Since 1981, ice hockey has been identified as a major cause of permanent serious spine injuries, especially among those players 11 to 20 years old. Studies indicate that on a per capita basis, there is a three times greater risk of catastrophic neck injuries in amateur hockey than in American football.1,2 The primary mechanism of injury is a push or shove from behind into the boards, striking the top of the head, with the neck slightly flexed. Impacting the boards at approximately walking speed is enough to fracture the cervical spine if it is in slight forward flexion.
Multiple factors have been implicated as to why there has been such an increase in serious neck injuries since the early 1980s. The mandatory use of helmets and full face masks have lead to a more aggressive style of play and have given players a sense of invulnerability to injury.1,2,4 The late Bob "Badger" Johnson, former executive director of the U.S. Amateur Hockey Association, commented on the effect that this had on a college game that he watched: "The lack of respect for an opponent ruined the college game, as players played fearlessly with no respect for each other, all because of face masks ..."2
Prevention begins with educating players on issues such as avoiding dangerous on-ice situations and the importance of preseason conditioning. In "Smart Hockey," a video produced by the Canadian Sports Spine and Head Injuries Research Centre, high risk situations are demonstrated and techniques are discussed in simulated real game situations on how to reduce the risk of serious injuries.6 All amateur players, coaches, and parents should view this tape and incorporate the techniques it discusses. Some amateur leagues make viewing it mandatory, having each player sign a form stating that he will play "smart hockey."
The importance of neck muscle strength1,3,4 has to be repeatedly emphasized and incorporated into the preseason training programs as well as the ongoing conditioning exercises during the season. Although this seems like common sense, players interviewed after catastrophic neck injury disclosed that they were unaware of the risks of spinal cord injury, felt "invincible" while wearing their protective equipment, and most disturbingly, indicated that they had never done specific exercises to strengthen their neck muscles; most claimed they had never been advised nor encouraged by their coaches to do so.1 Strength training not only builds bulk muscle power, but teaches contraction timing and proprioceptive awareness.4
Because 50 percent of all serious cervical spine injuries are preceded by an episode of significant neck pain,3,4 any neck pain or injury become important. Players need to report neck pain to the team trainer, coach or parents. While adequate treatment of the more minor neck injuries may seem less important at time, the above relationship would suggest that all neck injuries should be treated as a prodrome to a more devastating injury.4 Appropriate evaluation, treatment, and rehabilitation is essential to help minimize reoccurring injury. Reinjury is always a risk when the player returns to a collision sport environment like that of ice hockey. At the high school level, the reinjury rate after all neck injuries was 17.2 percent. The twice-injured players at all levels of play had an 87 percent chance of future injury.3 Return to competition after the initial neck injury should not be permitted until the athlete is asymptomatic. Specifically, the athlete must be free of all neck tenderness and spasm, neck and arm pain, numbness, paresthesia, and weakness not only at rest, but at full range of motion with and without axial compression.5 Posttraumatic rehabilitation of "minor" spinal injuries is often overlooked and contributes to reinjury. Neck muscles in neck injuries should be given the same emphasis as quadriceps strengthening in rehabilitation of knee injuries.3
Chiropractors practicing within the areas in which their patient's children play ice hockey can play a significant proactive role in preventing serious spinal injuries. By educating their patients about proper care and rehabilitation of any neck injury, to making sure appropriate preventative steps are being taken to avoid serious cervical spinal injuries, we can reduce the inherent risks that go with playing a collision sport such as ice hockey.
References
- Tator CH, Edmonds VE. National survey of spinal injuries in hockey players. Can Med Assoc J 130: 875-880, 1984.
- Raynen PD, Clancy WG. Cervical spine injury, hockey helmets, and face masks. Am J Sports Med 167-170, 1994.
- Watkins RG. Cervical spine injuries in football players. In: Hochschuler SH (ed). The Spine in Sports. Hanley & Belfus, Inc., 1990.
- Banks S. Cervical spine injuries in athletes, Certified Chiropractic Sports Physician course lecture notes, 1992.
- Cantu RC. Criteria for return to competition after head or cervical spine injury. In: Cantu RC, Micheli LJ (ed). American College of Sports Medicine's Guidelines for the Team Physician. Lea & Febiger, 1991.
- The Canadian Sports Spine and Head Injuries Research Centre, Smart Hockey with Mike Bossy, Al Stewart Enterprises Limited, 1988.
Editor's note: Dr. Tarnow is a National College of Chiropractic graduate with a B.S. in human biology from Western Michigan University. He obtained his CCSP from Logan College, and is a diplomate candidate (NYCC) of the American Chiropractic Board of Sports Physicians. He is a member of the ACA's Council on Sports Injuries and Physical Fitness, its Council on Physiological Therapeutics, and is a member of the American Rehabilitative Assoc. He is in private practice in Pittsburgh, Pennsylvania.
Gregory Tarnow, DC, CCRD, CCSP
Pittsburgh, Pennsylvania