in the PACU (P = .051).18 Finally, we report fewer admissions for the PNB group, as well as high rates of satisfaction and few complications across these studies.
Continue to: Unlike these measures...
Unlike these measures, postoperative nausea, vomiting, and antiemetic use, as well as time to discharge, showed more mixed results. With regard to nausea/vomiting, 2 studies16,18 reported nonsignificantly increased rates in the PNB group, whereas others reported significant reductions in nausea/vomiting29 and in the proportion of patients receiving antiemetics.17 Similarly, mixed results were seen in terms of patient discharge time from the PACU. Two studies16,18 reported a nonsignificant increase in time to discharge for the PNB group, while another29 noted a significant reduction for the PNB group compared with those receiving intravenous morphine. These mixed results were surprising, as we expected reductions in opioid use to result in fewer instances of nausea/vomiting and a quicker time to discharge. The reasons underlying these findings are not clear, although it has been suggested that current discharge guidelines and clinical pathways limit the ability to take advantage of the accelerated timeline offered by regional anesthesia.16,30 As experience with PNB grows, our guidelines and pathways are likely to adapt to capitalize on these advantages, and future studies may show more reliable improvements in these measures.
While rare, the risk of bleeding requiring blood transfusion following hip arthroscopy is one of the most common complications of this procedure. Though the studies included in this review did not report on the need for transfusion, a recent study by Cvetanovich and colleagues10 used a national database and found that, of patients undergoing hip arthroscopy (n = 1338), 0.4% (n = 5) had bleeding requiring a transfusion, with 0.3% (n = 4) requiring return to the operating room, similar to an earlier study by Clarke and colleagues,31 who noted bleeding from the portal site in 0.4% of hip arthroscopy patients. In terms of risk factors, Cvetanovich and colleagues10 found that ASA class, older age, and prior cardiac surgery were significantly associated with minor and overall complications, whereas both regional anesthesia/monitored anesthesia care and alcohol consumption of >2 drinks a day were significantly associated with minor complications, including bleeding requiring transfusions. They noted, however, that these risk factors accounted for only 5% of the variance in complication rates, indicating that other unidentified variables better explained the variance in complication rates. These authors concluded that complications associated with hip arthroscopy are so rare that we may not be able to predict which risk factors or anesthesia types are more likely to cause them. Further characterization of bleeding following hip arthroscopy and its associated risk factors is a valuable area for future research.
LIMITATIONS
Our study contains a number of limitations. This review included studies whose level of evidence varied from I to IV; therefore, our study is limited by any bias or heterogeneity introduced in patient recruitment, selection, variability of technique, data collection, and analysis used in these studies. This heterogeneity is most apparent in the block types and comparator groups. Furthermore, several different outcome measures were reported across the 6 studies used in this review, which decreased the relevance of any one of these individual outcomes. Finally, given the limited data that currently exist for the use of PNB in hip arthroscopy, we are unable to note meaningful differences between various types of PNBs, such as differences in postoperative pain or other measures such as quadriceps weakness, which can accompany femoral nerve block.12 While it is important to read our work with these limitations in mind, this systematic review is, to our knowledge, the only comprehensive review to date of studies reporting on PNB in hip arthroscopy, providing clinicians and patients with a greater understanding of the associated outcomes across these studies.
CONCLUSION
This systematic review shows improved outcomes and few complications with PNB use in hip arthroscopy, with reductions in postoperative pain, analgesic use, and the rate of inpatient admissions. Although opioid use was reduced in these studies, we found similar rates of postoperative nausea/vomiting as well as similar time to discharge from the PACU, which may reflect our continued reliance on outdated discharge guidelines and clinical pathways. Current attempts to provide peripheral nerve blockade are quite varied, with studies targeting femoral nerve, fascia iliaca, L1/L2 paravertebral, and lumbar plexus blockade. Future research efforts with a large prospective trial investigating these techniques should focus on which of these PNBs presents the optimal risk-benefit profile for hip arthroscopy patients and thus appropriately address the clinical questions at hand.
This paper will be judged for the Resident Writer’s Award.
- Baber YF, Robinson AH, Villar RN. Is diagnostic arthroscopy of the hip worthwhile? A prospective review of 328 adults investigated for hip pain. J Bone Joint Surg Br. 1999;81:600-603.
- Byrd JW, Jones KS. Arthroscopic management of femoroacetabular impingement: minimum 2-year follow-up. Arthroscopy. 2011;27:1379-1388.
- Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: early outcomes measures. Arthroscopy. 2008;24:540-546.
- O'Leary JA, Berend K, Vail TP. The relationship between diagnosis and outcome in arthroscopy of the hip. Arthroscopy. 2001;17:181-188.
- 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;15:908-914.
- Potter BK, Freedman BA, Andersen RC, Bojescul JA, Kuklo TR, Murphy KP. Correlation of Short Form-36 and disability status with outcomes of arthroscopic acetabular labral debridement. Am J Sports Med. 2005;33:864-870.
- Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: a systematic review of the literature. Clin Orthop Relat Res. 2007;455:88-92.
- Yusaf MA, Hame SL. Arthroscopy of the hip. Curr Sports Med Rep. 2008;7:269-274.
- Colvin AC, Harrast J, Harner C. Trends in hip arthroscopy. J Bone Joint Surg Am. 2012;94:e23.
- Cvetanovich GL, Chalmers PN, Levy DM, et al. Hip arthroscopy surgical volume trends and 30-day postoperative complications. Arthroscopy. 2016 Apr 8. [Epub before print].
- Baker JF, Byrne DP, Hunter K, Mulhall KJ. Post-operative opiate requirements after hip arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2011;19:1399-1402.
- Lee EM, Murphy KP, Ben-David B. Postoperative analgesia for hip arthroscopy: combined L1 and L2 paravertebral blocks. J Clin Anesth. 2008;20:462-465.
- Ganesh A, Rose JB, Wells L, et al. Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children. Anesth Analg. 2007;105:1234-1242.
- Williams BA, Kentor ML, Vogt MT, et al. Femoral-sciatic nerve blocks for complex outpatient knee surgery are associated with less postoperative pain before same-day discharge: a review of 1,200 consecutive cases from the period 1996-1999. Anesthesiology. 2003;98:1206-1213.
- Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am. 2011;93:1988-1993.
- Dold AP, Murnaghan L, Xing J, Abdallah FW, Brull R, Whelan DB. Preoperative femoral nerve block in hip arthroscopic surgery: a retrospective review of 108 consecutive cases. Am J Sports Med. 2014;42:144-149.
- Schroeder KM, Donnelly MJ, Anderson BM, Ford MP, Keene JS. The analgesic impact of preoperative lumbar plexus blocks for hip arthroscopy. A retrospective review. Hip Int. 2013;23:93-98.
- YaDeau JT, Tedore T, Goytizolo EA, et al. Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial. Anesth Analg. 2012;115:968-972.
- Smart LR, Oetgen M, Noonan B, Medvecky M. Beginning hip arthroscopy: indications, positioning, portals, basic techniques, and complications. Arthroscopy. 2007;23:1348-1353.
- Stevens M, Harrison G, McGrail M. A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty. Anaesth Intensive Care. 2007;35:949-952.
- Lehmann LJ, Loosen G, Weiss C, Schmittner MD. Interscalene plexus block versus general anaesthesia for shoulder surgery: a randomized controlled study. Eur J Orthop Surg Traumatol. 2015;25:255-261.
- Gonano C, Kettner SC, Ernstbrunner M, Schebesta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. Br J Anaesth. 2009;103:428-433.
- Hadzic A, Karaca PE, Hobeika P, et al. Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy. Anesth Analg. 2005;100:976-981.
- Hsu LP, Oh S, Nuber GW, et al. Nerve block of the infrapatellar branch of the saphenous nerve in knee arthroscopy: a prospective, double-blinded, randomized, placebo-controlled trial. J Bone Joint Surg Am. 2013;95:1465-1472.
- Montes FR, Zarate E, Grueso R, et al. Comparison of spinal anesthesia with combined sciatic-femoral nerve block for outpatient knee arthroscopy. J Clin Anesth. 2008;20:415-420.
- Wulf H, Lowe J, Gnutzmann KH, Steinfeldt T. Femoral nerve block with ropivacaine or bupivacaine in day case anterior crucial ligament reconstruction. Acta Anaesthesiol Scand. 2010;54:414-420.
- Krych AJ, Baran S, Kuzma SA, Smith HM, Johnson RL, Levy BA. Utility of multimodal analgesia with fascia iliaca blockade for acute pain management following hip arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2014;22:843-847.
- Nye ZB, Horn JL, Crittenden W, Abrahams MS, Aziz MF. Ambulatory continuous posterior lumbar plexus blocks following hip arthroscopy: a review of 213 cases. J Clin Anesth. 2013;25:268-274.
- Ward JP, Albert DB, Altman R, Goldstein RY, Cuff G, Youm T. Are femoral nerve blocks effective for early postoperative pain management after hip arthroscopy? Arthroscopy. 2012;28:1064-1069.
- Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg. 2005;101:1634-1642.
- Clarke MT, Arora A, Villar RN. Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res. 2003;406:84-88.
ABSTRACT
Pain control following hip arthroscopy presents a significant clinical challenge, with postoperative pain requiring considerable opioid use. Peripheral nerve blocks (PNBs) have emerged as one option to improve pain and limit the consequences of opioid use. The purpose of this study is to provide a comprehensive review of outcomes associated with PNB in hip arthroscopy. We hypothesize that the use of PNB in hip arthroscopy leads to improved outcomes and is associated with few complications. A systematic review of PubMed, Medline, Scopus, and Embase databases was conducted through January 2015 for English-language articles reporting outcome data, with 2 reviewers independently reviewing studies for inclusion. When available, similar outcomes were combined to generate frequency-weighted means. Six studies met the inclusion criteria for this review, reporting on 710 patients undergoing hip arthroscopy. The mean ages were 37.0 and 37.7 years for the PNB and comparator groups, respectively, with a reported total of 281 (40.5%) male and 412 (59.5%) female patients. Postoperative post-anesthesia care unit (PACU) pain was consistently reduced in the PNB group, with the use of a lower morphine equivalent dose and lower rates of inpatient admission, compared with that in the control groups. Postoperative nausea and/or vomiting as well as PACU discharge time showed mixed results. High satisfaction and few complications were reported. In conclusion, PNB is associated with reductions in postoperative pain, analgesic use, and the rate of inpatient admissions, though similar rates of nausea/vomiting and time to discharge were reported. Current PNB techniques are varied, and future research efforts should focus on examining which of these methods provides the optimal risk-benefit profile in hip arthroscopy.
Continue to: Hip arthroscopy has emerged...
Hip arthroscopy has emerged as a useful procedure in the diagnosis and treatment of hip pathology,1-8 experiencing a substantial rise in popularity in recent years, with the number of procedures growing by a factor of 18 from 1999 to 20099 and 25 from 2006 to 2013.10 Though hip arthroscopy is beneficial in many cases, marked postoperative pain has presented a substantial challenge, with patients requiring considerable doses of opiate-based medications in the post-anesthesia care unit (PACU).11,12 Increased narcotic use carries increased side effects, including postoperative nausea and vomiting,13 and poorly managed pain leads to increased unplanned admissions.14 Furthermore, patients with chronic hip pain and long-term opioid use may experience heightened and prolonged pain following the procedure, owing to medication tolerance and reduced opioid efficacy in this setting.15
Several pain control strategies have been employed in patients undergoing hip arthroscopy. General anesthesia16,17 and combined spinal epidural (CSE)18 are commonly used. However, such techniques rely heavily on opioids for postoperative pain control,11 and epidural anesthesia commonly requires adjunctive treatments (eg, neuromuscular blockade) to ensure muscle relaxation for joint distraction.19 One technique that has been employed recently is peripheral nerve block (PNB), which has been associated with a significant decrease in postoperative opioid use and nausea and vomiting.13,20 This method has proven successful in other fields of arthroscopy, including shoulder arthroscopy, in which it resulted in faster recovery, reduced opioid consumption,21 and demonstrated cost-effectiveness22 compared with general anesthesia and knee arthroscopy.23-26 As it is a relatively new field, little is known about the use of PNB in hip arthroscopy.
The goal of this systematic review was to comprehensively review the studies reporting on PNB in hip arthroscopy. We specifically focused on outcomes, including postoperative pain; analgesic use; nausea, vomiting, and antiemetic use; discharge time; inpatient admission; and patient satisfaction, as well as the complications associated with the use of PNB. Our knowledge of outcomes associated with PNB in hip arthroscopy is based on a few individual studies that have reported on small groups of patients using a variety of outcome measures and other findings. Furthermore, each of these studies commonly reflects the experience of an individual surgeon at a single institution and, when taken alone, may not be an accurate representation of the more general outcomes associated with PNB. A comprehensive review of such studies will provide surgeons, anesthesiologists, and patients with a better understanding of the anticipated outcomes of using PNB in hip arthroscopy. We hypothesize that the use of PNB in hip arthroscopy leads to improved outcomes and is associated with few complications.
MATERIALS AND METHODS
A systematic review of outcomes associated with PNB in hip arthroscopy was performed using the available English-language literature in accordance with the guidelines laid out by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included studies retrieved from the PubMed, Medline, Scopus, and Embase computerized literature databases. Searches were executed comprising all years from database inception through January 2015. Articles were retrieved by an electronic search of medical subject headings and keyword terms and their respective combinations (Table 1). The inclusion criteria for studies in this systematic review were studies that (1) were written in the English language and (2) reported explicit outcome data. The exclusion criteria were (1) review articles, meta-analyses, case reports, abstracts/conference papers, comments/letters, or technique articles without reported patient data and (2) basic research, biomechanics, or animal/cadaveric studies without reported patient data.
Table 1. Search Terms Entered to Identify English-Language Studies Through January 2015
Database | Search terms |
PubMed, Scopus | Keyword: (hip AND arthroscopy) AND (pain control OR pain management OR pain regimen OR nerve block OR spinal anesthesia OR regional anesthesia OR general anesthesia) |
Medline | MeSH (includes both MeSH terms and keywords): (Hip) AND (Arthroscopy) AND (“Pain Management” OR “Anesthesia, General” OR “Anesthesia” OR “Anesthesia, Inhalation”, OR “Balanced Anesthesia” OR “Anesthesia, Local” OR “Anesthesia, Spinal” OR “Anesthesia, Conduction” OR “Nerve Block”) |
Embase | MeSH (includes both MeSH terms and keywords): (Hip) AND (Arthroscopy) AND (“Pain Management” OR “General Anesthesia” OR “Anesthesia” OR “Inhalation Anesthesia”, OR “Balanced Anesthesia” OR “Local Anesthesia” OR “Spinal Anesthesia” OR “Regional Anesthesia” OR “Nerve Block”) |
The literature search strategy is outlined in the Figure. The initial title search yielded a subset of possible articles that were then further included or excluded on the basis of the contents of the article’s abstract, wherein articles were again selected on the basis of the aforementioned inclusion and exclusion criteria. Articles selected in both the title and abstract phases underwent full-text review, during which the full text of each qualifying article was reviewed. In addition, the reference sections from articles undergoing full-text review were scanned to identify any additional studies that had not been identified in the original literature search. Appropriate studies for final inclusion were then selected at this stage. The title, abstract, and full-text selection process were performed by 2 of the study authors (Dr. Steinhaus and Dr. Lynch), with any discrepancies being discussed and resolved by mutual agreement.
Continue to: For all 6 included studies...
For all 6 included studies,16-18,27-29 data were collected regarding the study specifics, patients included, and outcomes measured in the study. The journal of publication, type of study, level of evidence, and type of PNB, as well as the presence of a comparator group were noted (Table 2). Patient information included the number of patients at baseline and follow-up, mean age, gender, weight, height, body mass index, American Society of Anesthesiologists (ASA) status, and the specific procedures performed. In addition, data were collected on outcomes, including postoperative pain, as well as secondary outcomes and additional findings reported by the studies (Table 3). Where possible, weighted averages were calculated across all studies to obtain aggregate data.
RESULTS
STUDY INCLUSION
Six studies, all published between 2012 and 2014, were included in this systematic review (Table 2). Three studies involved lumbar plexus block, 2 studies involved femoral nerve block, and 1 study evaluated fascia iliaca block. Two studies used a control group of patients who received only general anesthesia (compared with the treatment group who received both general anesthesia and PNB); another study compared intravenous morphine with PNB; and 1 study compared CSE alone with PNB in addition to epidural.
DEMOGRAPHIC DATA
Demographic data from the included studies are presented in Table 2. In total, 710 and 549 patients were evaluated at baseline and final follow-up, respectively, which represents a follow-up rate of 77%. The frequency-weighted mean age of patients receiving PNB was 37.0 years compared with 37.7 years in the comparison groups, and the studies reported a total of 281 (40.5%) male and 412 (59.5%) female patients. The procedures performed were heterogeneously reported; therefore, totals were not tabulated, although the reported procedures included osteochondroplasty, labral débridement, labral and/or capsular repair, gluteus minimus repair, and synovectomy.
POSTOPERATIVE PAIN
Four studies reported on postoperative pain, and these data are presented in Table 3. In a retrospective study of patients receiving femoral nerve block in addition to general anesthesia, Dold and colleagues16 noted postoperative pain at 0, 15, 30, 45, and 60 minutes following arrival in the PACU, and discovered a statistically significantly lower level of pain at 60 minutes compared with inpatients receiving general anesthesia alone. YaDeau and colleagues18 found a significantly lower level of pain at rest in the PACU for those receiving CSE and lumbar plexus blockade compared with those receiving CSE alone. This significant difference did not persist at 24 hours or 6 months after the procedure, nor did it exist for pain with movement at any time point. Similarly, Schroeder and colleagues17 examined patients receiving general anesthesia and lumbar plexus block and found a significant reduction in pain immediately postoperatively in the PACU, though these effects disappeared the day following the procedure. Krych and colleagues27 also reported on postoperative pain in patients undergoing fascia iliaca blockade, although they did not include a comparator group. Outcome comparison between patients who received PNB and controls in the PACU and 1 day following the procedure are presented in Table 4.
ANALGESIC USE
Four studies reported on analgesic use after PNB, and these data are presented in Table 3. Dold and colleagues16 noted analgesic use intraoperatively, in the PACU, and in the surgical day care unit (SDCU). These authors found a significant reduction in morphine equivalent dose given in the operating room and in the PACU in the group receiving PNB, with a nonsignificant trend toward lower use of oxycodone in the SDCU. Schroeder and colleagues17 similarly reported significant reductions in morphine equivalent dose intraoperatively and in Phase I recovery for patients receiving PNB, and these differences disappeared in Phase II recovery as well as intraoperatively if the block dose was considered. In addition, these authors found a significant reduction in the use of fentanyl and hydromorphone in the operating room in the PNB group, as well as a significant reduction in the proportion of patients receiving ketorolac in the operating room or PACU. Finally, YaDeau and colleagues18 reported total analgesic usage in the PACU among PNB patients compared with those receiving CSE alone and showed a strong trend toward reduced use in the PNB group, although this difference was not significant (P = .051). PACU analgesic use is presented in Table 4.
Continue to: Postoperative nausea...
POSTOPERATIVE NAUSEA/VOMITING AND ANTIEMETIC USE
Five studies presented data on nausea, vomiting, or antiemetic use following PNB and are shown in Table 3. YaDeau and colleagues18 reported nausea among 34% of patients in the PNB group, compared with 20% in the control group, vomiting in 2% and 7%, respectively, and antiemetic use in 12% of both groups. Dold and colleagues16 identified a similar trend, with 41.1% of patients in the PNB group and 32.5% of patients in the control group experiencing postoperative nausea or vomiting, while Krych and colleagues27 noted only 10% of PNB patients with mild nausea and none requiring antiemetic use. In their study of patients receiving PNB, Schroeder and colleagues17 found a significant reduction in antiemetic use among PNB patients compared with those receiving general anesthesia alone. Similarly, Ward and colleagues29 noted a significant difference in postoperative nausea, with 10% of patients in the PNB group experiencing postoperative nausea compared with 75% of those in the comparator group who received intravenous morphine. The mean percentage of patients experiencing postoperative nausea and/or vomiting is shown in Table 4.
DISCHARGE TIME
Four studies presented data on discharge time from the PACU and are summarized in Table 3. Three of these studies included a comparator group. Both Dold and colleagues16 and YaDeau and colleagues18 reported an increase in the time to discharge for patients receiving PNB, although these differences were not significant. The study by Ward and colleagues,29 on the other hand, noted a significant reduction in the time to discharge for the PNB group. In addition to these studies, Krych and colleagues27 examined the time from skin closure to discharge for patients receiving PNB, noting a mean 199 minutes for the patients in their study. Mean times to discharge for the PNB and control groups are presented in Table 4.
INPATIENT ADMISSION
Four studies presented data on the proportion of study participants who were admitted as inpatients, and these data are shown in Table 3. Dold and colleagues16 reported no inpatient admissions in their PNB group compared with 5.0% for the control group (both cases of pain control), while YaDeau and colleagues18 found that 3 admissions occurred, with 2 in the control group (1 for oxygen desaturation and the other for intractable pain and nausea) and 1 from the PNB group (epidural spread and urinary retention). Two additional studies reported data on PNB groups alone. Krych and colleagues27 observed no overnight admissions in their study, while Nye and colleagues28 reported 1 readmission for bilateral leg numbness and weakness due to epidural spread, which resolved following discontinuation of the block. The mean proportion of inpatient admissions is presented in Table 4.
SATISFACTION
A total of 3 studies examined patient satisfaction, and these data are presented in Table 3. In their study, Ward and colleagues29 reported a significantly greater rate of satisfaction at 1 day postoperatively among the patients in the PNB group (90%) than among patients who received intravenous morphine (25%) (P < .0001). Similarly, YaDeau and colleagues18 noted greater satisfaction among the PNB group than among the control group, with PNB patients rating their satisfaction at a mean of 8.6 and control patients at a mean of 7.9 on a 10-point scale (0-10) 24 hours postoperatively, although this difference was not significant. Finally, Krych and colleagues27 found that 67% of patients were “very satisfied” and 33% were “satisfied”, based on a Likert scale.
COMPLICATIONS
Four studies presented data on complications, and these findings are summarized in Table 3. In their work, Nye and colleagues28 reported most extensively on complications associated with PNB. Overall, the authors found a rate of significant complications of 3.8%. In terms of specific complications, they noted local anesthetic systemic toxicity (0.9%), epidural spread (0.5%), sensory or motor deficits (9.4%), falls (0.5%), and catheter issues. In their study of patients receiving PNB and CSE, YaDeau and colleagues18 identified 1 patient in the PNB group with epidural spread and urinary retention, while they noted 1 case of oxygen desaturation and another case of intractable pain and nausea in the group receiving CSE alone, all 3 of which required inpatient admission. They found no permanent adverse events attributable to the PNB. In another study, Dold and colleagues16 observed no complications in patients receiving PNB compared with those in 2 admissions in the control group for inadequate pain control. Similarly, Krych and colleagues27 identified no complications in patients who received PNB in their study.
DISCUSSION
Hip arthroscopy has experienced a substantial gain in popularity in recent years, emerging as a beneficial technique for both the diagnosis and treatment of diverse hip pathologies in patients spanning a variety of demographics. Nevertheless, postoperative pain control, as well as medication side effects and unwanted patient admissions, present major challenges to the treating surgeon. As an adjuvant measure, peripheral nerve block represents one option to improve postoperative pain management, while at the same time addressing the adverse effects of considerable opioid use, which is commonly seen in these patients. Early experience with this method in hip arthroscopy was reported in a case series by Lee and colleagues.12 In an attempt to reduce postoperative pain, as well as limit the adverse effects and delay in discharge associated with considerable opioid use in the PACU, the authors used preoperative paravertebral blocks of L1 and L2 in 2 patients requiring hip arthroscopy with encouraging results. Since then, a number of studies have attempted the use of PNB in hip arthroscopy.16-18,27-29 However, we were unable to identify any prior reviews reporting on peripheral nerve blockade in hip arthroscopy, and thus this study is unique in providing a greater understanding of the outcomes associated with PNB use.
In general, we found that PNB was associated with improved outcomes. Based on the studies included in this review, there was a statistically significantly lower level of pain in the PACU for femoral nerve block (compared with general anesthesia alone)16 and lumbar plexus blockade (compared with general anesthesia17 and CSE18 alone). Nevertheless, these effects are likely short-lived, with differences disappearing the day following the procedure. In terms of analgesic use, 2 studies report significant reductions in analgesic use intraoperatively and in the PACU/Phase I recovery,16,17 with a third reporting a strong trend toward reduced analgesic use in the PACU (P = .051).18 Finally, we report fewer admissions for the PNB group, as well as high rates of satisfaction and few complications across these studies.
Continue to: Unlike these measures...
Unlike these measures, postoperative nausea, vomiting, and antiemetic use, as well as time to discharge, showed more mixed results. With regard to nausea/vomiting, 2 studies16,18 reported nonsignificantly increased rates in the PNB group, whereas others reported significant reductions in nausea/vomiting29 and in the proportion of patients receiving antiemetics.17 Similarly, mixed results were seen in terms of patient discharge time from the PACU. Two studies16,18 reported a nonsignificant increase in time to discharge for the PNB group, while another29 noted a significant reduction for the PNB group compared with those receiving intravenous morphine. These mixed results were surprising, as we expected reductions in opioid use to result in fewer instances of nausea/vomiting and a quicker time to discharge. The reasons underlying these findings are not clear, although it has been suggested that current discharge guidelines and clinical pathways limit the ability to take advantage of the accelerated timeline offered by regional anesthesia.16,30 As experience with PNB grows, our guidelines and pathways are likely to adapt to capitalize on these advantages, and future studies may show more reliable improvements in these measures.
While rare, the risk of bleeding requiring blood transfusion following hip arthroscopy is one of the most common complications of this procedure. Though the studies included in this review did not report on the need for transfusion, a recent study by Cvetanovich and colleagues10 used a national database and found that, of patients undergoing hip arthroscopy (n = 1338), 0.4% (n = 5) had bleeding requiring a transfusion, with 0.3% (n = 4) requiring return to the operating room, similar to an earlier study by Clarke and colleagues,31 who noted bleeding from the portal site in 0.4% of hip arthroscopy patients. In terms of risk factors, Cvetanovich and colleagues10 found that ASA class, older age, and prior cardiac surgery were significantly associated with minor and overall complications, whereas both regional anesthesia/monitored anesthesia care and alcohol consumption of >2 drinks a day were significantly associated with minor complications, including bleeding requiring transfusions. They noted, however, that these risk factors accounted for only 5% of the variance in complication rates, indicating that other unidentified variables better explained the variance in complication rates. These authors concluded that complications associated with hip arthroscopy are so rare that we may not be able to predict which risk factors or anesthesia types are more likely to cause them. Further characterization of bleeding following hip arthroscopy and its associated risk factors is a valuable area for future research.
LIMITATIONS
Our study contains a number of limitations. This review included studies whose level of evidence varied from I to IV; therefore, our study is limited by any bias or heterogeneity introduced in patient recruitment, selection, variability of technique, data collection, and analysis used in these studies. This heterogeneity is most apparent in the block types and comparator groups. Furthermore, several different outcome measures were reported across the 6 studies used in this review, which decreased the relevance of any one of these individual outcomes. Finally, given the limited data that currently exist for the use of PNB in hip arthroscopy, we are unable to note meaningful differences between various types of PNBs, such as differences in postoperative pain or other measures such as quadriceps weakness, which can accompany femoral nerve block.12 While it is important to read our work with these limitations in mind, this systematic review is, to our knowledge, the only comprehensive review to date of studies reporting on PNB in hip arthroscopy, providing clinicians and patients with a greater understanding of the associated outcomes across these studies.
CONCLUSION
This systematic review shows improved outcomes and few complications with PNB use in hip arthroscopy, with reductions in postoperative pain, analgesic use, and the rate of inpatient admissions. Although opioid use was reduced in these studies, we found similar rates of postoperative nausea/vomiting as well as similar time to discharge from the PACU, which may reflect our continued reliance on outdated discharge guidelines and clinical pathways. Current attempts to provide peripheral nerve blockade are quite varied, with studies targeting femoral nerve, fascia iliaca, L1/L2 paravertebral, and lumbar plexus blockade. Future research efforts with a large prospective trial investigating these techniques should focus on which of these PNBs presents the optimal risk-benefit profile for hip arthroscopy patients and thus appropriately address the clinical questions at hand.
This paper will be judged for the Resident Writer’s Award.
ABSTRACT
Pain control following hip arthroscopy presents a significant clinical challenge, with postoperative pain requiring considerable opioid use. Peripheral nerve blocks (PNBs) have emerged as one option to improve pain and limit the consequences of opioid use. The purpose of this study is to provide a comprehensive review of outcomes associated with PNB in hip arthroscopy. We hypothesize that the use of PNB in hip arthroscopy leads to improved outcomes and is associated with few complications. A systematic review of PubMed, Medline, Scopus, and Embase databases was conducted through January 2015 for English-language articles reporting outcome data, with 2 reviewers independently reviewing studies for inclusion. When available, similar outcomes were combined to generate frequency-weighted means. Six studies met the inclusion criteria for this review, reporting on 710 patients undergoing hip arthroscopy. The mean ages were 37.0 and 37.7 years for the PNB and comparator groups, respectively, with a reported total of 281 (40.5%) male and 412 (59.5%) female patients. Postoperative post-anesthesia care unit (PACU) pain was consistently reduced in the PNB group, with the use of a lower morphine equivalent dose and lower rates of inpatient admission, compared with that in the control groups. Postoperative nausea and/or vomiting as well as PACU discharge time showed mixed results. High satisfaction and few complications were reported. In conclusion, PNB is associated with reductions in postoperative pain, analgesic use, and the rate of inpatient admissions, though similar rates of nausea/vomiting and time to discharge were reported. Current PNB techniques are varied, and future research efforts should focus on examining which of these methods provides the optimal risk-benefit profile in hip arthroscopy.
Continue to: Hip arthroscopy has emerged...
Hip arthroscopy has emerged as a useful procedure in the diagnosis and treatment of hip pathology,1-8 experiencing a substantial rise in popularity in recent years, with the number of procedures growing by a factor of 18 from 1999 to 20099 and 25 from 2006 to 2013.10 Though hip arthroscopy is beneficial in many cases, marked postoperative pain has presented a substantial challenge, with patients requiring considerable doses of opiate-based medications in the post-anesthesia care unit (PACU).11,12 Increased narcotic use carries increased side effects, including postoperative nausea and vomiting,13 and poorly managed pain leads to increased unplanned admissions.14 Furthermore, patients with chronic hip pain and long-term opioid use may experience heightened and prolonged pain following the procedure, owing to medication tolerance and reduced opioid efficacy in this setting.15
Several pain control strategies have been employed in patients undergoing hip arthroscopy. General anesthesia16,17 and combined spinal epidural (CSE)18 are commonly used. However, such techniques rely heavily on opioids for postoperative pain control,11 and epidural anesthesia commonly requires adjunctive treatments (eg, neuromuscular blockade) to ensure muscle relaxation for joint distraction.19 One technique that has been employed recently is peripheral nerve block (PNB), which has been associated with a significant decrease in postoperative opioid use and nausea and vomiting.13,20 This method has proven successful in other fields of arthroscopy, including shoulder arthroscopy, in which it resulted in faster recovery, reduced opioid consumption,21 and demonstrated cost-effectiveness22 compared with general anesthesia and knee arthroscopy.23-26 As it is a relatively new field, little is known about the use of PNB in hip arthroscopy.
The goal of this systematic review was to comprehensively review the studies reporting on PNB in hip arthroscopy. We specifically focused on outcomes, including postoperative pain; analgesic use; nausea, vomiting, and antiemetic use; discharge time; inpatient admission; and patient satisfaction, as well as the complications associated with the use of PNB. Our knowledge of outcomes associated with PNB in hip arthroscopy is based on a few individual studies that have reported on small groups of patients using a variety of outcome measures and other findings. Furthermore, each of these studies commonly reflects the experience of an individual surgeon at a single institution and, when taken alone, may not be an accurate representation of the more general outcomes associated with PNB. A comprehensive review of such studies will provide surgeons, anesthesiologists, and patients with a better understanding of the anticipated outcomes of using PNB in hip arthroscopy. We hypothesize that the use of PNB in hip arthroscopy leads to improved outcomes and is associated with few complications.
MATERIALS AND METHODS
A systematic review of outcomes associated with PNB in hip arthroscopy was performed using the available English-language literature in accordance with the guidelines laid out by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included studies retrieved from the PubMed, Medline, Scopus, and Embase computerized literature databases. Searches were executed comprising all years from database inception through January 2015. Articles were retrieved by an electronic search of medical subject headings and keyword terms and their respective combinations (Table 1). The inclusion criteria for studies in this systematic review were studies that (1) were written in the English language and (2) reported explicit outcome data. The exclusion criteria were (1) review articles, meta-analyses, case reports, abstracts/conference papers, comments/letters, or technique articles without reported patient data and (2) basic research, biomechanics, or animal/cadaveric studies without reported patient data.
Table 1. Search Terms Entered to Identify English-Language Studies Through January 2015
Database | Search terms |
PubMed, Scopus | Keyword: (hip AND arthroscopy) AND (pain control OR pain management OR pain regimen OR nerve block OR spinal anesthesia OR regional anesthesia OR general anesthesia) |
Medline | MeSH (includes both MeSH terms and keywords): (Hip) AND (Arthroscopy) AND (“Pain Management” OR “Anesthesia, General” OR “Anesthesia” OR “Anesthesia, Inhalation”, OR “Balanced Anesthesia” OR “Anesthesia, Local” OR “Anesthesia, Spinal” OR “Anesthesia, Conduction” OR “Nerve Block”) |
Embase | MeSH (includes both MeSH terms and keywords): (Hip) AND (Arthroscopy) AND (“Pain Management” OR “General Anesthesia” OR “Anesthesia” OR “Inhalation Anesthesia”, OR “Balanced Anesthesia” OR “Local Anesthesia” OR “Spinal Anesthesia” OR “Regional Anesthesia” OR “Nerve Block”) |
The literature search strategy is outlined in the Figure. The initial title search yielded a subset of possible articles that were then further included or excluded on the basis of the contents of the article’s abstract, wherein articles were again selected on the basis of the aforementioned inclusion and exclusion criteria. Articles selected in both the title and abstract phases underwent full-text review, during which the full text of each qualifying article was reviewed. In addition, the reference sections from articles undergoing full-text review were scanned to identify any additional studies that had not been identified in the original literature search. Appropriate studies for final inclusion were then selected at this stage. The title, abstract, and full-text selection process were performed by 2 of the study authors (Dr. Steinhaus and Dr. Lynch), with any discrepancies being discussed and resolved by mutual agreement.
Continue to: For all 6 included studies...
For all 6 included studies,16-18,27-29 data were collected regarding the study specifics, patients included, and outcomes measured in the study. The journal of publication, type of study, level of evidence, and type of PNB, as well as the presence of a comparator group were noted (Table 2). Patient information included the number of patients at baseline and follow-up, mean age, gender, weight, height, body mass index, American Society of Anesthesiologists (ASA) status, and the specific procedures performed. In addition, data were collected on outcomes, including postoperative pain, as well as secondary outcomes and additional findings reported by the studies (Table 3). Where possible, weighted averages were calculated across all studies to obtain aggregate data.
RESULTS
STUDY INCLUSION
Six studies, all published between 2012 and 2014, were included in this systematic review (Table 2). Three studies involved lumbar plexus block, 2 studies involved femoral nerve block, and 1 study evaluated fascia iliaca block. Two studies used a control group of patients who received only general anesthesia (compared with the treatment group who received both general anesthesia and PNB); another study compared intravenous morphine with PNB; and 1 study compared CSE alone with PNB in addition to epidural.
DEMOGRAPHIC DATA
Demographic data from the included studies are presented in Table 2. In total, 710 and 549 patients were evaluated at baseline and final follow-up, respectively, which represents a follow-up rate of 77%. The frequency-weighted mean age of patients receiving PNB was 37.0 years compared with 37.7 years in the comparison groups, and the studies reported a total of 281 (40.5%) male and 412 (59.5%) female patients. The procedures performed were heterogeneously reported; therefore, totals were not tabulated, although the reported procedures included osteochondroplasty, labral débridement, labral and/or capsular repair, gluteus minimus repair, and synovectomy.
POSTOPERATIVE PAIN
Four studies reported on postoperative pain, and these data are presented in Table 3. In a retrospective study of patients receiving femoral nerve block in addition to general anesthesia, Dold and colleagues16 noted postoperative pain at 0, 15, 30, 45, and 60 minutes following arrival in the PACU, and discovered a statistically significantly lower level of pain at 60 minutes compared with inpatients receiving general anesthesia alone. YaDeau and colleagues18 found a significantly lower level of pain at rest in the PACU for those receiving CSE and lumbar plexus blockade compared with those receiving CSE alone. This significant difference did not persist at 24 hours or 6 months after the procedure, nor did it exist for pain with movement at any time point. Similarly, Schroeder and colleagues17 examined patients receiving general anesthesia and lumbar plexus block and found a significant reduction in pain immediately postoperatively in the PACU, though these effects disappeared the day following the procedure. Krych and colleagues27 also reported on postoperative pain in patients undergoing fascia iliaca blockade, although they did not include a comparator group. Outcome comparison between patients who received PNB and controls in the PACU and 1 day following the procedure are presented in Table 4.
ANALGESIC USE
Four studies reported on analgesic use after PNB, and these data are presented in Table 3. Dold and colleagues16 noted analgesic use intraoperatively, in the PACU, and in the surgical day care unit (SDCU). These authors found a significant reduction in morphine equivalent dose given in the operating room and in the PACU in the group receiving PNB, with a nonsignificant trend toward lower use of oxycodone in the SDCU. Schroeder and colleagues17 similarly reported significant reductions in morphine equivalent dose intraoperatively and in Phase I recovery for patients receiving PNB, and these differences disappeared in Phase II recovery as well as intraoperatively if the block dose was considered. In addition, these authors found a significant reduction in the use of fentanyl and hydromorphone in the operating room in the PNB group, as well as a significant reduction in the proportion of patients receiving ketorolac in the operating room or PACU. Finally, YaDeau and colleagues18 reported total analgesic usage in the PACU among PNB patients compared with those receiving CSE alone and showed a strong trend toward reduced use in the PNB group, although this difference was not significant (P = .051). PACU analgesic use is presented in Table 4.
Continue to: Postoperative nausea...
POSTOPERATIVE NAUSEA/VOMITING AND ANTIEMETIC USE
Five studies presented data on nausea, vomiting, or antiemetic use following PNB and are shown in Table 3. YaDeau and colleagues18 reported nausea among 34% of patients in the PNB group, compared with 20% in the control group, vomiting in 2% and 7%, respectively, and antiemetic use in 12% of both groups. Dold and colleagues16 identified a similar trend, with 41.1% of patients in the PNB group and 32.5% of patients in the control group experiencing postoperative nausea or vomiting, while Krych and colleagues27 noted only 10% of PNB patients with mild nausea and none requiring antiemetic use. In their study of patients receiving PNB, Schroeder and colleagues17 found a significant reduction in antiemetic use among PNB patients compared with those receiving general anesthesia alone. Similarly, Ward and colleagues29 noted a significant difference in postoperative nausea, with 10% of patients in the PNB group experiencing postoperative nausea compared with 75% of those in the comparator group who received intravenous morphine. The mean percentage of patients experiencing postoperative nausea and/or vomiting is shown in Table 4.
DISCHARGE TIME
Four studies presented data on discharge time from the PACU and are summarized in Table 3. Three of these studies included a comparator group. Both Dold and colleagues16 and YaDeau and colleagues18 reported an increase in the time to discharge for patients receiving PNB, although these differences were not significant. The study by Ward and colleagues,29 on the other hand, noted a significant reduction in the time to discharge for the PNB group. In addition to these studies, Krych and colleagues27 examined the time from skin closure to discharge for patients receiving PNB, noting a mean 199 minutes for the patients in their study. Mean times to discharge for the PNB and control groups are presented in Table 4.
INPATIENT ADMISSION
Four studies presented data on the proportion of study participants who were admitted as inpatients, and these data are shown in Table 3. Dold and colleagues16 reported no inpatient admissions in their PNB group compared with 5.0% for the control group (both cases of pain control), while YaDeau and colleagues18 found that 3 admissions occurred, with 2 in the control group (1 for oxygen desaturation and the other for intractable pain and nausea) and 1 from the PNB group (epidural spread and urinary retention). Two additional studies reported data on PNB groups alone. Krych and colleagues27 observed no overnight admissions in their study, while Nye and colleagues28 reported 1 readmission for bilateral leg numbness and weakness due to epidural spread, which resolved following discontinuation of the block. The mean proportion of inpatient admissions is presented in Table 4.
SATISFACTION
A total of 3 studies examined patient satisfaction, and these data are presented in Table 3. In their study, Ward and colleagues29 reported a significantly greater rate of satisfaction at 1 day postoperatively among the patients in the PNB group (90%) than among patients who received intravenous morphine (25%) (P < .0001). Similarly, YaDeau and colleagues18 noted greater satisfaction among the PNB group than among the control group, with PNB patients rating their satisfaction at a mean of 8.6 and control patients at a mean of 7.9 on a 10-point scale (0-10) 24 hours postoperatively, although this difference was not significant. Finally, Krych and colleagues27 found that 67% of patients were “very satisfied” and 33% were “satisfied”, based on a Likert scale.
COMPLICATIONS
Four studies presented data on complications, and these findings are summarized in Table 3. In their work, Nye and colleagues28 reported most extensively on complications associated with PNB. Overall, the authors found a rate of significant complications of 3.8%. In terms of specific complications, they noted local anesthetic systemic toxicity (0.9%), epidural spread (0.5%), sensory or motor deficits (9.4%), falls (0.5%), and catheter issues. In their study of patients receiving PNB and CSE, YaDeau and colleagues18 identified 1 patient in the PNB group with epidural spread and urinary retention, while they noted 1 case of oxygen desaturation and another case of intractable pain and nausea in the group receiving CSE alone, all 3 of which required inpatient admission. They found no permanent adverse events attributable to the PNB. In another study, Dold and colleagues16 observed no complications in patients receiving PNB compared with those in 2 admissions in the control group for inadequate pain control. Similarly, Krych and colleagues27 identified no complications in patients who received PNB in their study.
DISCUSSION
Hip arthroscopy has experienced a substantial gain in popularity in recent years, emerging as a beneficial technique for both the diagnosis and treatment of diverse hip pathologies in patients spanning a variety of demographics. Nevertheless, postoperative pain control, as well as medication side effects and unwanted patient admissions, present major challenges to the treating surgeon. As an adjuvant measure, peripheral nerve block represents one option to improve postoperative pain management, while at the same time addressing the adverse effects of considerable opioid use, which is commonly seen in these patients. Early experience with this method in hip arthroscopy was reported in a case series by Lee and colleagues.12 In an attempt to reduce postoperative pain, as well as limit the adverse effects and delay in discharge associated with considerable opioid use in the PACU, the authors used preoperative paravertebral blocks of L1 and L2 in 2 patients requiring hip arthroscopy with encouraging results. Since then, a number of studies have attempted the use of PNB in hip arthroscopy.16-18,27-29 However, we were unable to identify any prior reviews reporting on peripheral nerve blockade in hip arthroscopy, and thus this study is unique in providing a greater understanding of the outcomes associated with PNB use.
In general, we found that PNB was associated with improved outcomes. Based on the studies included in this review, there was a statistically significantly lower level of pain in the PACU for femoral nerve block (compared with general anesthesia alone)16 and lumbar plexus blockade (compared with general anesthesia17 and CSE18 alone). Nevertheless, these effects are likely short-lived, with differences disappearing the day following the procedure. In terms of analgesic use, 2 studies report significant reductions in analgesic use intraoperatively and in the PACU/Phase I recovery,16,17 with a third reporting a strong trend toward reduced analgesic use in the PACU (P = .051).18 Finally, we report fewer admissions for the PNB group, as well as high rates of satisfaction and few complications across these studies.
Continue to: Unlike these measures...
Unlike these measures, postoperative nausea, vomiting, and antiemetic use, as well as time to discharge, showed more mixed results. With regard to nausea/vomiting, 2 studies16,18 reported nonsignificantly increased rates in the PNB group, whereas others reported significant reductions in nausea/vomiting29 and in the proportion of patients receiving antiemetics.17 Similarly, mixed results were seen in terms of patient discharge time from the PACU. Two studies16,18 reported a nonsignificant increase in time to discharge for the PNB group, while another29 noted a significant reduction for the PNB group compared with those receiving intravenous morphine. These mixed results were surprising, as we expected reductions in opioid use to result in fewer instances of nausea/vomiting and a quicker time to discharge. The reasons underlying these findings are not clear, although it has been suggested that current discharge guidelines and clinical pathways limit the ability to take advantage of the accelerated timeline offered by regional anesthesia.16,30 As experience with PNB grows, our guidelines and pathways are likely to adapt to capitalize on these advantages, and future studies may show more reliable improvements in these measures.
While rare, the risk of bleeding requiring blood transfusion following hip arthroscopy is one of the most common complications of this procedure. Though the studies included in this review did not report on the need for transfusion, a recent study by Cvetanovich and colleagues10 used a national database and found that, of patients undergoing hip arthroscopy (n = 1338), 0.4% (n = 5) had bleeding requiring a transfusion, with 0.3% (n = 4) requiring return to the operating room, similar to an earlier study by Clarke and colleagues,31 who noted bleeding from the portal site in 0.4% of hip arthroscopy patients. In terms of risk factors, Cvetanovich and colleagues10 found that ASA class, older age, and prior cardiac surgery were significantly associated with minor and overall complications, whereas both regional anesthesia/monitored anesthesia care and alcohol consumption of >2 drinks a day were significantly associated with minor complications, including bleeding requiring transfusions. They noted, however, that these risk factors accounted for only 5% of the variance in complication rates, indicating that other unidentified variables better explained the variance in complication rates. These authors concluded that complications associated with hip arthroscopy are so rare that we may not be able to predict which risk factors or anesthesia types are more likely to cause them. Further characterization of bleeding following hip arthroscopy and its associated risk factors is a valuable area for future research.
LIMITATIONS
Our study contains a number of limitations. This review included studies whose level of evidence varied from I to IV; therefore, our study is limited by any bias or heterogeneity introduced in patient recruitment, selection, variability of technique, data collection, and analysis used in these studies. This heterogeneity is most apparent in the block types and comparator groups. Furthermore, several different outcome measures were reported across the 6 studies used in this review, which decreased the relevance of any one of these individual outcomes. Finally, given the limited data that currently exist for the use of PNB in hip arthroscopy, we are unable to note meaningful differences between various types of PNBs, such as differences in postoperative pain or other measures such as quadriceps weakness, which can accompany femoral nerve block.12 While it is important to read our work with these limitations in mind, this systematic review is, to our knowledge, the only comprehensive review to date of studies reporting on PNB in hip arthroscopy, providing clinicians and patients with a greater understanding of the associated outcomes across these studies.
CONCLUSION
This systematic review shows improved outcomes and few complications with PNB use in hip arthroscopy, with reductions in postoperative pain, analgesic use, and the rate of inpatient admissions. Although opioid use was reduced in these studies, we found similar rates of postoperative nausea/vomiting as well as similar time to discharge from the PACU, which may reflect our continued reliance on outdated discharge guidelines and clinical pathways. Current attempts to provide peripheral nerve blockade are quite varied, with studies targeting femoral nerve, fascia iliaca, L1/L2 paravertebral, and lumbar plexus blockade. Future research efforts with a large prospective trial investigating these techniques should focus on which of these PNBs presents the optimal risk-benefit profile for hip arthroscopy patients and thus appropriately address the clinical questions at hand.
This paper will be judged for the Resident Writer’s Award.
- Baber YF, Robinson AH, Villar RN. Is diagnostic arthroscopy of the hip worthwhile? A prospective review of 328 adults investigated for hip pain. J Bone Joint Surg Br. 1999;81:600-603.
- Byrd JW, Jones KS. Arthroscopic management of femoroacetabular impingement: minimum 2-year follow-up. Arthroscopy. 2011;27:1379-1388.
- Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: early outcomes measures. Arthroscopy. 2008;24:540-546.
- O'Leary JA, Berend K, Vail TP. The relationship between diagnosis and outcome in arthroscopy of the hip. Arthroscopy. 2001;17:181-188.
- 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;15:908-914.
- Potter BK, Freedman BA, Andersen RC, Bojescul JA, Kuklo TR, Murphy KP. Correlation of Short Form-36 and disability status with outcomes of arthroscopic acetabular labral debridement. Am J Sports Med. 2005;33:864-870.
- Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: a systematic review of the literature. Clin Orthop Relat Res. 2007;455:88-92.
- Yusaf MA, Hame SL. Arthroscopy of the hip. Curr Sports Med Rep. 2008;7:269-274.
- Colvin AC, Harrast J, Harner C. Trends in hip arthroscopy. J Bone Joint Surg Am. 2012;94:e23.
- Cvetanovich GL, Chalmers PN, Levy DM, et al. Hip arthroscopy surgical volume trends and 30-day postoperative complications. Arthroscopy. 2016 Apr 8. [Epub before print].
- Baker JF, Byrne DP, Hunter K, Mulhall KJ. Post-operative opiate requirements after hip arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2011;19:1399-1402.
- Lee EM, Murphy KP, Ben-David B. Postoperative analgesia for hip arthroscopy: combined L1 and L2 paravertebral blocks. J Clin Anesth. 2008;20:462-465.
- Ganesh A, Rose JB, Wells L, et al. Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children. Anesth Analg. 2007;105:1234-1242.
- Williams BA, Kentor ML, Vogt MT, et al. Femoral-sciatic nerve blocks for complex outpatient knee surgery are associated with less postoperative pain before same-day discharge: a review of 1,200 consecutive cases from the period 1996-1999. Anesthesiology. 2003;98:1206-1213.
- Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am. 2011;93:1988-1993.
- Dold AP, Murnaghan L, Xing J, Abdallah FW, Brull R, Whelan DB. Preoperative femoral nerve block in hip arthroscopic surgery: a retrospective review of 108 consecutive cases. Am J Sports Med. 2014;42:144-149.
- Schroeder KM, Donnelly MJ, Anderson BM, Ford MP, Keene JS. The analgesic impact of preoperative lumbar plexus blocks for hip arthroscopy. A retrospective review. Hip Int. 2013;23:93-98.
- YaDeau JT, Tedore T, Goytizolo EA, et al. Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial. Anesth Analg. 2012;115:968-972.
- Smart LR, Oetgen M, Noonan B, Medvecky M. Beginning hip arthroscopy: indications, positioning, portals, basic techniques, and complications. Arthroscopy. 2007;23:1348-1353.
- Stevens M, Harrison G, McGrail M. A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty. Anaesth Intensive Care. 2007;35:949-952.
- Lehmann LJ, Loosen G, Weiss C, Schmittner MD. Interscalene plexus block versus general anaesthesia for shoulder surgery: a randomized controlled study. Eur J Orthop Surg Traumatol. 2015;25:255-261.
- Gonano C, Kettner SC, Ernstbrunner M, Schebesta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. Br J Anaesth. 2009;103:428-433.
- Hadzic A, Karaca PE, Hobeika P, et al. Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy. Anesth Analg. 2005;100:976-981.
- Hsu LP, Oh S, Nuber GW, et al. Nerve block of the infrapatellar branch of the saphenous nerve in knee arthroscopy: a prospective, double-blinded, randomized, placebo-controlled trial. J Bone Joint Surg Am. 2013;95:1465-1472.
- Montes FR, Zarate E, Grueso R, et al. Comparison of spinal anesthesia with combined sciatic-femoral nerve block for outpatient knee arthroscopy. J Clin Anesth. 2008;20:415-420.
- Wulf H, Lowe J, Gnutzmann KH, Steinfeldt T. Femoral nerve block with ropivacaine or bupivacaine in day case anterior crucial ligament reconstruction. Acta Anaesthesiol Scand. 2010;54:414-420.
- Krych AJ, Baran S, Kuzma SA, Smith HM, Johnson RL, Levy BA. Utility of multimodal analgesia with fascia iliaca blockade for acute pain management following hip arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2014;22:843-847.
- Nye ZB, Horn JL, Crittenden W, Abrahams MS, Aziz MF. Ambulatory continuous posterior lumbar plexus blocks following hip arthroscopy: a review of 213 cases. J Clin Anesth. 2013;25:268-274.
- Ward JP, Albert DB, Altman R, Goldstein RY, Cuff G, Youm T. Are femoral nerve blocks effective for early postoperative pain management after hip arthroscopy? Arthroscopy. 2012;28:1064-1069.
- Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg. 2005;101:1634-1642.
- Clarke MT, Arora A, Villar RN. Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res. 2003;406:84-88.
- Baber YF, Robinson AH, Villar RN. Is diagnostic arthroscopy of the hip worthwhile? A prospective review of 328 adults investigated for hip pain. J Bone Joint Surg Br. 1999;81:600-603.
- Byrd JW, Jones KS. Arthroscopic management of femoroacetabular impingement: minimum 2-year follow-up. Arthroscopy. 2011;27:1379-1388.
- Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: early outcomes measures. Arthroscopy. 2008;24:540-546.
- O'Leary JA, Berend K, Vail TP. The relationship between diagnosis and outcome in arthroscopy of the hip. Arthroscopy. 2001;17:181-188.
- 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;15:908-914.
- Potter BK, Freedman BA, Andersen RC, Bojescul JA, Kuklo TR, Murphy KP. Correlation of Short Form-36 and disability status with outcomes of arthroscopic acetabular labral debridement. Am J Sports Med. 2005;33:864-870.
- Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: a systematic review of the literature. Clin Orthop Relat Res. 2007;455:88-92.
- Yusaf MA, Hame SL. Arthroscopy of the hip. Curr Sports Med Rep. 2008;7:269-274.
- Colvin AC, Harrast J, Harner C. Trends in hip arthroscopy. J Bone Joint Surg Am. 2012;94:e23.
- Cvetanovich GL, Chalmers PN, Levy DM, et al. Hip arthroscopy surgical volume trends and 30-day postoperative complications. Arthroscopy. 2016 Apr 8. [Epub before print].
- Baker JF, Byrne DP, Hunter K, Mulhall KJ. Post-operative opiate requirements after hip arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2011;19:1399-1402.
- Lee EM, Murphy KP, Ben-David B. Postoperative analgesia for hip arthroscopy: combined L1 and L2 paravertebral blocks. J Clin Anesth. 2008;20:462-465.
- Ganesh A, Rose JB, Wells L, et al. Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children. Anesth Analg. 2007;105:1234-1242.
- Williams BA, Kentor ML, Vogt MT, et al. Femoral-sciatic nerve blocks for complex outpatient knee surgery are associated with less postoperative pain before same-day discharge: a review of 1,200 consecutive cases from the period 1996-1999. Anesthesiology. 2003;98:1206-1213.
- Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am. 2011;93:1988-1993.
- Dold AP, Murnaghan L, Xing J, Abdallah FW, Brull R, Whelan DB. Preoperative femoral nerve block in hip arthroscopic surgery: a retrospective review of 108 consecutive cases. Am J Sports Med. 2014;42:144-149.
- Schroeder KM, Donnelly MJ, Anderson BM, Ford MP, Keene JS. The analgesic impact of preoperative lumbar plexus blocks for hip arthroscopy. A retrospective review. Hip Int. 2013;23:93-98.
- YaDeau JT, Tedore T, Goytizolo EA, et al. Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial. Anesth Analg. 2012;115:968-972.
- Smart LR, Oetgen M, Noonan B, Medvecky M. Beginning hip arthroscopy: indications, positioning, portals, basic techniques, and complications. Arthroscopy. 2007;23:1348-1353.
- Stevens M, Harrison G, McGrail M. A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty. Anaesth Intensive Care. 2007;35:949-952.
- Lehmann LJ, Loosen G, Weiss C, Schmittner MD. Interscalene plexus block versus general anaesthesia for shoulder surgery: a randomized controlled study. Eur J Orthop Surg Traumatol. 2015;25:255-261.
- Gonano C, Kettner SC, Ernstbrunner M, Schebesta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. Br J Anaesth. 2009;103:428-433.
- Hadzic A, Karaca PE, Hobeika P, et al. Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy. Anesth Analg. 2005;100:976-981.
- Hsu LP, Oh S, Nuber GW, et al. Nerve block of the infrapatellar branch of the saphenous nerve in knee arthroscopy: a prospective, double-blinded, randomized, placebo-controlled trial. J Bone Joint Surg Am. 2013;95:1465-1472.
- Montes FR, Zarate E, Grueso R, et al. Comparison of spinal anesthesia with combined sciatic-femoral nerve block for outpatient knee arthroscopy. J Clin Anesth. 2008;20:415-420.
- Wulf H, Lowe J, Gnutzmann KH, Steinfeldt T. Femoral nerve block with ropivacaine or bupivacaine in day case anterior crucial ligament reconstruction. Acta Anaesthesiol Scand. 2010;54:414-420.
- Krych AJ, Baran S, Kuzma SA, Smith HM, Johnson RL, Levy BA. Utility of multimodal analgesia with fascia iliaca blockade for acute pain management following hip arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2014;22:843-847.
- Nye ZB, Horn JL, Crittenden W, Abrahams MS, Aziz MF. Ambulatory continuous posterior lumbar plexus blocks following hip arthroscopy: a review of 213 cases. J Clin Anesth. 2013;25:268-274.
- Ward JP, Albert DB, Altman R, Goldstein RY, Cuff G, Youm T. Are femoral nerve blocks effective for early postoperative pain management after hip arthroscopy? Arthroscopy. 2012;28:1064-1069.
- Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg. 2005;101:1634-1642.
- Clarke MT, Arora A, Villar RN. Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res. 2003;406:84-88.
TAKE-HOME POINTS
- Postoperative PACU pain was consistently reduced in the PNB group.
- Patients with PNBs had lower postoperative pain medication requirements and lower rates of inpatient admission compared with controls.
- Similar rates of nausea/vomiting and time to discharge were reported for PNB patients and controls.
- PNBs are associated with high rates of satisfaction and few complications.
- Future research should focus on comparing across PNB techniques.
Head, Neck, and Shoulder Injuries in Ice Hockey: Current Concepts
Take-Home Points
- Hockey is a high-speed collision sport with one of the highest injury rates among all sports.
- Use of a helmet with visors or full-face shields significantly reduces the risk for eye injury.
- Broken portions of teeth should be found and placed in a protective medium such as saline, saliva, or milk for transport.
- A player with unresolved concussion symptoms should not be allowed to return to the ice.
- Shoulder dominance, which determines stick grip, is an important consideration in the treatment of shoulder instability in an ice hockey player.
On a surface of ice in Windsor, Nova Scotia in the middle of the 19th century, the modern game of ice hockey evolved.1 A blend of hurley, a Gaelic sport, and lacrosse, from the native Mi’kmaq culture, the sport of ice hockey gained rapidly in popularity throughout Canada and is now the country’s national sport. Hockey quickly spread to the United States and then Europe. It is presently played in 77 countries across the world.2
Hockey players can reach speeds of up to 48 km (~30 miles) per hour on razor-sharp skates on an ice surface surrounded by rigid plastic composite boards topped with plexiglass.3 They use sticks made of wood, aluminum, or a composite material to advance a 6-ounce vulcanized rubber puck on the opposing goal, and this puck sometimes reaches speeds over 160 km (~100 miles) per hour. Older, male players are allowed to make physical contact with their opposing counterparts to separate them from the puck (body-checking). Not surprisingly, the potential risk for injury in hockey is high. At the 2010 Winter Olympics, men’s ice hockey players had the highest rate of injury of any other competitors there—more than 30% were affected.4
Hockey is played and enjoyed by athletes ranging widely in age. Youth hockey leagues accept players as young as 5 years. Hockey can become a lifelong recreational activity. In North America, old timers’ leagues have many players up to age 70 years.6 According to International Ice Hockey Federation data for 2016, more than 543,000 and 639,500 people play hockey in the United States and Canada, respectively.2 Most of the rules, protective equipment, skates, ice surfaces, and goal sizes are the same in men’s and women’s hockey.7 The major difference is in body-checking—this practice is not allowed at any age in women’s ice hockey.
In this article, we review the evaluation and management of common head, neck, and shoulder hockey injuries for physicians who provide medical support and coverage for youth, amateur, and senior hockey teams.
Evaluation and Management of Common Hockey Injuries
Eye Injuries
Although eye injuries are less common than musculoskeletal injuries and concussions in hockey, they are a serious risk for recreational and competitive players alike. Furthermore, recovery may be difficult, and eye injuries can have serious lifelong consequences.8 In hockey, the most commonly reported eye injuries are periorbital contusions and lacerations, hyphema, corneal and conjunctival abrasions, orbital fractures, and ruptured globes (Table 2).9,10
As a contact sport, hockey often involves high-impact, blunt-force trauma. The trauma in hockey results from collisions with other players, the boards, hockey sticks, and pucks. It is therefore not surprising that the most common ocular injuries in this sport are periorbital contusions. Although most contusions cause only mild swelling and ecchymosis of the soft tissues around the eye, there is potential for serious consequences. In a Scandinavia study, Leivo and colleagues10 found that 9% of patients who sustained a periocular contusion also had a clinically significant secondary diagnosis, such as retinal tear or hemorrhage, eyelid laceration, vitreous hemorrhage, or retinal detachment. Although the study was hospital-based, and therefore biased toward more severe cases, its findings highlight the potential severity of eye injuries in hockey. Furthermore, the study found that the majority of players who sustained blunt trauma to the eye itself required lifelong follow-up because of increased risk for glaucoma. This is particularly true for hyphema, as this finding indicates significant damage to intraocular tissues.10Players can also sustain fractures of the orbital bones, including orbital blowout fractures. Typical signs and symptoms of blowout fractures include diplopia, proptosis or enophthalmos, infraorbital hypoesthesia, painful and decreased extraocular movement (particularly upgaze), and palpable crepitance caused by sinus air entering the lower eyelid.11 If orbital fracture is suspected, as it should be in any case in which the injured player experiences pain with eye movement or diplopia, the player should be referred to the ED for computed tomography (CT) and ophthalmologic evaluation.12 Continued participation seriously risks making the injury much worse, particularly should another impact occur. In addition, given the impact needed to cause orbital fractures, consideration must be given to the potential for a coexisting concussion injury.
Severe direct trauma to the eye—from a puck, a stick, or a fist—can result in a ruptured globe, a particularly serious injury that requires immediate surgical attention. Signs and symptoms of a ruptured globe are rarely subtle, but associated eyelid swelling or laceration may obscure the injury, delaying proper diagnosis and treatment. More obvious signs include severely reduced vision, hemorrhagic chemosis (swelling) of the conjunctiva, and an irregular or peaked pupil. If a rupture or any significant intraocular injury is suspected, it is crucial to avoid applying any pressure to the globe, as this can significantly worsen the damage to the intraocular tissues. Use of a helmet with protective shields and cages attached markedly reduces the risk for such injuries.13All eye injuries require prompt assessment, which allows for appropriate management and prevention of secondary damage.14 Initial evaluation of a patient with ocular trauma should begin with external examination for lacerations, swelling, or orbital rim step-off deformity. The physician should also check visual acuity in order to assess for significant vision impairment (counting fingers or reading a sign in the arena; confrontation visual fields). This should be done before attending to any periocular injuries, with the uninjured side serving as a control. Next, the physician should assess the extraocular eye movements as well as the size, shape, and reactivity of the pupils. Particular attention should be paid to detecting any deficit in extraocular movement or irregularity in pupil size, shape, or reactivity, as such findings are highly suggestive of serious injury to the globe.13 Hyphema (blood in anterior chamber of eye anterior to pupil) should be suspected if vision is reduced and the pupil cannot be clearly visualized. However, a bright red clot is not always apparent at time of injury or if the amount of blood is small. An irregular pupil, or a pupil that does not constrict well to light, is also a red flag for serious contusion injury to the eye, and requires ophthalmologic evaluation. It is important to keep in mind that blunt trauma severe enough to produce hyphema or an irregular and poorly reactive pupil is often associated with retinal damage as well, including retinal edema or detachment.
Minor injuries (eg, small foreign bodies, minor periocular contusions and lacerations) can often be managed rink-side. Foreign bodies not embedded in the cornea, but lodged under the upper eyelid, can sometimes be removed by everting the eyelid and sweeping with a moistened cotton swab or using diffuse, sterile saline irrigation.11 Corneal abrasions generally cause severe pain, photophobia, and tearing and are easily diagnosed with use of topical fluorescein and a blue light. A topical anesthetic can be extremely helpful in this setting, as it allows for proper pain-free evaluation, but should never be used in an ongoing manner for pain relief. Small lacerations of the brow can be sutured with 5-0 or 6-0 nylon or closed with 2-Octyl cyanoacrylate tissue adhesive (Dermabond). Eyelid lacerations, unless very small, are best managed by an ophthalmologist; care must be taken to rule out injury to the deeper orbital tissues and eye. If serious injury is suspected, or the eye cannot be appropriately evaluated, it should be stabilized and protected with a protective shield or plastic cup, and the player should be transferred to an ED for appropriate ophthalmologic evaluation.13Most eye injuries are accidental, caused by sticks or deflected pucks, but 18% are acquired in fights.8 Use of visors or full-face cages effectively minimizes the rate of eye injuries.8,13,15,16 In a cohort study of 282 elite amateur ice hockey players, the risk of eye injury was 4.7 times higher in players without face protection than in players who used half-face shields; there were no eye injuries in players who used full-face protection.13 For visors to prevent eye injury, they must be positioned to cover the eyes and the lower edge of the nose in all projections.10
Dental Injuries
The incidence and type of facial and dental injuries depend directly on the type of face protection used.11,17,18 In a study of face, head, and neck injuries in elite amateur ice hockey players, Stuart and colleagues13 found game-related injury rates of 158.9 per 1000 player-hours in players without face protection, 73.5 in players who used half-face shields, and 23.2 in players who used full-face shields. Players who wore full-face shields had facial, head, and neck injury rates of only 23.2 per 1000 player-game hours.13 Other studies clearly support the important role face shields play in lowering injury risk in hockey. Face and head injuries account for 20% to 40% of all hockey-related injuries,3,16,19 and dental injuries up to 11.5%.20 In a study from Finland, Lahti and colleagues19 found that over a 2-year period, 479 hockey players sustained injuries, including 650 separate dental injuries. The most commonly diagnosed dental injury was an uncomplicated crown fracture, and the most common cause was a hit with a hockey stick, which accounted for 52.7% and 40.3% of dental injuries in games and practices, respectively.19
In the management of dental fractures, the broken portions of teeth should be found and placed in a transportation-protective medium, such as saline, saliva, or milk,16 which can improve functional and esthetic replacement outcomes.21,22 Loose pieces of teeth should not be left in the player’s mouth. The residual tooth should be stabilized and exposure to air and occlusion limited. Dental fractures can affect the enamel, the enamel and dentin structures (uncomplicated fracture), or enamel, dentin, and pulp (complicated).23 Fractures involving only the enamel do not require urgent dental evaluation. Dentin or pulp involvement may cause temperature and air sensitivity.23 If a tooth is air-sensitive, the player should be referred to a specialist immediately.11
Direct trauma can cause instability without displacement (subluxation) or complete displacement of the tooth from its alveolar socket (avulsion).23 An avulsed tooth should be handled by the crown to avoid further damage to the root and periodontal ligament.16,24 The tooth should be rinsed gently with saline and reimplanted in its socket, ideally within 5 to 10 minutes,23with the athlete biting down gently on gauze to hold the tooth in place. A 1-mL supraperiosteal infiltration of 1% or 2% lidocaine hydrochloride (1:100,000 epinephrine) can be given into the apex of the tooth being anesthetized (Figure 1). 
Concussions
A concussion is a “complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”25 Concussion is largely a functional disturbance instead of a structural injury, owing to the rotational and/or shearing forces involved. Many studies have identified concussion as the most common type of injury in all of youth hockey.26 Concussions account for up to 19% of all injuries in men’s collegiate hockey.3
Concussion can be challenging to diagnose on the ice. The most important factor in concussion management is symptom reporting by the athlete.27 Despite significant efforts in education and awareness, student athletes, especially hockey players, withhold reporting a possible concussion.28 Reasons for underreporting include fear of letting down other players and coaches, thinking the injury is not severe enough to warrant evaluation, and fear of losing standing with the current team or future teams.28
As postinjury concussion assessments are ideal when comparisons can be made with preseason (baseline) scores, preseason testing is becoming standard in professional, college, junior, and high school hockey. This testing involves the Sport Concussion Assessment Tool, 3rd edition (SCAT3), and the King-Devick (K-D) test.30,31 Some youth leagues have baseline testing as well, though the frequency of baseline testing in their players is controversial,32 as the adolescent mind’s processing speed and memory increase exponentially.33 For these younger athletes, it may be necessary to perform baseline testing more frequently than annually.32 A physician can use baseline test results to help diagnose a concussion at the rink and then track the athlete’s recovery and help with return-to-play decisions.29 Vision involves almost half of the brain’s circuits,34 including areas vulnerable to head impact. A neuro-ophthalmologic test can assess for irregularities in accommodation, convergence, ocular muscle balance, pursuit, and saccades.29 The K-D test is a visual performance examination that allows easy and objective assessment of eye movements. Use of both the K-D test and the SCAT3 at the rink may increase the number of concussions detected.29,35 We recommend that physicians use both tests to assess for concussion at the hockey rink.
Initial treatment involves a period of physical rest and relative cognitive rest. Acute worsening of symptoms warrants urgent imaging to rule out a subdural or subarachnoid bleed. Once a player is symptom-free, a graded return-to-play protocol should be followed (Table 4). 
On the prevention side, great efforts have been made to improve hockey helmets. (Some manufacturers claim to have made concussion-proof helmets, but there is no evidence supporting this claim.6) Numerous investigators have reported a lower overall injury rate in players who wear a helmet and a full-face shield.6,13 In addition, rule changes aimed at decreasing head contact have been implemented to decrease the incidence of sport-related concussions.36 Moreover, education on proper helmet use and wear should be emphasized. A study of the effects of hockey helmet fit on cervical motion found that 7 (39%) of 18 players wore a game or competition helmet so loosely that it could be removed without unbuttoning its chinstrap.37 Improperly worn helmets cannot prevent injury as well as properly worn helmets can.
Cervical Spine Injuries
Whereas American football is associated with a higher annual number of nonfatal catastrophic neck injuries, hockey has a 3 to 6 times higher incidence of cervical spine injuries and spinal cord damage.38,39 A Canadian Ice Hockey Spinal Injuries Registry review of the period 2006 to 2011 identified 44 cervical spine injuries, 7.3 per year on average.40 Severe injury, defined as complete motor and sensory loss, complete motor loss and incomplete sensory, or complete motor loss, occurred in 4 (9.1%) of the 44 injured players. In hockey, a major mechanism of cervical spine injury is an axial load to the slightly flexed spine.39 Of 355 hockey-related cervical spine injuries in a Canada study, 95 (35.5%) were caused by a check from behind.40,41 The Canadian neurosurgeons’ work led to rule changes prohibiting checks from behind, and this prohibition has reduced the incidence of cervical spine injuries in ice hockey.38,40
Team physicians should be comfortable managing serious neck and spine injuries on the ice. Initial evaluation should follow the standard ABCs (airway, breathing, circulation). The physician places a hand on each side of the head to stabilize the neck until the initial examination is complete. The goal is to minimize cervical spine motion until transportation to the hospital for advanced imaging and definitive treatment.37 The decision to remove or leave on the helmet is now controversial. Hockey helmets differ from football helmets in that their chinstraps do not afford significant cervical stabilization, and the helmets have less padding and cover less of the head; in addition, a shockingly high percentage of hockey players do not wear properly fitting helmets.37 In one study, 3-dimensional motion analysis of a hockey player during the logroll technique showed less transverse and sagittal cervical plane motion with the helmet removed than with the helmet (properly fitting or not) in place; the authors recommended removing the helmet to limit extraneous cervical spine motion during the technique.37 However, 2 other studies found that helmet removal can result in significantly increased cervical spine motion of the immobilized hockey player.42,43Recommendation 4 of the recently released interassociation consensus statement of the National Athletic Trainers’ Association reads, “Protective athletic equipment should be removed before transport to an emergency facility for an athlete-patient with suspected cervical spine instability.”44 This represents a shift from leaving the helmet and shoulder pads in place. For ice hockey players with suspected cervical spine injury, more research is needed on cervical motion during the entire sequence—partial logrolls, spine-boarding, placement of cervical collar before or after logroll, and different immobilization techniques for transport.37
The athlete must be carefully transferred to a spine board with either logroll or lift-and-slide. Although an extrication cervical collar can be placed before the spine board is placed, the effectiveness of this collar in executing the spine-board transfer is not proven.45 When the player is on the spine board, the head can be secured with pads and straps en route to the hospital.
Return-to-Play Criteria for Cervical Spine Injuries There is no clear consensus on return-to-play guidelines for cervical spine injuries in athletes.46
Shoulder Injuries
For hockey players, the upper extremity traditionally has been considered a well-protected area.48 However, shoulder pads are considerably more flexible in hockey than in football and other collision sports. In addition, hockey gloves allow a fair amount of motion for stick handling, and the wrist may be in maximal flexion or extension when a hit against the boards or the ice occurs. Open-ice checking, board collisions, and hockey stick use have been postulated as reasons for the high incidence of upper extremity injuries in hockey. Researchers in Finland found that upper extremity injuries accounted for up to 31% of all hockey injuries.49 More than 50% of these injuries resulted from checking or board collisions. Furthermore, study findings highlighted a low rate of injury in younger players and indicated the rate increases with age.49,50
In hockey players, the acromioclavicular (AC) joint is the most commonly injured shoulder structure.51 The mechanism of injury can be a board collision or an open-ice hit, but most often is a direct blow to the shoulder. The collision disrupts the AC joint and can sprain or tear the coracoclavicular ligaments. The Rockwood classification is used to categorize AC joint injuries (Figure 2). 
Initial management involves icing the AC joint and placing a sling for comfort. Type I and type II injuries can be managed with progressive range-of-motion (ROM) exercises, strengthening, cryotherapy, and a period of rest. Treatment of type III injuries remains controversial,52 but in hockey players these injuries are almost always treated nonoperatively. Return to play requires full motion, normal strength, and minimal discomfort. Players return a few days to 2 weeks after a grade I injury; recovery from grade II injuries may take 2 to 3 weeks, and recovery from grade III injuries, 6 to 12 weeks. Surgical treatment is usually required in type IV and type V injuries, but we have had experience treating these injuries nonoperatively in high-level players. AC joint reinjury in hockey players is common, and surgical treatment should be approached cautiously, as delayed fracture after return to sport has been reported.53 Special precautions should be taken in collision athletes who undergo AC joint reconstruction. In the anatomical reconstruction described by Carofino and Mazzocca,54 2 holes are drilled in the clavicle; these holes are a potential source of fracture when the collision athlete returns to sport (Figure 3). 
Clavicle fracture is another common hockey injury.55 Studies have shown clavicle fractures proportionally occur most often in people 15 to 19 years old.49 The injury presents with pain and deformity over the clavicle; in more severe fractures, skin tenting is identified. Initial management of suspected clavicle fracture includes cryotherapy, sling, and radiographs. Radiographs should include an AP view and then a 45° cephalad view, which eliminates overshadowing from the ribs. Most clavicle fractures are successfully managed nonoperatively, though there is evidence that significantly displaced or comminuted fractures have better union rates and shoulder function when treated with open reduction and internal fixation.56 After a clavicle fracture, return to skating and noncontact practice usually takes 8 weeks, with return to full contact occurring around 12 weeks.
Sternoclavicular injuries are relatively uncommon, but potentially serious. Special attention should also be given to adolescent athletes with sternoclavicular pain. Although sternoclavicular dislocations have been reported in hockey players, instead these likely are fractures involving the medial clavicle physis.57
The shoulder is the most commonly dislocated major joint, and the incidence of shoulder dislocation in elite hockey players is 8% to 21%.50,58 Anterior shoulder instability occurs from a fall with the shoulder in an abducted, externally rotated and extended position or from a direct anteriorly placed impact to the posterior shoulder. We recommend taking players off the ice for evaluation. Depending on physician comfort, the shoulder can be reduced in the training room, and the athlete sent for radiographs after reduction. If resources or support for closed reduction is not available at the rink, the athlete should be sent to the ED. Initial radiographic evaluation of a player with shoulder injury begins with plain radiographs, including a true AP (Grashey) view with the humerus in neutral, internal, and external rotation and an axillary view. The axillary radiograph is crucial in determining anterior or posterior dislocation. If the patient cannot tolerate the pain associated with having an axillary radiograph taken, a Velpeau radiograph can be used. This radiograph is taken with the patient’s arm in a sling and with the patient leaning back 30° while the x-ray beam is directed superior to inferior.
CT is performed for a suspected osseous injury. CT is more accurate than plain radiographs in showing glenoid and humeral fractures in the acute setting as well as the amount of bone loss in the case of chronic instability. Magnetic resonance arthrography is the imaging modality of choice for the diagnoses of capsulolabral injury.
After shoulder reduction, treatment with a sling, cryotherapy, and a nonsteroidal anti-inflammatory drug is initiated. In a Minnesota study of nonoperative management of shoulder instability, 9 of 10 hockey players were able to return to play the same season, and 6 of the 10 required surgery at the end of the season.59
Compared with noncontact athletes, hockey players and other collision athletes are at increased risk for recurrence.60-62 For collision athletes who want to continue playing their sport after recurrent instability, surgery is recommended. A shoulder instability study in Toronto found that more than 54% of 24 professional hockey players had associated Hill-Sachs lesions, but only 3 shoulders (12.5%) had glenoid defects.50 Arthroscopic and open techniques both demonstrate good results, and identification of bone loss can help determine which surgery to recommend.63 Hockey players can usually return to sport 6 months after shoulder stabilization.
Another important consideration in managing shoulder instability in hockey players is shoulder dominance, which determines stick grip. A left-handed player places the right hand on top of the stick for support, but most of the motion associated with shooting the puck—including abduction and external rotation—occurs with the left shoulder. Thus, a left-handed player with a history of previous left-side shoulder dislocation may dislocate with each shot, but a right-handed player with left shoulder instability may have considerably less trouble on the ice.58Shoulder and rotator cuff contusions (RCCs) occur in hockey and other collision sports.49,64 RCCs almost always result from a direct blow to the shoulder, and present with shoulder function loss, weakness, and pain.
Summary
Hockey is a high-speed collision sport with one of the highest injury rates among all sports. Physicians caring for youth, amateur, and senior hockey teams see a range of acute head, neck, and shoulder injuries. Although treatment of eye injuries, dental injuries, and concussions is not always considered orthopedic care, an orthopedic surgeon who is covering hockey needs to be comfortable managing these injuries acutely. Quality rink-side care minimizes the impact of the injury, maximizes the functional result, and expedites the safe return of the injured player back to the ice.
Am J Orthop. 2017;46(3):123-134. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
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54. Carofino BC, Mazzocca AD. The anatomic coracoclavicular ligament reconstruction: surgical technique and indications. J Shoulder Elbow Surg. 2010;19(2 suppl):37-46.
55. 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(1):4-10.
56. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1-10.
57. Lee JT, Nasreddine AY, Black EM, Bae DS, Kocher MS. Posterior sternoclavicular joint injuries in skeletally immature patients. J Pediatr Orthop. 2014;34(4):369-375.
58. Hovelius L. Shoulder dislocation in Swedish ice hockey players. Am J Sports Med. 1978;6(6):373-377.
59. Buss DD, Lynch GP, Meyer CP, Huber SM, Freehill MQ. Nonoperative management for in-season athletes with anterior shoulder instability. Am J Sports Med. 2004;32(6):1430-1433.
60. Mazzocca AD, Brown FM Jr, Carreira DS, Hayden J, Romeo AA. Arthroscopic anterior shoulder stabilization of collision and contact athletes. Am J Sports Med. 2005;33(1):52-60.
61. Harris JD, Romeo AA. Arthroscopic management of the contact athlete with instability. Clin Sports Med. 2013;32(4):709-730.
62. Cho NS, Hwang JC, Rhee YG. Arthroscopic stabilization in anterior shoulder instability: collision athletes versus noncollision athletes. Arthroscopy. 2006;22(9):947-953.
63. Griffin JW, Brockmeier SF. Shoulder instability with concomitant bone loss in the athlete. Orthop Clin North Am. 2015;46(1):89-103.
64. Cohen SB, Towers JD, Bradley JP. Rotator cuff contusions of the shoulder in professional football players: epidemiology and magnetic resonance imaging findings. Am J Sports Med. 2007;35(3):442-447.
65. Lorentzon R, Wedrèn H, Pietilä T. Incidence, nature, and causes of ice hockey injuries. A three-year prospective study of a Swedish elite ice hockey team. Am J Sports Med. 1988;16(4):392-396.
66. Stuart MJ, Smith A. Injuries in Junior A ice hockey. A three-year prospective study. Am J Sports Med. 1995;23(4):458-461.
67. Voaklander DC, Saunders LD, Quinney HA, Macnab RB. Epidemiology of recreational and old-timer ice hockey injuries. Clin J Sport Med. 1996;6(1):15-21.
68. Mölsä J, Airaksinen O, Näsman O, Torstila I. Ice hockey injuries in Finland. A prospective epidemiologic study. Am J Sports Med. 1997;25(4):495-499.
69. Ferrara MS, Schurr KT. Intercollegiate ice hockey injuries: a casual analysis. Clin J Sport Med. 1999;9(1):30-33.
70. Pinto M, Kuhn JE, Greenfield ML, Hawkins RJ. Prospective analysis of ice hockey injuries at the Junior A level over the course of one season. Clin J Sport Med. 1999;9(2):70-74.
71. Emery CA, Meeuwisse WH. Injury rates, risk factors, and mechanisms of injury in minor hockey. Am J Sports Med. 2006;34(12):1960-1969.
72. Kuzuhara K, Shimamoto H, Mase Y. Ice hockey injuries in a Japanese elite team: a 3-year prospective study. J Athl Train. 2009;44(2):208-214.
73. Rishiraj N, Lloyd-Smith R, Lorenz T, Niven B, Michel M. University men’s ice hockey: rates and risk of injuries over 6-years. J Sports Med Phys Fitness. 2009;49(2):159-166.
74. Tuominen M, Stuart MJ, Aubry M, Kannus P, Parkkari J. 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. Br J Sports Med. 2015;49(1):30-36.
75. Heckman JD, Bucholz RW. In: Rockwood CA, Green DP, Heckman JD, Bucholz RW, eds. Rockwood and Green’s Fractures in Adults, Volume 1. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.
Take-Home Points
- Hockey is a high-speed collision sport with one of the highest injury rates among all sports.
- Use of a helmet with visors or full-face shields significantly reduces the risk for eye injury.
- Broken portions of teeth should be found and placed in a protective medium such as saline, saliva, or milk for transport.
- A player with unresolved concussion symptoms should not be allowed to return to the ice.
- Shoulder dominance, which determines stick grip, is an important consideration in the treatment of shoulder instability in an ice hockey player.
On a surface of ice in Windsor, Nova Scotia in the middle of the 19th century, the modern game of ice hockey evolved.1 A blend of hurley, a Gaelic sport, and lacrosse, from the native Mi’kmaq culture, the sport of ice hockey gained rapidly in popularity throughout Canada and is now the country’s national sport. Hockey quickly spread to the United States and then Europe. It is presently played in 77 countries across the world.2
Hockey players can reach speeds of up to 48 km (~30 miles) per hour on razor-sharp skates on an ice surface surrounded by rigid plastic composite boards topped with plexiglass.3 They use sticks made of wood, aluminum, or a composite material to advance a 6-ounce vulcanized rubber puck on the opposing goal, and this puck sometimes reaches speeds over 160 km (~100 miles) per hour. Older, male players are allowed to make physical contact with their opposing counterparts to separate them from the puck (body-checking). Not surprisingly, the potential risk for injury in hockey is high. At the 2010 Winter Olympics, men’s ice hockey players had the highest rate of injury of any other competitors there—more than 30% were affected.4
Hockey is played and enjoyed by athletes ranging widely in age. Youth hockey leagues accept players as young as 5 years. Hockey can become a lifelong recreational activity. In North America, old timers’ leagues have many players up to age 70 years.6 According to International Ice Hockey Federation data for 2016, more than 543,000 and 639,500 people play hockey in the United States and Canada, respectively.2 Most of the rules, protective equipment, skates, ice surfaces, and goal sizes are the same in men’s and women’s hockey.7 The major difference is in body-checking—this practice is not allowed at any age in women’s ice hockey.
In this article, we review the evaluation and management of common head, neck, and shoulder hockey injuries for physicians who provide medical support and coverage for youth, amateur, and senior hockey teams.
Evaluation and Management of Common Hockey Injuries
Eye Injuries
Although eye injuries are less common than musculoskeletal injuries and concussions in hockey, they are a serious risk for recreational and competitive players alike. Furthermore, recovery may be difficult, and eye injuries can have serious lifelong consequences.8 In hockey, the most commonly reported eye injuries are periorbital contusions and lacerations, hyphema, corneal and conjunctival abrasions, orbital fractures, and ruptured globes (Table 2).9,10
As a contact sport, hockey often involves high-impact, blunt-force trauma. The trauma in hockey results from collisions with other players, the boards, hockey sticks, and pucks. It is therefore not surprising that the most common ocular injuries in this sport are periorbital contusions. Although most contusions cause only mild swelling and ecchymosis of the soft tissues around the eye, there is potential for serious consequences. In a Scandinavia study, Leivo and colleagues10 found that 9% of patients who sustained a periocular contusion also had a clinically significant secondary diagnosis, such as retinal tear or hemorrhage, eyelid laceration, vitreous hemorrhage, or retinal detachment. Although the study was hospital-based, and therefore biased toward more severe cases, its findings highlight the potential severity of eye injuries in hockey. Furthermore, the study found that the majority of players who sustained blunt trauma to the eye itself required lifelong follow-up because of increased risk for glaucoma. This is particularly true for hyphema, as this finding indicates significant damage to intraocular tissues.10Players can also sustain fractures of the orbital bones, including orbital blowout fractures. Typical signs and symptoms of blowout fractures include diplopia, proptosis or enophthalmos, infraorbital hypoesthesia, painful and decreased extraocular movement (particularly upgaze), and palpable crepitance caused by sinus air entering the lower eyelid.11 If orbital fracture is suspected, as it should be in any case in which the injured player experiences pain with eye movement or diplopia, the player should be referred to the ED for computed tomography (CT) and ophthalmologic evaluation.12 Continued participation seriously risks making the injury much worse, particularly should another impact occur. In addition, given the impact needed to cause orbital fractures, consideration must be given to the potential for a coexisting concussion injury.
Severe direct trauma to the eye—from a puck, a stick, or a fist—can result in a ruptured globe, a particularly serious injury that requires immediate surgical attention. Signs and symptoms of a ruptured globe are rarely subtle, but associated eyelid swelling or laceration may obscure the injury, delaying proper diagnosis and treatment. More obvious signs include severely reduced vision, hemorrhagic chemosis (swelling) of the conjunctiva, and an irregular or peaked pupil. If a rupture or any significant intraocular injury is suspected, it is crucial to avoid applying any pressure to the globe, as this can significantly worsen the damage to the intraocular tissues. Use of a helmet with protective shields and cages attached markedly reduces the risk for such injuries.13All eye injuries require prompt assessment, which allows for appropriate management and prevention of secondary damage.14 Initial evaluation of a patient with ocular trauma should begin with external examination for lacerations, swelling, or orbital rim step-off deformity. The physician should also check visual acuity in order to assess for significant vision impairment (counting fingers or reading a sign in the arena; confrontation visual fields). This should be done before attending to any periocular injuries, with the uninjured side serving as a control. Next, the physician should assess the extraocular eye movements as well as the size, shape, and reactivity of the pupils. Particular attention should be paid to detecting any deficit in extraocular movement or irregularity in pupil size, shape, or reactivity, as such findings are highly suggestive of serious injury to the globe.13 Hyphema (blood in anterior chamber of eye anterior to pupil) should be suspected if vision is reduced and the pupil cannot be clearly visualized. However, a bright red clot is not always apparent at time of injury or if the amount of blood is small. An irregular pupil, or a pupil that does not constrict well to light, is also a red flag for serious contusion injury to the eye, and requires ophthalmologic evaluation. It is important to keep in mind that blunt trauma severe enough to produce hyphema or an irregular and poorly reactive pupil is often associated with retinal damage as well, including retinal edema or detachment.
Minor injuries (eg, small foreign bodies, minor periocular contusions and lacerations) can often be managed rink-side. Foreign bodies not embedded in the cornea, but lodged under the upper eyelid, can sometimes be removed by everting the eyelid and sweeping with a moistened cotton swab or using diffuse, sterile saline irrigation.11 Corneal abrasions generally cause severe pain, photophobia, and tearing and are easily diagnosed with use of topical fluorescein and a blue light. A topical anesthetic can be extremely helpful in this setting, as it allows for proper pain-free evaluation, but should never be used in an ongoing manner for pain relief. Small lacerations of the brow can be sutured with 5-0 or 6-0 nylon or closed with 2-Octyl cyanoacrylate tissue adhesive (Dermabond). Eyelid lacerations, unless very small, are best managed by an ophthalmologist; care must be taken to rule out injury to the deeper orbital tissues and eye. If serious injury is suspected, or the eye cannot be appropriately evaluated, it should be stabilized and protected with a protective shield or plastic cup, and the player should be transferred to an ED for appropriate ophthalmologic evaluation.13Most eye injuries are accidental, caused by sticks or deflected pucks, but 18% are acquired in fights.8 Use of visors or full-face cages effectively minimizes the rate of eye injuries.8,13,15,16 In a cohort study of 282 elite amateur ice hockey players, the risk of eye injury was 4.7 times higher in players without face protection than in players who used half-face shields; there were no eye injuries in players who used full-face protection.13 For visors to prevent eye injury, they must be positioned to cover the eyes and the lower edge of the nose in all projections.10
Dental Injuries
The incidence and type of facial and dental injuries depend directly on the type of face protection used.11,17,18 In a study of face, head, and neck injuries in elite amateur ice hockey players, Stuart and colleagues13 found game-related injury rates of 158.9 per 1000 player-hours in players without face protection, 73.5 in players who used half-face shields, and 23.2 in players who used full-face shields. Players who wore full-face shields had facial, head, and neck injury rates of only 23.2 per 1000 player-game hours.13 Other studies clearly support the important role face shields play in lowering injury risk in hockey. Face and head injuries account for 20% to 40% of all hockey-related injuries,3,16,19 and dental injuries up to 11.5%.20 In a study from Finland, Lahti and colleagues19 found that over a 2-year period, 479 hockey players sustained injuries, including 650 separate dental injuries. The most commonly diagnosed dental injury was an uncomplicated crown fracture, and the most common cause was a hit with a hockey stick, which accounted for 52.7% and 40.3% of dental injuries in games and practices, respectively.19
In the management of dental fractures, the broken portions of teeth should be found and placed in a transportation-protective medium, such as saline, saliva, or milk,16 which can improve functional and esthetic replacement outcomes.21,22 Loose pieces of teeth should not be left in the player’s mouth. The residual tooth should be stabilized and exposure to air and occlusion limited. Dental fractures can affect the enamel, the enamel and dentin structures (uncomplicated fracture), or enamel, dentin, and pulp (complicated).23 Fractures involving only the enamel do not require urgent dental evaluation. Dentin or pulp involvement may cause temperature and air sensitivity.23 If a tooth is air-sensitive, the player should be referred to a specialist immediately.11
Direct trauma can cause instability without displacement (subluxation) or complete displacement of the tooth from its alveolar socket (avulsion).23 An avulsed tooth should be handled by the crown to avoid further damage to the root and periodontal ligament.16,24 The tooth should be rinsed gently with saline and reimplanted in its socket, ideally within 5 to 10 minutes,23with the athlete biting down gently on gauze to hold the tooth in place. A 1-mL supraperiosteal infiltration of 1% or 2% lidocaine hydrochloride (1:100,000 epinephrine) can be given into the apex of the tooth being anesthetized (Figure 1).
Concussions
A concussion is a “complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”25 Concussion is largely a functional disturbance instead of a structural injury, owing to the rotational and/or shearing forces involved. Many studies have identified concussion as the most common type of injury in all of youth hockey.26 Concussions account for up to 19% of all injuries in men’s collegiate hockey.3
Concussion can be challenging to diagnose on the ice. The most important factor in concussion management is symptom reporting by the athlete.27 Despite significant efforts in education and awareness, student athletes, especially hockey players, withhold reporting a possible concussion.28 Reasons for underreporting include fear of letting down other players and coaches, thinking the injury is not severe enough to warrant evaluation, and fear of losing standing with the current team or future teams.28
As postinjury concussion assessments are ideal when comparisons can be made with preseason (baseline) scores, preseason testing is becoming standard in professional, college, junior, and high school hockey. This testing involves the Sport Concussion Assessment Tool, 3rd edition (SCAT3), and the King-Devick (K-D) test.30,31 Some youth leagues have baseline testing as well, though the frequency of baseline testing in their players is controversial,32 as the adolescent mind’s processing speed and memory increase exponentially.33 For these younger athletes, it may be necessary to perform baseline testing more frequently than annually.32 A physician can use baseline test results to help diagnose a concussion at the rink and then track the athlete’s recovery and help with return-to-play decisions.29 Vision involves almost half of the brain’s circuits,34 including areas vulnerable to head impact. A neuro-ophthalmologic test can assess for irregularities in accommodation, convergence, ocular muscle balance, pursuit, and saccades.29 The K-D test is a visual performance examination that allows easy and objective assessment of eye movements. Use of both the K-D test and the SCAT3 at the rink may increase the number of concussions detected.29,35 We recommend that physicians use both tests to assess for concussion at the hockey rink.
Initial treatment involves a period of physical rest and relative cognitive rest. Acute worsening of symptoms warrants urgent imaging to rule out a subdural or subarachnoid bleed. Once a player is symptom-free, a graded return-to-play protocol should be followed (Table 4).
On the prevention side, great efforts have been made to improve hockey helmets. (Some manufacturers claim to have made concussion-proof helmets, but there is no evidence supporting this claim.6) Numerous investigators have reported a lower overall injury rate in players who wear a helmet and a full-face shield.6,13 In addition, rule changes aimed at decreasing head contact have been implemented to decrease the incidence of sport-related concussions.36 Moreover, education on proper helmet use and wear should be emphasized. A study of the effects of hockey helmet fit on cervical motion found that 7 (39%) of 18 players wore a game or competition helmet so loosely that it could be removed without unbuttoning its chinstrap.37 Improperly worn helmets cannot prevent injury as well as properly worn helmets can.
Cervical Spine Injuries
Whereas American football is associated with a higher annual number of nonfatal catastrophic neck injuries, hockey has a 3 to 6 times higher incidence of cervical spine injuries and spinal cord damage.38,39 A Canadian Ice Hockey Spinal Injuries Registry review of the period 2006 to 2011 identified 44 cervical spine injuries, 7.3 per year on average.40 Severe injury, defined as complete motor and sensory loss, complete motor loss and incomplete sensory, or complete motor loss, occurred in 4 (9.1%) of the 44 injured players. In hockey, a major mechanism of cervical spine injury is an axial load to the slightly flexed spine.39 Of 355 hockey-related cervical spine injuries in a Canada study, 95 (35.5%) were caused by a check from behind.40,41 The Canadian neurosurgeons’ work led to rule changes prohibiting checks from behind, and this prohibition has reduced the incidence of cervical spine injuries in ice hockey.38,40
Team physicians should be comfortable managing serious neck and spine injuries on the ice. Initial evaluation should follow the standard ABCs (airway, breathing, circulation). The physician places a hand on each side of the head to stabilize the neck until the initial examination is complete. The goal is to minimize cervical spine motion until transportation to the hospital for advanced imaging and definitive treatment.37 The decision to remove or leave on the helmet is now controversial. Hockey helmets differ from football helmets in that their chinstraps do not afford significant cervical stabilization, and the helmets have less padding and cover less of the head; in addition, a shockingly high percentage of hockey players do not wear properly fitting helmets.37 In one study, 3-dimensional motion analysis of a hockey player during the logroll technique showed less transverse and sagittal cervical plane motion with the helmet removed than with the helmet (properly fitting or not) in place; the authors recommended removing the helmet to limit extraneous cervical spine motion during the technique.37 However, 2 other studies found that helmet removal can result in significantly increased cervical spine motion of the immobilized hockey player.42,43Recommendation 4 of the recently released interassociation consensus statement of the National Athletic Trainers’ Association reads, “Protective athletic equipment should be removed before transport to an emergency facility for an athlete-patient with suspected cervical spine instability.”44 This represents a shift from leaving the helmet and shoulder pads in place. For ice hockey players with suspected cervical spine injury, more research is needed on cervical motion during the entire sequence—partial logrolls, spine-boarding, placement of cervical collar before or after logroll, and different immobilization techniques for transport.37
The athlete must be carefully transferred to a spine board with either logroll or lift-and-slide. Although an extrication cervical collar can be placed before the spine board is placed, the effectiveness of this collar in executing the spine-board transfer is not proven.45 When the player is on the spine board, the head can be secured with pads and straps en route to the hospital.
Return-to-Play Criteria for Cervical Spine Injuries There is no clear consensus on return-to-play guidelines for cervical spine injuries in athletes.46
Shoulder Injuries
For hockey players, the upper extremity traditionally has been considered a well-protected area.48 However, shoulder pads are considerably more flexible in hockey than in football and other collision sports. In addition, hockey gloves allow a fair amount of motion for stick handling, and the wrist may be in maximal flexion or extension when a hit against the boards or the ice occurs. Open-ice checking, board collisions, and hockey stick use have been postulated as reasons for the high incidence of upper extremity injuries in hockey. Researchers in Finland found that upper extremity injuries accounted for up to 31% of all hockey injuries.49 More than 50% of these injuries resulted from checking or board collisions. Furthermore, study findings highlighted a low rate of injury in younger players and indicated the rate increases with age.49,50
In hockey players, the acromioclavicular (AC) joint is the most commonly injured shoulder structure.51 The mechanism of injury can be a board collision or an open-ice hit, but most often is a direct blow to the shoulder. The collision disrupts the AC joint and can sprain or tear the coracoclavicular ligaments. The Rockwood classification is used to categorize AC joint injuries (Figure 2).
Initial management involves icing the AC joint and placing a sling for comfort. Type I and type II injuries can be managed with progressive range-of-motion (ROM) exercises, strengthening, cryotherapy, and a period of rest. Treatment of type III injuries remains controversial,52 but in hockey players these injuries are almost always treated nonoperatively. Return to play requires full motion, normal strength, and minimal discomfort. Players return a few days to 2 weeks after a grade I injury; recovery from grade II injuries may take 2 to 3 weeks, and recovery from grade III injuries, 6 to 12 weeks. Surgical treatment is usually required in type IV and type V injuries, but we have had experience treating these injuries nonoperatively in high-level players. AC joint reinjury in hockey players is common, and surgical treatment should be approached cautiously, as delayed fracture after return to sport has been reported.53 Special precautions should be taken in collision athletes who undergo AC joint reconstruction. In the anatomical reconstruction described by Carofino and Mazzocca,54 2 holes are drilled in the clavicle; these holes are a potential source of fracture when the collision athlete returns to sport (Figure 3).
Clavicle fracture is another common hockey injury.55 Studies have shown clavicle fractures proportionally occur most often in people 15 to 19 years old.49 The injury presents with pain and deformity over the clavicle; in more severe fractures, skin tenting is identified. Initial management of suspected clavicle fracture includes cryotherapy, sling, and radiographs. Radiographs should include an AP view and then a 45° cephalad view, which eliminates overshadowing from the ribs. Most clavicle fractures are successfully managed nonoperatively, though there is evidence that significantly displaced or comminuted fractures have better union rates and shoulder function when treated with open reduction and internal fixation.56 After a clavicle fracture, return to skating and noncontact practice usually takes 8 weeks, with return to full contact occurring around 12 weeks.
Sternoclavicular injuries are relatively uncommon, but potentially serious. Special attention should also be given to adolescent athletes with sternoclavicular pain. Although sternoclavicular dislocations have been reported in hockey players, instead these likely are fractures involving the medial clavicle physis.57
The shoulder is the most commonly dislocated major joint, and the incidence of shoulder dislocation in elite hockey players is 8% to 21%.50,58 Anterior shoulder instability occurs from a fall with the shoulder in an abducted, externally rotated and extended position or from a direct anteriorly placed impact to the posterior shoulder. We recommend taking players off the ice for evaluation. Depending on physician comfort, the shoulder can be reduced in the training room, and the athlete sent for radiographs after reduction. If resources or support for closed reduction is not available at the rink, the athlete should be sent to the ED. Initial radiographic evaluation of a player with shoulder injury begins with plain radiographs, including a true AP (Grashey) view with the humerus in neutral, internal, and external rotation and an axillary view. The axillary radiograph is crucial in determining anterior or posterior dislocation. If the patient cannot tolerate the pain associated with having an axillary radiograph taken, a Velpeau radiograph can be used. This radiograph is taken with the patient’s arm in a sling and with the patient leaning back 30° while the x-ray beam is directed superior to inferior.
CT is performed for a suspected osseous injury. CT is more accurate than plain radiographs in showing glenoid and humeral fractures in the acute setting as well as the amount of bone loss in the case of chronic instability. Magnetic resonance arthrography is the imaging modality of choice for the diagnoses of capsulolabral injury.
After shoulder reduction, treatment with a sling, cryotherapy, and a nonsteroidal anti-inflammatory drug is initiated. In a Minnesota study of nonoperative management of shoulder instability, 9 of 10 hockey players were able to return to play the same season, and 6 of the 10 required surgery at the end of the season.59
Compared with noncontact athletes, hockey players and other collision athletes are at increased risk for recurrence.60-62 For collision athletes who want to continue playing their sport after recurrent instability, surgery is recommended. A shoulder instability study in Toronto found that more than 54% of 24 professional hockey players had associated Hill-Sachs lesions, but only 3 shoulders (12.5%) had glenoid defects.50 Arthroscopic and open techniques both demonstrate good results, and identification of bone loss can help determine which surgery to recommend.63 Hockey players can usually return to sport 6 months after shoulder stabilization.
Another important consideration in managing shoulder instability in hockey players is shoulder dominance, which determines stick grip. A left-handed player places the right hand on top of the stick for support, but most of the motion associated with shooting the puck—including abduction and external rotation—occurs with the left shoulder. Thus, a left-handed player with a history of previous left-side shoulder dislocation may dislocate with each shot, but a right-handed player with left shoulder instability may have considerably less trouble on the ice.58Shoulder and rotator cuff contusions (RCCs) occur in hockey and other collision sports.49,64 RCCs almost always result from a direct blow to the shoulder, and present with shoulder function loss, weakness, and pain.
Summary
Hockey is a high-speed collision sport with one of the highest injury rates among all sports. Physicians caring for youth, amateur, and senior hockey teams see a range of acute head, neck, and shoulder injuries. Although treatment of eye injuries, dental injuries, and concussions is not always considered orthopedic care, an orthopedic surgeon who is covering hockey needs to be comfortable managing these injuries acutely. Quality rink-side care minimizes the impact of the injury, maximizes the functional result, and expedites the safe return of the injured player back to the ice.
Am J Orthop. 2017;46(3):123-134. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Take-Home Points
- Hockey is a high-speed collision sport with one of the highest injury rates among all sports.
- Use of a helmet with visors or full-face shields significantly reduces the risk for eye injury.
- Broken portions of teeth should be found and placed in a protective medium such as saline, saliva, or milk for transport.
- A player with unresolved concussion symptoms should not be allowed to return to the ice.
- Shoulder dominance, which determines stick grip, is an important consideration in the treatment of shoulder instability in an ice hockey player.
On a surface of ice in Windsor, Nova Scotia in the middle of the 19th century, the modern game of ice hockey evolved.1 A blend of hurley, a Gaelic sport, and lacrosse, from the native Mi’kmaq culture, the sport of ice hockey gained rapidly in popularity throughout Canada and is now the country’s national sport. Hockey quickly spread to the United States and then Europe. It is presently played in 77 countries across the world.2
Hockey players can reach speeds of up to 48 km (~30 miles) per hour on razor-sharp skates on an ice surface surrounded by rigid plastic composite boards topped with plexiglass.3 They use sticks made of wood, aluminum, or a composite material to advance a 6-ounce vulcanized rubber puck on the opposing goal, and this puck sometimes reaches speeds over 160 km (~100 miles) per hour. Older, male players are allowed to make physical contact with their opposing counterparts to separate them from the puck (body-checking). Not surprisingly, the potential risk for injury in hockey is high. At the 2010 Winter Olympics, men’s ice hockey players had the highest rate of injury of any other competitors there—more than 30% were affected.4
Hockey is played and enjoyed by athletes ranging widely in age. Youth hockey leagues accept players as young as 5 years. Hockey can become a lifelong recreational activity. In North America, old timers’ leagues have many players up to age 70 years.6 According to International Ice Hockey Federation data for 2016, more than 543,000 and 639,500 people play hockey in the United States and Canada, respectively.2 Most of the rules, protective equipment, skates, ice surfaces, and goal sizes are the same in men’s and women’s hockey.7 The major difference is in body-checking—this practice is not allowed at any age in women’s ice hockey.
In this article, we review the evaluation and management of common head, neck, and shoulder hockey injuries for physicians who provide medical support and coverage for youth, amateur, and senior hockey teams.
Evaluation and Management of Common Hockey Injuries
Eye Injuries
Although eye injuries are less common than musculoskeletal injuries and concussions in hockey, they are a serious risk for recreational and competitive players alike. Furthermore, recovery may be difficult, and eye injuries can have serious lifelong consequences.8 In hockey, the most commonly reported eye injuries are periorbital contusions and lacerations, hyphema, corneal and conjunctival abrasions, orbital fractures, and ruptured globes (Table 2).9,10
As a contact sport, hockey often involves high-impact, blunt-force trauma. The trauma in hockey results from collisions with other players, the boards, hockey sticks, and pucks. It is therefore not surprising that the most common ocular injuries in this sport are periorbital contusions. Although most contusions cause only mild swelling and ecchymosis of the soft tissues around the eye, there is potential for serious consequences. In a Scandinavia study, Leivo and colleagues10 found that 9% of patients who sustained a periocular contusion also had a clinically significant secondary diagnosis, such as retinal tear or hemorrhage, eyelid laceration, vitreous hemorrhage, or retinal detachment. Although the study was hospital-based, and therefore biased toward more severe cases, its findings highlight the potential severity of eye injuries in hockey. Furthermore, the study found that the majority of players who sustained blunt trauma to the eye itself required lifelong follow-up because of increased risk for glaucoma. This is particularly true for hyphema, as this finding indicates significant damage to intraocular tissues.10Players can also sustain fractures of the orbital bones, including orbital blowout fractures. Typical signs and symptoms of blowout fractures include diplopia, proptosis or enophthalmos, infraorbital hypoesthesia, painful and decreased extraocular movement (particularly upgaze), and palpable crepitance caused by sinus air entering the lower eyelid.11 If orbital fracture is suspected, as it should be in any case in which the injured player experiences pain with eye movement or diplopia, the player should be referred to the ED for computed tomography (CT) and ophthalmologic evaluation.12 Continued participation seriously risks making the injury much worse, particularly should another impact occur. In addition, given the impact needed to cause orbital fractures, consideration must be given to the potential for a coexisting concussion injury.
Severe direct trauma to the eye—from a puck, a stick, or a fist—can result in a ruptured globe, a particularly serious injury that requires immediate surgical attention. Signs and symptoms of a ruptured globe are rarely subtle, but associated eyelid swelling or laceration may obscure the injury, delaying proper diagnosis and treatment. More obvious signs include severely reduced vision, hemorrhagic chemosis (swelling) of the conjunctiva, and an irregular or peaked pupil. If a rupture or any significant intraocular injury is suspected, it is crucial to avoid applying any pressure to the globe, as this can significantly worsen the damage to the intraocular tissues. Use of a helmet with protective shields and cages attached markedly reduces the risk for such injuries.13All eye injuries require prompt assessment, which allows for appropriate management and prevention of secondary damage.14 Initial evaluation of a patient with ocular trauma should begin with external examination for lacerations, swelling, or orbital rim step-off deformity. The physician should also check visual acuity in order to assess for significant vision impairment (counting fingers or reading a sign in the arena; confrontation visual fields). This should be done before attending to any periocular injuries, with the uninjured side serving as a control. Next, the physician should assess the extraocular eye movements as well as the size, shape, and reactivity of the pupils. Particular attention should be paid to detecting any deficit in extraocular movement or irregularity in pupil size, shape, or reactivity, as such findings are highly suggestive of serious injury to the globe.13 Hyphema (blood in anterior chamber of eye anterior to pupil) should be suspected if vision is reduced and the pupil cannot be clearly visualized. However, a bright red clot is not always apparent at time of injury or if the amount of blood is small. An irregular pupil, or a pupil that does not constrict well to light, is also a red flag for serious contusion injury to the eye, and requires ophthalmologic evaluation. It is important to keep in mind that blunt trauma severe enough to produce hyphema or an irregular and poorly reactive pupil is often associated with retinal damage as well, including retinal edema or detachment.
Minor injuries (eg, small foreign bodies, minor periocular contusions and lacerations) can often be managed rink-side. Foreign bodies not embedded in the cornea, but lodged under the upper eyelid, can sometimes be removed by everting the eyelid and sweeping with a moistened cotton swab or using diffuse, sterile saline irrigation.11 Corneal abrasions generally cause severe pain, photophobia, and tearing and are easily diagnosed with use of topical fluorescein and a blue light. A topical anesthetic can be extremely helpful in this setting, as it allows for proper pain-free evaluation, but should never be used in an ongoing manner for pain relief. Small lacerations of the brow can be sutured with 5-0 or 6-0 nylon or closed with 2-Octyl cyanoacrylate tissue adhesive (Dermabond). Eyelid lacerations, unless very small, are best managed by an ophthalmologist; care must be taken to rule out injury to the deeper orbital tissues and eye. If serious injury is suspected, or the eye cannot be appropriately evaluated, it should be stabilized and protected with a protective shield or plastic cup, and the player should be transferred to an ED for appropriate ophthalmologic evaluation.13Most eye injuries are accidental, caused by sticks or deflected pucks, but 18% are acquired in fights.8 Use of visors or full-face cages effectively minimizes the rate of eye injuries.8,13,15,16 In a cohort study of 282 elite amateur ice hockey players, the risk of eye injury was 4.7 times higher in players without face protection than in players who used half-face shields; there were no eye injuries in players who used full-face protection.13 For visors to prevent eye injury, they must be positioned to cover the eyes and the lower edge of the nose in all projections.10
Dental Injuries
The incidence and type of facial and dental injuries depend directly on the type of face protection used.11,17,18 In a study of face, head, and neck injuries in elite amateur ice hockey players, Stuart and colleagues13 found game-related injury rates of 158.9 per 1000 player-hours in players without face protection, 73.5 in players who used half-face shields, and 23.2 in players who used full-face shields. Players who wore full-face shields had facial, head, and neck injury rates of only 23.2 per 1000 player-game hours.13 Other studies clearly support the important role face shields play in lowering injury risk in hockey. Face and head injuries account for 20% to 40% of all hockey-related injuries,3,16,19 and dental injuries up to 11.5%.20 In a study from Finland, Lahti and colleagues19 found that over a 2-year period, 479 hockey players sustained injuries, including 650 separate dental injuries. The most commonly diagnosed dental injury was an uncomplicated crown fracture, and the most common cause was a hit with a hockey stick, which accounted for 52.7% and 40.3% of dental injuries in games and practices, respectively.19
In the management of dental fractures, the broken portions of teeth should be found and placed in a transportation-protective medium, such as saline, saliva, or milk,16 which can improve functional and esthetic replacement outcomes.21,22 Loose pieces of teeth should not be left in the player’s mouth. The residual tooth should be stabilized and exposure to air and occlusion limited. Dental fractures can affect the enamel, the enamel and dentin structures (uncomplicated fracture), or enamel, dentin, and pulp (complicated).23 Fractures involving only the enamel do not require urgent dental evaluation. Dentin or pulp involvement may cause temperature and air sensitivity.23 If a tooth is air-sensitive, the player should be referred to a specialist immediately.11
Direct trauma can cause instability without displacement (subluxation) or complete displacement of the tooth from its alveolar socket (avulsion).23 An avulsed tooth should be handled by the crown to avoid further damage to the root and periodontal ligament.16,24 The tooth should be rinsed gently with saline and reimplanted in its socket, ideally within 5 to 10 minutes,23with the athlete biting down gently on gauze to hold the tooth in place. A 1-mL supraperiosteal infiltration of 1% or 2% lidocaine hydrochloride (1:100,000 epinephrine) can be given into the apex of the tooth being anesthetized (Figure 1).
Concussions
A concussion is a “complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”25 Concussion is largely a functional disturbance instead of a structural injury, owing to the rotational and/or shearing forces involved. Many studies have identified concussion as the most common type of injury in all of youth hockey.26 Concussions account for up to 19% of all injuries in men’s collegiate hockey.3
Concussion can be challenging to diagnose on the ice. The most important factor in concussion management is symptom reporting by the athlete.27 Despite significant efforts in education and awareness, student athletes, especially hockey players, withhold reporting a possible concussion.28 Reasons for underreporting include fear of letting down other players and coaches, thinking the injury is not severe enough to warrant evaluation, and fear of losing standing with the current team or future teams.28
As postinjury concussion assessments are ideal when comparisons can be made with preseason (baseline) scores, preseason testing is becoming standard in professional, college, junior, and high school hockey. This testing involves the Sport Concussion Assessment Tool, 3rd edition (SCAT3), and the King-Devick (K-D) test.30,31 Some youth leagues have baseline testing as well, though the frequency of baseline testing in their players is controversial,32 as the adolescent mind’s processing speed and memory increase exponentially.33 For these younger athletes, it may be necessary to perform baseline testing more frequently than annually.32 A physician can use baseline test results to help diagnose a concussion at the rink and then track the athlete’s recovery and help with return-to-play decisions.29 Vision involves almost half of the brain’s circuits,34 including areas vulnerable to head impact. A neuro-ophthalmologic test can assess for irregularities in accommodation, convergence, ocular muscle balance, pursuit, and saccades.29 The K-D test is a visual performance examination that allows easy and objective assessment of eye movements. Use of both the K-D test and the SCAT3 at the rink may increase the number of concussions detected.29,35 We recommend that physicians use both tests to assess for concussion at the hockey rink.
Initial treatment involves a period of physical rest and relative cognitive rest. Acute worsening of symptoms warrants urgent imaging to rule out a subdural or subarachnoid bleed. Once a player is symptom-free, a graded return-to-play protocol should be followed (Table 4).
On the prevention side, great efforts have been made to improve hockey helmets. (Some manufacturers claim to have made concussion-proof helmets, but there is no evidence supporting this claim.6) Numerous investigators have reported a lower overall injury rate in players who wear a helmet and a full-face shield.6,13 In addition, rule changes aimed at decreasing head contact have been implemented to decrease the incidence of sport-related concussions.36 Moreover, education on proper helmet use and wear should be emphasized. A study of the effects of hockey helmet fit on cervical motion found that 7 (39%) of 18 players wore a game or competition helmet so loosely that it could be removed without unbuttoning its chinstrap.37 Improperly worn helmets cannot prevent injury as well as properly worn helmets can.
Cervical Spine Injuries
Whereas American football is associated with a higher annual number of nonfatal catastrophic neck injuries, hockey has a 3 to 6 times higher incidence of cervical spine injuries and spinal cord damage.38,39 A Canadian Ice Hockey Spinal Injuries Registry review of the period 2006 to 2011 identified 44 cervical spine injuries, 7.3 per year on average.40 Severe injury, defined as complete motor and sensory loss, complete motor loss and incomplete sensory, or complete motor loss, occurred in 4 (9.1%) of the 44 injured players. In hockey, a major mechanism of cervical spine injury is an axial load to the slightly flexed spine.39 Of 355 hockey-related cervical spine injuries in a Canada study, 95 (35.5%) were caused by a check from behind.40,41 The Canadian neurosurgeons’ work led to rule changes prohibiting checks from behind, and this prohibition has reduced the incidence of cervical spine injuries in ice hockey.38,40
Team physicians should be comfortable managing serious neck and spine injuries on the ice. Initial evaluation should follow the standard ABCs (airway, breathing, circulation). The physician places a hand on each side of the head to stabilize the neck until the initial examination is complete. The goal is to minimize cervical spine motion until transportation to the hospital for advanced imaging and definitive treatment.37 The decision to remove or leave on the helmet is now controversial. Hockey helmets differ from football helmets in that their chinstraps do not afford significant cervical stabilization, and the helmets have less padding and cover less of the head; in addition, a shockingly high percentage of hockey players do not wear properly fitting helmets.37 In one study, 3-dimensional motion analysis of a hockey player during the logroll technique showed less transverse and sagittal cervical plane motion with the helmet removed than with the helmet (properly fitting or not) in place; the authors recommended removing the helmet to limit extraneous cervical spine motion during the technique.37 However, 2 other studies found that helmet removal can result in significantly increased cervical spine motion of the immobilized hockey player.42,43Recommendation 4 of the recently released interassociation consensus statement of the National Athletic Trainers’ Association reads, “Protective athletic equipment should be removed before transport to an emergency facility for an athlete-patient with suspected cervical spine instability.”44 This represents a shift from leaving the helmet and shoulder pads in place. For ice hockey players with suspected cervical spine injury, more research is needed on cervical motion during the entire sequence—partial logrolls, spine-boarding, placement of cervical collar before or after logroll, and different immobilization techniques for transport.37
The athlete must be carefully transferred to a spine board with either logroll or lift-and-slide. Although an extrication cervical collar can be placed before the spine board is placed, the effectiveness of this collar in executing the spine-board transfer is not proven.45 When the player is on the spine board, the head can be secured with pads and straps en route to the hospital.
Return-to-Play Criteria for Cervical Spine Injuries There is no clear consensus on return-to-play guidelines for cervical spine injuries in athletes.46
Shoulder Injuries
For hockey players, the upper extremity traditionally has been considered a well-protected area.48 However, shoulder pads are considerably more flexible in hockey than in football and other collision sports. In addition, hockey gloves allow a fair amount of motion for stick handling, and the wrist may be in maximal flexion or extension when a hit against the boards or the ice occurs. Open-ice checking, board collisions, and hockey stick use have been postulated as reasons for the high incidence of upper extremity injuries in hockey. Researchers in Finland found that upper extremity injuries accounted for up to 31% of all hockey injuries.49 More than 50% of these injuries resulted from checking or board collisions. Furthermore, study findings highlighted a low rate of injury in younger players and indicated the rate increases with age.49,50
In hockey players, the acromioclavicular (AC) joint is the most commonly injured shoulder structure.51 The mechanism of injury can be a board collision or an open-ice hit, but most often is a direct blow to the shoulder. The collision disrupts the AC joint and can sprain or tear the coracoclavicular ligaments. The Rockwood classification is used to categorize AC joint injuries (Figure 2).
Initial management involves icing the AC joint and placing a sling for comfort. Type I and type II injuries can be managed with progressive range-of-motion (ROM) exercises, strengthening, cryotherapy, and a period of rest. Treatment of type III injuries remains controversial,52 but in hockey players these injuries are almost always treated nonoperatively. Return to play requires full motion, normal strength, and minimal discomfort. Players return a few days to 2 weeks after a grade I injury; recovery from grade II injuries may take 2 to 3 weeks, and recovery from grade III injuries, 6 to 12 weeks. Surgical treatment is usually required in type IV and type V injuries, but we have had experience treating these injuries nonoperatively in high-level players. AC joint reinjury in hockey players is common, and surgical treatment should be approached cautiously, as delayed fracture after return to sport has been reported.53 Special precautions should be taken in collision athletes who undergo AC joint reconstruction. In the anatomical reconstruction described by Carofino and Mazzocca,54 2 holes are drilled in the clavicle; these holes are a potential source of fracture when the collision athlete returns to sport (Figure 3).
Clavicle fracture is another common hockey injury.55 Studies have shown clavicle fractures proportionally occur most often in people 15 to 19 years old.49 The injury presents with pain and deformity over the clavicle; in more severe fractures, skin tenting is identified. Initial management of suspected clavicle fracture includes cryotherapy, sling, and radiographs. Radiographs should include an AP view and then a 45° cephalad view, which eliminates overshadowing from the ribs. Most clavicle fractures are successfully managed nonoperatively, though there is evidence that significantly displaced or comminuted fractures have better union rates and shoulder function when treated with open reduction and internal fixation.56 After a clavicle fracture, return to skating and noncontact practice usually takes 8 weeks, with return to full contact occurring around 12 weeks.
Sternoclavicular injuries are relatively uncommon, but potentially serious. Special attention should also be given to adolescent athletes with sternoclavicular pain. Although sternoclavicular dislocations have been reported in hockey players, instead these likely are fractures involving the medial clavicle physis.57
The shoulder is the most commonly dislocated major joint, and the incidence of shoulder dislocation in elite hockey players is 8% to 21%.50,58 Anterior shoulder instability occurs from a fall with the shoulder in an abducted, externally rotated and extended position or from a direct anteriorly placed impact to the posterior shoulder. We recommend taking players off the ice for evaluation. Depending on physician comfort, the shoulder can be reduced in the training room, and the athlete sent for radiographs after reduction. If resources or support for closed reduction is not available at the rink, the athlete should be sent to the ED. Initial radiographic evaluation of a player with shoulder injury begins with plain radiographs, including a true AP (Grashey) view with the humerus in neutral, internal, and external rotation and an axillary view. The axillary radiograph is crucial in determining anterior or posterior dislocation. If the patient cannot tolerate the pain associated with having an axillary radiograph taken, a Velpeau radiograph can be used. This radiograph is taken with the patient’s arm in a sling and with the patient leaning back 30° while the x-ray beam is directed superior to inferior.
CT is performed for a suspected osseous injury. CT is more accurate than plain radiographs in showing glenoid and humeral fractures in the acute setting as well as the amount of bone loss in the case of chronic instability. Magnetic resonance arthrography is the imaging modality of choice for the diagnoses of capsulolabral injury.
After shoulder reduction, treatment with a sling, cryotherapy, and a nonsteroidal anti-inflammatory drug is initiated. In a Minnesota study of nonoperative management of shoulder instability, 9 of 10 hockey players were able to return to play the same season, and 6 of the 10 required surgery at the end of the season.59
Compared with noncontact athletes, hockey players and other collision athletes are at increased risk for recurrence.60-62 For collision athletes who want to continue playing their sport after recurrent instability, surgery is recommended. A shoulder instability study in Toronto found that more than 54% of 24 professional hockey players had associated Hill-Sachs lesions, but only 3 shoulders (12.5%) had glenoid defects.50 Arthroscopic and open techniques both demonstrate good results, and identification of bone loss can help determine which surgery to recommend.63 Hockey players can usually return to sport 6 months after shoulder stabilization.
Another important consideration in managing shoulder instability in hockey players is shoulder dominance, which determines stick grip. A left-handed player places the right hand on top of the stick for support, but most of the motion associated with shooting the puck—including abduction and external rotation—occurs with the left shoulder. Thus, a left-handed player with a history of previous left-side shoulder dislocation may dislocate with each shot, but a right-handed player with left shoulder instability may have considerably less trouble on the ice.58Shoulder and rotator cuff contusions (RCCs) occur in hockey and other collision sports.49,64 RCCs almost always result from a direct blow to the shoulder, and present with shoulder function loss, weakness, and pain.
Summary
Hockey is a high-speed collision sport with one of the highest injury rates among all sports. Physicians caring for youth, amateur, and senior hockey teams see a range of acute head, neck, and shoulder injuries. Although treatment of eye injuries, dental injuries, and concussions is not always considered orthopedic care, an orthopedic surgeon who is covering hockey needs to be comfortable managing these injuries acutely. Quality rink-side care minimizes the impact of the injury, maximizes the functional result, and expedites the safe return of the injured player back to the ice.
Am J Orthop. 2017;46(3):123-134. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
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