Hockey Doc

The Hockey Doc the current management of concussions

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Last Updated on Sunday, 27 May 2012 23:31

By Dr. Rob LaPrade

http://drrobertlaprademd.com

Question: I took an elbow to my head in a game. I still have a slight headache when I skate hard, but otherwise I feel OK. When is it safe to return back to practice?

Answer: It appears you sustained a concussion from your collision. Concussions are now the most common injury in hockey and are commonly due to hits to the head.

Unfortunately, even the best “concussion helmets” do little to prevent a concussion with a head hit due to the sheer forces delivered to the brain. Proper instructions in checking techniques and strict rule enforcement by referees may be the only way to decrease the incidence of concussions.

Concussions are basically bruises to the brain and brain bruises need to be treated carefully! The bruise causes the normal electrical signals in the brain to go haywire. Confusion and amnesia following a concussion are common and the amnesia may be instantaneous or may develop over several minutes.

Unfortunately, the results of concussions are cumulative over time. You have an increased risk of suffering subsequent concussions compared to a person who has not had a previous concussion. This risk may be up to four times higher compared to an athlete who has never had a concussion.

Coaches, trainers and players should be aware that concussions and spinal cord injuries can have similar causes, and for athletes who are conscious and alert, one of the first and most important things to ask them about is where they hurt. Athletes with any head, neck or back pain should be evaluated very carefully and not moved without assistance.

One of the most important things to do in a hockey player who has sustained a potential head or neck injury is to not remove their helmet. This is because the helmet provides important support to their spine and if they do have a neck fracture; it can cause motion of the fracture which could lead to permanent nerve damage or paralysis.

In all cases where athletes have head or neck pain, however trivial it may seem, it is reasonable to wait for emergency medical services to assist them off of the ice to make sure that there is no significant neck or skull injury present.

The signs of concussion are usually headaches, nausea, dizziness, disorientation, ringing in the ears, impaired concentration or a faulty recall of information. Your lingering headache is classic for the signs of a concussion.

At the college and professional levels, we use the ImPACT neuropsychological testing program for concussion evaluation. Some states have required that all high school athletes participate in this program. Athletes are tested before the season and after concussions to determine their ability to function normally. We couple this information with their symptoms and restrict the athlete from activity as long as they have evidence of post-concussion symptoms.

The treatment of concussions has changed dramatically over the past couple of years. We now recommend that every athlete who has a blow to the head that has a headache, confusion, sees stars or has other head-related issues not return to competition that night. It is now recognized that the long-term sequelae of concussions are much more serious than we ever thought even a few years ago.

Athletes with any lingering symptoms over the next 24 hours should consider seeing a physician before returning to any on-ice activities. In fact, some states now require high school athletes to be cleared by a health care professional before they are allowed to return back to sports.

New high field MRI scans have demonstrated that brain function can be affected for six weeks or longer, even after a mild concussion. Thus, similar to letting a shoulder injury or knee injury heal properly prior to returning to activity, it is important to also protect the brain while it is healing.

It is essential that athletes not return to any exertional activities in which any headaches or any other concussion symptoms (like impaired concentration or a lack of memory) recur. Athletes should first work on a stationary bike and progress to increasing levels of exertional activities, based upon their symptoms.

They may return to participation if they do not have any symptoms with biking or low impact activities. We generally keep our athletes out of contact episodes for at least one week and then determine if they can return back to play based upon whether they have a headache with on-ice activities.

These guidelines are for returning to competition after the first concussion. Any athlete who has a second concussion needs to be taken out of their practice or game and be medically cleared before they return to play.

Hockey is a high-risk sport which leaves athletes at risk for concussions from any head contact event. These guidelines should serve as general guidelines for any athlete returning to competition following a head injury. We recommend that, if there is any doubt, we should always act on the conservative side due to the potential long-term implications of any brain injury. At a minimum, athletes should refrain from practicing or from competition until all their symptoms from their “brain bruise” have resolved.

Robert F. LaPrade, M.D., Ph.D. is a complex knee surgeon at The Steadman Clinic in Vail, Colorado. He is very active in research for the prevention and treatment of ice hockey injuries. Dr. LaPrade is also the Chief Medical Research Officer at the Steadman Philippon Research Institute. Formerly, he was the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the U of M. If you have a question for the Hockey Doc, e-mail it to This email address is being protected from spambots. You need JavaScript enabled to view it. .

The Hockey Doc: Groin Pain and Femoroacetabular Impingement

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Last Updated on Sunday, 27 May 2012 23:31

By Dr. Rob LaPrade

http://drrobertlaprademd.com

Question: I play goalie and have had hip and groin pain for the past couple weeks at summer camp. What could be the cause?

Answer: Hip pain can have several different causes,

Read more: The Hockey Doc: Groin Pain and Femoroacetabular Impingement

The Hockey Doc lateral (fibular) collateral knee injuries

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Last Updated on Sunday, 27 May 2012 23:31

By Dr. Rob LaPrade

http://drrobertlaprademd.com

Question: I got checked on the inside of my left leg and felt a pop on the outside of my knee. I was told that I have a partial tear of my lateral collateral ligament. How long will this take to heal, and what do I need to do to get back sooner?

Answer: The type of injury that you have is an injury to the lateral collateral ligament on the outside of your knee, also known as the fibular collateral ligament (FCL). These types of injuries are much less common than medial collateral ligament (MCL) injuries, because most on-ice contact injuries happen when you are hit on the outside of your knee rather than the inside. What happens is that the ligaments are damaged on the side opposite of where you were hit because they were stretched or torn on that side.

The fibular collateral ligament is a very important structure to prevent one’s knee from feeling unstable in side-to-side activities. This is especially true in hockey players who put more weight on the inside part of their knee, which causes the outside to have more stress on it. If the fibular collateral ligament is torn, the knee can gap open and make it very difficult for any type of push off or striding activities toward the injured side. This is especially true in hockey players because most of them are bowlegged.

Probably the most important thing about the fibular collateral ligament is that when it is completely torn, it usually does not heal. This is in contrast to the medial collateral ligament, on the inside of the knee, which almost always heals. If the FCL is only partially torn, it may heal with proper treatment in about 6-8 weeks. Therefore, it is very important to determine if there is a complete tear, or not, using a good clinical exam, MRI scans, and stress x-rays. If there is a complete tear, a surgical reconstruction is recommended and the post-surgery off-ice recovery time is about 4-5 months.

In your case, where there appears to be only a partial tear, it is important to give the ligament some time to heal prior to putting significant stress on it, or it could heal in an elongated position and you could have some residual instability problems. We usually recommend that athletes be braced for 2-3 weeks with no significant twisting, turning, or pivoting activities to make sure that this ligament heals. To maintain your endurance prior to going back to any on-ice activities, you may bike with increasing resistance for the first 2-3 weeks.

For high level athletes with a partial tear, we usually recommend the use of a custom made medial compartment unloader brace. Although, it is called a “medial” brace, it is also effective for FCL injuries because it pushes the knee towards the outside. Using this type of brace for the first 6-8 weeks after partial tears protects the FCL injury from going on to a complete tear. While it is possible that a well-fitted hinged knee brace may be effective, we believe that the use of the medial unloader brace significantly minimizes the risk of re-injury.

About 1-2 weeks after the injury, we usually recommend that you can return to on-ice activities with the use of the medial unloader brace. For those athletes that chose to return to on ice activities prior to this time, the medial unloader brace is essential to minimize your chance of re-injury. We recommend that athletes use this brace for a minimum of 3 months, or until the end of the current season, to minimize their chance of a reinjury or complete tear.

Robert F. LaPrade, M.D., Ph.D. is a complex knee surgeon at The Steadman Clinic in Vail, Colorado. He is very active in research for the prevention and treatment of ice hockey injuries. Dr. LaPrade is also the Chief Medical Research Officer at the Steadman Philippon Research Institute. Formerly, he was the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the U of M. If you have a question for the Hockey Doc, e-mail it to This email address is being protected from spambots. You need JavaScript enabled to view it. .

The Hockey Doc on hip pointers

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Last Updated on Sunday, 27 May 2012 23:31

By Dr. Rob LaPrade

http://drrobertlaprademd.com

Question: I was checked hard into the boards and hit the outside of my hip. It’s very painful and I have difficulty in extending my stride. How can I get back to skating normally?

Answer: What you described is consistent with a “hip pointer.” Hip pointers are very painful injuries and can make it very difficult to skate and even walk. Hip pointers are caused by damage to the muscles which allow you to lift your leg away from your body (hip abductors). Injuries to these muscles can make it very difficult to cross over your leg when skating, to perform on-ice transitions, and for your trailing leg to have a long stride.

When the hip muscles are crushed between the boards and your strong pelvic bones, there can be a lot of bleeding into the muscles which can cause significant pain. The treatment for a hip pointer depends upon the amount of symptoms. The main focus of treatment initially is to try to minimize swelling. By controlling the amount of swelling and bleeding which occurs in the tissues, one can return to competition sooner. The best way to try to control the swelling is to put ice directly on the outside of the hip over the area that was injured as soon as possible. This can be done up to a maximum of 20 minutes every hour and is best applied over a towel or your undergarments. The ice is important because it will make the blood vessels decrease in size (constrict) and there will be less bleeding into the ruptured muscles.

In more severe hip pointers, we place our athletes on crutches until they can walk without a limp. While almost all of our players will argue with us that they can tough it out and limp around with this type of injury, athletes get better quicker if they only stop using crutches when they can walk without a limp.

Pain medicines can also be helpful after the injury. Our main medications for this are acetaminophen or acetaminophen with codeine. Generally, we try to avoid aspirin or any of the anti-inflammatory medications because they can thin the blood and are counterproductive because they actually increase the amount of bleeding and swelling in the first few days after this injury.

A good compression wrap applied around the hip and upper thigh can also be very useful to help minimize the amount of swelling that may occur. This can also be done with a foam pad directly over the area of the injury to help apply some pressure to minimize further bleeding of the injured muscles.

Once the bleeding and swelling have been controlled, a rehabilitation program can be initiated. Your athletic trainer or physical therapist may choose to use ultrasound and warm packs to encourage new blood vessel formation into the damaged tissue and also to decrease the swelling. In addition, they will work with you to work on hip abduction exercises to regain the strength in your pelvic muscles.

Because the muscles that control hip abduction are essential to the skating motion for an ice hockey player, it’s important that you should gain your full strength prior to attempting to get back to competition. Otherwise, you will not have the speed and agility to properly transition for on-ice competition.

While a hip pointer can be a very painful injury, if they are properly treated and rehabilitated, they generally cause no long-term problems. Most of these injuries only need to be iced and rested until the symptoms resolve. In addition, athletes who do sustain a hip pointer should check their breezers to make sure that they have appropriate padding over this area to prevent a reinjury to this area of the pelvis.

Robert F. LaPrade, M.D., Ph.D. is a complex knee surgeon at The Steadman Clinic in Vail, Colorado. He is very active in research for the prevention and treatment of ice hockey injuries. Dr. LaPrade is also the Chief Medical Research Officer at the Steadman Philippon Research Institute. Formerly, he was the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the U of M. If you have a question for the Hockey Doc, e-mail it to This email address is being protected from spambots. You need JavaScript enabled to view it. .