Hockey Doc
The Hockey Doc on early-season groin injuries
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- Last Updated on Sunday, 27 May 2012 23:31
Over the years, one of the most commonly asked questions that I get asked is “What are some of the most common early-season hockey injuries and what can I do to prevent them?”
I can say without a doubt that the most common early-season injury that we see at the University of Minnesota is a hip adductor, or groin strain. In addition, in reviewing the NCAA and NHL ice hockey injury data, it is also the most common early-season loss of player practice and on-ice time.
Groin strains are caused by an irritation of one of the hip adductor muscles at the insertion of the pubic part of the pelvic bone. In addition, the point at which the muscle joins the tendon (the musculotendonous junction) can also become strained, irritated and swollen.
Groin strains are almost always due to a sudden change in training habits. In the majority of cases that we have seen, this occurs at the start of the season, with the initiation of a hard, on-ice training regimen.
The pain from a groin strain is almost always localized to the pubic part of the pelvic bone or at the muscle-tendon interface of the adductor muscles in the groin region. This pain is almost always increased with any maneuver in which the thigh crosses the midline of the body, especially with power skating and crossovers.
The treatment of groin strains is usually based upon the symptoms that are present with activities. Luckily, in the majority of cases, groin strains are a self-limited condition that will resolve with time. However, we recognize that a few days off during the early part of the season, especially during try-outs, can seem like an eternity to some players and coaches and can make the difference in making the team or not.
For minor injuries, a good stretching and warm-up program, followed by avoiding on-ice activities which cause symptoms, will usually result in the resolution of pain over the course of a few days. This would include avoiding any significant power skating or crossovers until the symptoms have completely resolved.
Over-the-counter anti-inflammatory medications, such as ibuprofen, can also serve a useful purpose to decrease some of the pain caused by the inflammation process. However, these anti-inflammatory medications will not cause this tissue to heal. They need to be used with a stretching, and appropriate warm-up program, to maximize the chance that you will get back on the ice sooner.
In the case where an athlete cannot skate because of pain, a program of rest, ice, and ultrasound is recommended until the athlete can resume skating. Cross training by cycling or pool therapy can help to keep up one’s cardiovascular status until the symptoms improve.
In those cases where symptoms do not resolve over a week or two, further investigation should be performed to determine if that pain is from another source. These other sources include stress fractures (especially in female skaters), sports hernias, or an irritation of the pubic symphysis (where the two pelvic bones meet).
Overall, the best way to treat groin strains is to work on prevention. We attempt to have our players work with our strength coach and athletic trainer on a program of stretching, prior to the initiation of any on-ice activities, so that they do not develop groin injuries.
It is also equally important to know that a stretching program should not be initiated prior to warming-up appropriately. Studies have shown that the incidence of muscle strains is actually higher in athletes who stretch before warming-up than those who stretch after warming-up. Therefore, a short ¼ mile jog or 4-5 laps around the ice may be necessary to get the blood circulation going to the muscles, so that you will be able to stretch appropriately.
If the symptoms from a groin stain do not improve using this program, then follow-up with a physician may be advised to see if there are other causes of the source of the pain. It is not uncommon for the symptoms of sports hernias, which are due to tears of the abdominal wall muscles, to present similar to groin strains. Therefore, any groin strain which lasts more than a couple of weeks should be considered to be a possible sports hernia until it is ruled out of the diagnosis.
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 ACL reconstructions
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- Last Updated on Sunday, 27 May 2012 23:31
QUESTION: I have had several people contact me about anterior cruciate ligament reconstructions and their implication on ice hockey. I will try to answer several of these questions in this column.
ANSWER: One of the most frequent questions that I have about ACL reconstructions is when they need to be performed. As we have mentioned previously, hockey is one of the few sports that we can play where one has a minimal chance of injuring a knee further with participation with an anterior cruciate ligament tear.
Thus, it is not unreasonable for someone with minimal instability and at the end of the year to try to rehabilitate their knee in an attempt to get back to skating for the rest of the season. However, for those athletes at the beginning of a season or who have significant instability on their exam, it is probably best to look at having the ACL reconstruction to protect ones knee prior to having any further damage to the knee.
In terms of the choice of grafts, for athletes younger then 25, it is almost universally recommended that they have their own tissues used rather than that of a cadaver (allograft). This is because studies have shown that the risk of re-tear is much higher at this age group when using an allograft.
While using an allograft does allow one to have less pain and theoretically get back to competition sooner, the results of revision ACL reconstructions are nowhere near as good as the first time around and for this age group we would recommend using their own tendons.
The issue of whether to use a patellar tendon autograft or hamstring autograft can be depended upon one’s natural laxity, whether one plays other contact sports and what the surgeon does best in his or her own hands. In general, using one’s patellar tendon autograft is still considered the gold standard for an ACL reconstruction.
In terms of rehabilitation issues after an anterior cruciate ligament reconstruction, for the first few weeks we stress patients to try to get their range of motion back and also work on reactivation of their quadriceps mechanism. We have found that those patients that get their knee out straight after surgery tend to have a much quicker return to function.
For the first couple of weeks after surgery, we stress patients staying on crutches until they can walk without a limp. We also request that they stay in their knee immobilizer until they can do a straight leg raise without an extension sag. Once they can do this, they can usually progress off of crutches.
It is important for the first six weeks after surgery not to do any extensive lifting, twisting, turning or pivoting as it takes a minimum of six weeks for the bone plug from the ACL graft to heal in the bone tunnel.
Between weeks 6 and 12, athletes are allowed to progressively increase their activities on the use of a stationary bike, an elliptical machine and leg presses as tolerated. Towards the end of this time frame, they may work on more involved exercises and work on the balancing program.
At three months postoperatively, most athletes are strong enough that they could start a jogging and running program. They may also work on more sports specific activities. It is usually about this time that we allow athletes to return back to skating but they should not have any contact. We also recommend that they avoid any significant twists, turns or pivoting and usually avoid crossovers for the first 1-2 weeks after they get back to skating.
When an athlete has full return of their strength and function, which is usually right around five months after surgery, we will test them to make sure that they have good agility, balance and overall strength. If they pass these tests, we then allow them to get back to full on-ice activities.
We have found out that athletes that return back to competition sooner then this have a higher risk of re-injury of their anterior cruciate ligament and we generally recommend against returning to competition sooner then 4 1/2 to 5 months postoperatively.
The issue of when to return to play after an ACL reconstruction is important. We have seen several athletes this year who have torn their ACL reconstruction grafts after a return to on-ice activities prior to the first five months after their reconstructions. Thus, it is important to make sure that one is properly rehabilitated and has the necessary strength and balance to be able to return back to on-ice activities without re-injuring their reconstruction grafts.
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 bursitis
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- Last Updated on Sunday, 27 May 2012 23:31
QUESTION:
I’m a high school defenseman and I hit my knee hard into the boards. Over the past two weeks, I have developed swelling like a baseball over the front of one of my knees. I’ve been told that it is a bursitis - what should I do about it?
ANSWER:
It does indeed sound like you have bursitis of one of the large bursas in the body – the prepatellar bursa. The bursa in your case is over your kneecap (the patella) and it normally allows the skin over the front part of your knee to glide over your kneecap with a minimal amount of friction.
In this case, it sounds like it has been contused, or banged up, and is now inflamed and is producing a larger amount of fluid than it normally would because of inflammation.
Prepatellar bursitis is fairly common in ice hockey players. It is usually caused by taking a slapshot to a relatively unprotected knee or falling on the front part of a bent (flexed) knee. The swelling around the knee in this case is not actually inside the knee and does not restrict motion of the knee joint.
The main treatment for a prepatellar bursitis is a well fitted compression wrap or sleeve over the kneecap to place constant pressure over the bursa. I have commonly supplemented this wrap with a piece of foam to further apply pressure over the bursa. The main goal of this wrap is to decrease the size of the bursal sack and prevent reaccumulation of fluid.
Other concurrent treatments for prepatella bursitis include ice and over- the-counter anti-inflammatory medications. In rare occasions, a knee immobilizer may be used for a limited time to prevent further swelling of the bursa.
Once an athlete has normal strength and knee motion, return to play is allowed. The athlete should keep a protective pad and compression bandage over the knee to prevent further blows and repeated swelling.
If there are any small lacerations or abrasions around the bursa or any redness of the skin or increased warmth of the bursa, it should be evaluated by a physician to make sure there is not an infection present. In general, we do not tend to drain a prepatellar bursa that is swollen as they commonly continue to drain out the needle site of the aspiration and can become secondarily infected.
To summarize, the usual effective treatment for prepatellar bursitis is a well fitted compression wrap, ice and anti-inflammatory medications if needed.
Once an athlete has full motion and strength of their knee, return to play is allowed with a compression wrap and protective pad over the knee. If this treatment does not prove effective, further medical evaluation should be sought.
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 concussions
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- Last Updated on Sunday, 27 May 2012 23:31
QUESTION: Since I wrote the article about concussion evaluation several months ago, I have had multiple questions about what type of helmet to wear, when to return after a concussion and what to do about a post-concussion headache. I will try to give some general guidelines to answer these questions.
ANSWER: First of all, it is important to remember that a concussion is basically a big bruise to one’s brain. Since our brain is all about electrical signals, anything that disrupts those signals, either short-term or long-term, can affect our ability to function. Thus, often some athletes will complain of “seeing stars” after they get bumped in the head because of the effect on the electrical impulses in the brain.
Since a concussion is a bruise to the brain, the best way to prevent one, short of avoiding checks or contact alltogether, is to wear a good quality helmet and a well fitting mouth guard. Without trying to advocate for a particular company or brand, we have found that the Nike Bauer-5000 and Nike Bauer-8800 helmets, with occipital straps, do seem to offer the best padding and protection against concussions. In addition, it is important to recognize that due to sweat and use, the padding in most helmets is most effective for absorbing shocks for 1-2 years.
In addition to a well-fitted and a relatively new helmet, a well-fitting mouth guard is also important to minimize in the effects of a concussion. This is because the mouthguard helps absorb some of the force transmitted to the brain by one’s jaw (mandible). While most athletes utilize mouthguards that are one-size-fit-all and sized after placing in boiling water for a couple of minutes, athletes who have had concussions should seriously consider having a mouthguard made by their dentist or orthodontist which provides better overall protection against concussions.
In terms of what to do with a post concussion headache, I would first assume that the athlete has been evaluated by a physician, preferably a neurologist, and had either a CT scan or an MRI scan which does not show any visible damage to their brain.
First of all, no matter how much an athlete wants to return back to skating, they should not be allowed to skate until their headache has completely resolved. This is important because if they receive another concussion during this timeframe, the next concussion can be even more severe.
It is also important to recognize that the timeframe for a post-concussion headache to totally resolve is unpredictable. Even for professional athletes who have the best of care, like Jordan Leopold had a couple of years ago, or Corey Koskie of the Milwaukee Brewers currently has, the timeframe for resolution of the headache symptoms can take several months or longer.
If an athlete has a headache, either at rest or in the classroom, or with exertion while skating, this indicates that there is still something wrong with the electrical signals of their brain and they should rest, without any significant physical exertion, until the headache resolves. If it doesn’t resolve after a couple of weeks, after one has been cleared by a physician, it would then be appropriate to be further evaluated by either a neurologist or a “concussion clinic” to further evaluate the ability for one to return back to skating.
In addition, for our athletes, we perform IMPACT testing both before the season and then after any concussion to evaluate their memory and motor skills and they aren’t allowed to return back to competition until they pass these portions of the IMPACT test.
Concussions are a very difficult problem to treat. There is no real medication or surgery to treat the average sports concussion, and after one receives a proper work-up to make sure that there is no other brain damage present, it is just a matter of time to let the brain recover. Perhaps the most important thing to recognize is that prevention of concussions, by wearing a proper helmet and mouthguard, is still the best way to treat this problem.
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 facial lacerations
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- Last Updated on Sunday, 27 May 2012 23:31
QUESTION: I sustained a deep cut on my chin when my helmet rode up on my face in a Bantam game. I used a butterfly band-aid to close it but was told later that I should have gone to the doctor to have it sutured. What is the proper treatment for this type of cut?
ANSWER: First, it sounds like you sustained a laceration which went down into the deeper layers of the skin. We tend to separate out injuries into how deep they go into the skin in terms of making further recommendations.
First, abrasions are basically scuffs off the surface layer of the skin which generally need some covering to prevent bleeding and exposure to other players during other events, but heal quite quickly.
Superficial lacerations just extend down into the surface layer of the skin, and even when one attempts to pull the skin margins apart there is very little spreading occurring at the edges of the laceration. For these superficial lacerations, it would be appropriate to use a band-aid, butterfly band-aid, steristrips, or other means to hold the skin edges together for a couple of days until it heals. In all cases, the wound that is created should be thoroughly cleaned out to make sure that there is little risk of infection, especially with the onset of antibiotic resistant bacteria causing infection in sporting events.
Once the laceration extends into the deeper layers of the skin, it is more important to obtain a watertight seal and to keep the skin edges together to allow for quicker healing.
Although we are currently working on some types of skin glue to hold the edges together, the accepted form of treatment for these type of lacerations is to use stitches to hold the skin edges together. The stitches help to decrease the chance of infection, allow for quicker healing, and when properly placed, leave less of a scar.
The use of steristrips or a butterfly band-aid may be appropriate for a brief period of time until one can reach appropriate treatment for these deeper lacerations. At that point, a doctor can make the proper decision on whether this type of treatment is appropriate because the lesion is small enough to handle it, or whether stitches may be necessary.
We have found it especially difficult in hockey players to use steristrips or butterfly band-aids to hold even the smallest lacerations together because of perspiration while playing hockey. The perspiration will generally cause the adhesive tape to become loose and ineffective in holding the edges of the laceration together.
To summarize, the initial steps in taking care of a cut on your face would be to make sure it is cleaned out appropriately so that you minimize the chance of infection. Superficial abrasions can be treated with appropriate coverage until the skin heals. Small cuts into the surface layer of the skin which do not spread apart when pulled at its edges can be treated with a band-aid or other adhesive means. Deeper cuts in which the skin comes apart in its deeper layers, when stretched apart at its edges, should be evaluated by a physician or other medical personnel to see if stitches are necessary.
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. .
