Hockey Doc
Protocol for removing injured players from the ice
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- Last Updated on Sunday, 27 May 2012 23:31
By Dr. Rob LaPrade
Question: What is the best protocol to evaluate and remove injured athletes from the ice?
Answer: This is a very important question because the correct treatment of a potentially injured athlete can be very important to their ultimate outcome. Proper training and attention to detail recently saved the life of a college hockey player with a C2 fracture, which is usually 95% fatal, in Grand Forks. In the evaluation of an injured athlete, especially one that may have been checked from behind or checked or tripped into the boards, it is first important to do a basic safety evaluation starting with an ABC evaluation.
A.B.C. stands for Airway, Breathing, and Circulation. If an athlete is unconscious, it is important to verify they are breathing and also to check their pulse. For any athlete who does not appear to have the normal ABC’s, the basics of CPR should be initiated and this is beyond the ability to describe here.
For those 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.
For those athletes who have no head or neck pain and who may have a feeling like they have lost their breath or who have extremity pain, it is reasonable at this point to assist them with rolling onto their back so that they can be better evaluated. One of the most important things to do in injured hockey players, when they are unconscious or alert with neck or head pain, is not to 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.
We have done studies which demonstrate that the most significant risk of increased motion in the cervical spine occurs at the mid-level of the neck when the helmet is removed. This is the exact level at which the majority of ice hockey spinal fractures occur. Thus, it is important to leave the helmet on to make sure that if the athlete does have a neck fracture, that the fracture does not move and cause paralysis.
In athletes who have neck pain and are on their face in the prone position, they should not be moved until people trained and comfortable with proper log rolling technique can help move them onto their back. At all times, the neck should be stabilized and the helmet should be left in place.
This same protocol should be followed in athletes who have low back pain because they may have a thoracic or lumbar spine injury also. For those athletes who note that they may have had a blow to their chest or simply lost their breath, it is reasonable to allow them to catch their breath prior to attempting to move them.
It is reasonable to assume that anyone who has hit their head has a concussion until proven otherwise. Athletes who have a headache, neck pain, who are disoriented and appear confused should not be allowed to be back into competition. It is important to ask them if they know which rink they are in, what period it is, what the score is and other questions which help to determine how alert they may be.
To summarize this important topic, in any athlete who may have had a head or neck injury, it is important to leave their helmet on. For athletes who may have isolated extremity pain, splinting of the extremity and/or assisting them off the ice could be considered. In all cases, in those athletes who may 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 are no significant neck or skull injuries present.
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 groin strains and sports hernias
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- Last Updated on Sunday, 27 May 2012 23:31
By Dr. Rob LaPrade
Question: I have had a nagging groin strain. What can I do to try to prevent this from being a problem this year?
Answer: What you are describing is common history for someone who may have a “sports hernia.” Most true adductor strains, commonly called groin strains, resolve within a couple weeks after injury. True adductor strains most commonly occur at the junction between the muscle and the tendon and resolve with rest, icing, stretching, and hip adductor exercises.
Almost by definition, groin strains which linger more then a few weeks are commonly sports hernias or femoroacetabular impingement. This article will focus on sports hernias.
While sports hernias have probably been around for a long time, it is only more recently that we have begun to recognize them. Sports hernias are not like inguinal hernias, where some of the intestines may slip into the inguinal ring, but rather injuries to the small and thin abdominal wall muscles which attach around the inguinal ring. Because they have only become recognized in the sports community in over the last 5-10 years, it is not uncommon for an athlete to see several physicians before their true pathology is identified.
The most common complaint of athletes with sports hernias is that they cannot transition for on-ice activities and have difficulty twisting or turning on the affected side. On exam, almost everyone will have pain to palpation of the inguinal ring region, but they also have pain with performing an abdominal crunch or with performing a resisted one legged straight leg raise. In fact, it is felt that the most common physical exam finding in patients with a sports hernia is that they have difficulty performing abdominal crunches without pain.
Unfortunately, since sports hernias involve a tear of the abdominal wall muscles, the only effective treatment is either to stop participating in those activities which cause the irritation or to look at surgery. Surgery is almost always performed by a general surgeon who specializes in this area. The surgery involves reattaching the abdominal muscles and placing in a plastic reinforcing mesh to reinforce the muscles to minimize the chance of tearing again. Depending upon the surgeon, their experience and their protocol, most athletes can return to on-ice activities within 2-4 weeks after surgery.
When one does have lingering groin pain, it is important to see a physician to make sure that the proper diagnosis is obtained. There can be many different causes of groin pain in athletes to include femoroacetabular impingement (FAI – especially in goalies), stress fractures, infections, nerve entrapments and other causes. Any lingering “groin strains” should be carefully evaluated if they do not resolve within a couple of weeks.
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. .
Peak performance in hockey – stay hydrated!
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- Last Updated on Sunday, 27 May 2012 23:31
By Dr. Rob LaPrade, MD, PhD
Let’s Play Hockey Columnist
Question: What can I do to stay at a top level of performance in playoff games?
Answer: Proper hydration is absolutely essential for maximal on-ice performance. Dehydration can reduce one’s endurance and on-ice performance. This is perhaps the one thing players and coaches can influence the most in trying to keep their teams at their highest competition levels.
It is very important for one to recognize that thirst is a poor indicator of the body’s hydration status. We do not experience thirst until we have lost two percent of our body water content. Since high level active skaters have been found to lose up to two liters or more of water per hour from sweating, it is essential to replenish this loss by drinking.
Mild dehydration of 2-3 percent, which is common after a hard workout on the ice in full gear, can decrease work capacity by 15-20 percent. In this regard, one of the best ways that coaches and athletic trainers can help their teams to perform at maximal capacity is to make sure that they do have sufficient water on the bench to treat their athletes and also to make sure that they have frequent water breaks.
For every liter of fluid lost by the body by sweat or through other means, ones body core temperature can increase by 0.5° F, blood output by the heart can decline by a liter a minute and the baseline heart rate will increase 8-10 beats per minute. Since active skaters can lose between 1-2 liters of water per hour through sweating, it is essential to replenish this loss by drinking.
Cool and cold fluids are absorbed better than warm fluids. It is important to drink before, during and after exercising to maintain fluid balance. Our recommendations are to consume between 500-600 mL of cold water or a carbohydrate-electrolyte beverage 15-20 minutes before exercising. During exercising, 250 mL for every 15-20 minutes of hard on-ice activities should be a minimal replacement gage.
Fluid replacement is essential to maximize on-ice competition. Players should attempt to drink water after every shift if possible. Hockey players are at risk for mild dehydration, with a subsequent loss of on-ice skating capability, due to the gear that they wear and the hard workouts, even in refrigerated indoor ice rinks. It is important that players consume an appropriate amount of fluid replacement for practices and games to maximize their on-ice competitive levels.
Dr. Rob LaPrade, MD, PhD, is the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the University of Minnesota. If you have a question for the Hockey Doc, send it to 2721 East 42nd Street, Minneapolis, MN 55406, fax it to 612-729-0259 or e-mail it to This email address is being protected from spambots. You need JavaScript enabled to view it. .
The Hockey Doc on hip and groin pain
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- Last Updated on Sunday, 27 May 2012 23:31
By Dr. Rob LaPrade, M.D., Ph.D.
Let’s Play Hockey Columnist
Question: I play goalie and have had hip and groin pain for the past couple weeks. What could be the cause?
Answer: Hip pain can have several different causes, but one common cause of groin and hip pain in hockey players is femoroacetabular impingement (FAI). It is often found in athletes that engage in repetitive hip movements that may involve excessive range of motion. In hockey players, the injury can occur in goalies when they do the butterfly maneuver and turn their foot in. It can be caused by a sudden movement, but can also develop gradually.
It is now recognized that the diagnosis of hip adductor strains and sports hernias in the past may have been misdiagnosed cases of FAI. In any event, it is now recognized that FAI is an epidemic in hockey players and my hip surgery partner, Marc Phlippon MD, and I are conducting studies to try and determine its cause in hockey players.
FAI occurs as a result of abnormal bone structures where the ball of the femur inserts into the hip socket. The cause of FAI is unknown, but these abnormal bony formations may be the result of an injury, genetics, or excessive exercise during early bone formation. There are three types of FAI – cam, pincer, and mixed. Cam FAI is an abnormality of the ball, which is the upper part of the femur bone. Pincer FAI is an abnormality of the cup like part of the hip socket. Mixed Impingement is a combination of abnormalities in both the ball and the hip socket. FAI may result in damage to the cartilage, labral tears, and/or early hip osteoarthritis.
Pain in the groin is the most common symptom, but pain may also show up in the buttocks, hip, outer part of the upper leg, and sacroiliac joint. Another indication is pain with prolonged sitting, walking, or athletic activities. Stiffness, weakness, clicking, and snapping are signs that are reported by some FAI patients.
If you are having hip and groin pain, it is best to get it checked out since untreated FAI may lead to additional problems and osteoarthritis down the road. Your orthopaedic doctor will most likely order x-rays and an MRI. A physical exam that tests your pain with various hip, leg, and foot motions will help to determine whether you have FAI. If you are diagnosed with FAI, then surgery may be necessary to correct the bone abnormalities and restore normal motion between the ball of the femur and the hip socket. Hockey players often return to their sport between three and four months after surgery.
Dr. Rob LaPrade, MD, PhD, is a complex knee surgeon at The Steadman Clinic in Vail, Colo. 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 high ankle sprains
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- Last Updated on Sunday, 27 May 2012 23:31
By Dr. Rob LaPrade
Let’s Play Hockey Columnist
Question: I recently caught an edge on my skate while playing pond hockey and twisted my ankle. I can’t skate well on it and my trainer tells me that I have a high ankle sprain. What can I do to get back to playing sooner?
Answer: High ankle sprains can be very difficult to quickly return to on-ice activity for hockey players. While the much more common low ankle sprains can usually be taped and fit into a tight skate, with a rather quick return to skating once the pain and swelling have resolved, it takes a much longer time to recover from high ankle sprains.
For high ankle sprains, the connecting membrane between the two leg bones (tibia and fibula) is either partially stretched or torn. High ankle sprains can be a real problem for skaters because there is a very poor blood supply to this area of the ankle, and it takes a long time for these injuries to heal. Any type of twisting or turning maneuver results in recurrent tearing of this area, which can delay healing of this tissue, and make it especially difficult to skate.
With time, athletes who have high ankle sprains can walk fairly normally, can even jog on level ground normally, but cannot push off or twist on their skate edges and can be limited in terms of their ability to return to transitioning for on-ice activities. High ankle injuries can take up to six weeks or longer to heal.
The initial treatment for high ankle sprains is to follow the standard RICE protocol. This consists of a program of Rest, Icing, Compression and Elevation to allow the athlete to get back to activities sooner.
In our experience, we have found that for even the most severe ankle sprains, if treated immediately, can decrease the downtime for athletes. However, if the ankle is allowed to swell up after the injury and the athlete loses ankle motion, their ability to return in a timely fashion will be compromised.
Once the ankle has quieted down and swelling is minimized, the athlete starts on a program of ankle strengthening. We usually use rubber tubing, or have them push against a desk or table leg, to strengthen the outside ankle muscles (peroneals) as well as the other ankle muscles, to protect the ankle from being reinjured by twisting again.
In addition, the ankle structures which are injured need to “re-recognize” where the joint is located after injury so the muscles can fire to prevent reinjury. These exercises, such as balancing (proprioception), are important to help the athlete return to function quickly.
Once an athlete has minimal swelling and has appropriate strength, a functional on-ice evaluation needs to be performed to see when they can return to play. It is especially important for the treatment of high ankle sprains because an athlete should not try to play through the pain. If they find that they cannot push off on their edges and have difficulty with transitioning from forward to backward skating, the injury needs to continue to be rested. If not, trying to skate through the pain will ultimately prolong the total time of rehabilitation.
In conclusion, the treatment of high ankle sprains is much more difficult than that of low ankle sprains. The treatment of high ankle sprains often needs to be individualized to the specific injured athlete, and athletes need to have resolution of their symptoms prior to returning back to skating to minimize their downtime.
Dr. Rob LaPrade, MD, PhD, is the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the University of Minnesota. If you have a question for the Hockey Doc, send it to 2721 East 42nd Street, Minneapolis, MN 55406, fax it to 612-729-0259 or e-mail it to This email address is being protected from spambots. You need JavaScript enabled to view it. .
