Abstract
Background
The sport of ice hockey has reached worldwide popularity, and it continues to grow. With this growth, however, there has also been an increase in the number of injuries related to the high-speed physical nature of the sport. Upper extremity related traumas and maladies are amongst the most commonly experienced injuries in this population of athletes. The objective of this narrative review is to appraise the current literary landscape as to the epidemiology, treatment, and return to play experienced with the most common upper extremity orthopedic injuries related to ice hockey play.
Methods
PubMed, Google Scholar, and OVID were searched individually using the filtered terms “shoulder”, “injury”, and “ice hockey”. Articles that were published after 2000 were analyzed. Notably, the concepts of athlete sex, compete level, and post injury productivity were explored in detail.
Results
It is evident in the literature that upper extremity injury rates increased as level of play increased, were more common in males, and occurred more often during in-game situations. Acromioclavicular joint separations, shoulder instability, and clavicle fractures were amongst the most commonly cited ice hockey upper extremity injury presentations; acromioclavicular joint injuries were considered the most common upper extremity injury in ice hockey players. Return to play depends on injury type and severity. Overall, performance decreased upon initial return from injury.
Conclusion
Ultimately, further research needs to be conducted on shoulder related ice hockey injuries, their prevention, and the accurate management of specific presentations in order to ensure efficient and safe return to play.
Keywords: Ice hockey, Athletics, Upper extremity, Shoulder, Shoulder injury, Shoulder surgery
1. Introduction
Ice hockey has established itself as a worldwide sport with over 1.76 million registered athletes according to a 2017 International Ice Hockey Federation (IIHF) survey.1 Currently, 83 countries have national teams participating in the IIHF, representing six continents. With such a rapid growth in the sport's popularity, it is anticipated that an increasing number of patients will present with injuries related to competition. Alongside facial and hand/wrist injuries, shoulder injuries are amongst the most common ailments seen in ice hockey players.2,3 In fact, 13.8% of ice hockey related presentations to United States emergency departments were attributed to shoulder/upper arm injuries between 1990-2006.2 Being a contact sport, this is unsurprising. Yet, while there is a growing body of literature that analyzes ice hockey related injuries, no study, to our knowledge, has summarized the existing research as it pertains to shoulder related hockey injuries. The goal of this narrative review was to appraise the epidemiology, common injuries, and return to play (RTP) for ice hockey players following shoulder injuries.
2. Methods
PubMed, Google Scholar, and OVID articles were reviewed using the filtered terms “shoulder”, “injury”, and “ice hockey”. Articles that were published after 2000 were analyzed and included for discussion. The examined literature was divided into three sections for discussion: epidemiology of, common types of, and RTP following shoulder injury in ice hockey players. Original articles were analyzed for injury type (Table 1); injury types that were accounted for included acromioclavicular joint (ACJ) sprain, instability, dislocation, rotator cuff tears, labral tears, and clavicle fractures. Included in the definition of shoulder “instability” in this study were dislocations, rotator cuff tears, labral tears, subluxation, and chondral defects. It is important to note the limitations inherent in this study, including its retrospective nature, lack of exclusion criteria, and the use of a non-specific “instability” definition.
Table 1.
Characteristics of ice hockey injuries defined in the included original studies.
| Author | Year | Injuries | UE Injuries | Shoulder Injuries | ACJ | Instability | Dislocation | RC Tear | Labrum Injury | Clavicle Fracture |
|---|---|---|---|---|---|---|---|---|---|---|
| Caputo et al. | 2005 | 34 | 7 | 4 | 1 | – | 1 | – | – | – |
| Flik et al. | 2005 | 113 | 25 | 17 | – | – | – | – | – | – |
| Agel et al. | 2010 | 3595 | – | 292a | – | – | – | – | – | – |
| Deits et al. | 2010 | 302,368 | 84,312 | 41,713b | – | – | – | – | – | – |
| Dwyer et al. | 2013 | – | – | 24 | – | – | – | – | – | – |
| Lee et al. | 2013 | 9 | 9 | 9 | – | 9 | – | – | – | – |
| Forward et al. | 2014 | 33,233 | 14,849 | – | – | – | – | – | – | – |
| McKay et al. | 2014 | 1685 | 404 | 202 | – | – | – | – | – | – |
| Matic et al. | 2015 | 724 | 227 | 149b | – | – | – | – | – | 22 |
| Tuominen et al. | 2015 | 528 | 115 | 57 | 29 | – | – | – | – | – |
| Rangavajjula et al. | 2016 | 13 | 13 | 13 | – | – | – | – | 13 | – |
| Tuominen et al. | 2016 | 168 | 37 | 12 | 6 | – | – | – | – | – |
| Tuominen et al. | 2017 | 633 | 182 | 106 | 63 | – | – | – | – | – |
| Lynall et al. | 2018 | 4194 | 316 | 155 | – | – | – | – | – | – |
| Melvin et al. | 2018 | 1593 | 1593 | 830 | 420 | – | 60 | 15 | – | – |
| McCarthy et al. | 2019 | 25 | 25 | 25 | – | – | – | – | – | 25 |
| Swindell et al. | 2020 | 67 | 67 | 67 | – | 67 | 67 | – | – | – |
| Trojan et al. | 2020 | 81 | 81 | 81 | – | 81 | 26 | – | 7 | – |
| White et al. | 2020 | 24 | 24 | 24 | 24 | – | – | – | – | – |
| Aguiar et al. | 2021 | – | – | – | – | – | – | – | – | – |
| Higgins et al. | 2021 | 37 | 37 | 37 | 1 | 1 | 3 | 4 | 12 | – |
| Lubbe et al. | 2021 | 405 | 142 | 58 | 0 | 16 | – | – | – | – |
| Castle et al. | 2022 | 29 | 29 | 29 | – | – | – | – | 29 | – |
| Kelley et al. | 2022 | 24 | 24 | 24 | – | 24 | – | – | – | – |
UE = Upper Extremity, ACJ = Acromioclavicular Joint Injury, RC = Rotator Cuff.
Indicates only male shoulder injuries reported.
Defined as shoulder/upper arm injuries.
3. Results
Overall, 36 studies were identified and included in this narrative review. Of these, 24 studies were considered original articles and included in the sub-analysis of injury type (Table 1). 102,518 upper extremity (UE) injuries were identified; 42.8% (n = 43,928) of UE injuries were explicitly deemed a shoulder injury. ACJ sprains, shoulder instability, dislocation, labral tear, clavicular fracture, and rotator cuff tear were identified in 544, 198, 157, 61, 47, and 19 reported injuries respectively.
4. Discussion
4.1. Epidemiology of shoulder injuries in ice hockey
Ice hockey is a high-speed contact sport that has inherent risks due to its physical nature. With the “shoulder check” being an intrinsic component of the game, it is predictable that injuries will occur. However, the prevalence and type of injury may differ depending on an athlete's sex, level of play, body habitus, and equipment.
4.1.1. Impact of sex on injury type and rate
Body checking is a penalty in women's ice hockey, influencing injury type and rate. In a 2014 review, UE injuries were found to be the most commonly injured extremity in men while it was the lower extremity in women players.4 This was supported by a Canadian study where female youth athletes (n = 2637) sustained less UE injuries (F: 39.2% vs. M: 45.2%; p < 0.01) compared to males (n = 30,596).5 Further, at IIHF and Olympic levels, the UE injury rate was 1.5/1000 games and 0.5/1000 games in men and women respectively.6,7 In collegiate play, the two most common injury types were sprains and contusions for both sexes, however third was fractures and contusions for men and women respectively.8 Moreover, Trojan et al. showed that the incidence of shoulder instability was 1.8x higher in male ice hockey players; this study was limited by sample size.9 Undoubtedly, these differences are in part due to checking rules and differences in the speed of play between sexes. Nevertheless, collisions still represent the primary mechanism of injury for both sexes.4
4.1.2. Injury rates and types by level of play
Boys’ high school hockey players experience injury at a rate of 2.3 injuries per 1000 athlete-exposures (AE). At the collegiate level, male hockey players experience injury at a higher rate of 4.7 injuries per 1000 AEs; in both demographics, shoulder/clavicle injuries make up approximately 1/5th of all competition-based injuries.10 At the IIHF junior level, the overall injury rate was 11 injuries per 1000 games and 40 injuries per 1000 game hours. The most common injury at the U18 tournaments was a shoulder injury, most commonly an ACJ sprain.11 In the adult IIHF world championships and Olympic games, injuries occurred at a higher rate than the junior level, at 14.2 per 1000 games and 52.1 per 1000 game hours. Here, shoulder injuries represented 49.6% of upper body injuries, with ACJ sprains again being the most common.6 The National Hockey League (NHL) represents the highest level of play in ice hockey worldwide. In this population, injuries occur at a rate of 15.6/1000 AEs and 49.4 injuries per 1000 game hours, similar to international adult hockey injury rates.12 Studies show that shoulder injuries represent 12% of NHL injuries and trails only the head as the most commonly injured area of the upper body.12,13 Injury rates increase as the level of play gets higher and at all levels shoulder injuries constitute a large component of upper body injuries overall.
4.1.3. Injury rate in the practice environment
There is an injury risk every time a player steps on the ice, but the risk of injury in games is higher than the risk in practices. This is despite substantially more time being spent practicing. In collegiate play, game injuries were 6.3x more common than practice injuries.14 In boys’ high school hockey, the same trend was seen.10 This trend is consistent regardless of player sex. In one study, male college hockey players had an 8.4-fold increase in injury rate in games and women had a 4.2-fold increase in injury rate.15 Most injuries occur from player contact, which is greatly reduced during practice compared to games.4
4.1.4. Role of equipment and biomechanics
The ice hockey equipment industry is seeing rapid growth, with a projected worth of $1.1 billion in 2025 according to Grand View Research estimates. However, research has primarily focused on lower extremity injury and concussion prevention with a paucity of studies analyzing shoulder protection. Shoulder injuries are primarily a result of contact with players and the boards. In one study, a reduction in injuries by 29% was seen in rinks with flexible boards and glass.6 Jang et al. highlights this point in their review with an added stress of equipment and rule adherence.16 Recent biomechanical studies looking into shoulder stiffness and damping during a shoulder check have shown that shoulder checks are thrown with 47% of body mass, primarily focused at the deltoid region.17 Further, current reports note only minor differences in arthrokinematics when comparing the stick hand to the empty hand.18 Overall, due to the paucity of research on UE protective equipment in ice hockey, we propose the integration of biomechanics and level of play into future equipment designs, with an emphasis on developing equipment with laterality and on the different anatomy of men and women. Interestingly, in adult recreational leagues where checking is not allowed, primary shoulder injuries occurred 50% of the time when players were not wearing shoulder pads.19 This stresses the importance of protective equipment at all levels.
4.2. Common ice hockey injuries
As previously mentioned, shoulder injuries are amongst the most common traumas experienced by ice hockey players. Unmistakable in the current literature, there is a focus on ACJ injury, shoulder instability, and clavicle fractures amongst ice hockey players (Table 1).
4.2.1. ACJ separation
ACJ sprains are consistently reported as one of the most common shoulder injuries in ice hockey players.6, 7, 8,11 For example, Tuominen et al. reported that they represent 51% and 50% of all shoulder injuries in men and women players, respectively, at the international level6,7; ACJ injuries are also the most common UE injury in collegiate players.16 The grading criteria for ACJ separations is well established. Grades I-III are managed with pain medication and physical therapy while Grades IV-VI, and non-responsive Grade III, often require reconstruction.16 Non-operative versus operative management of high grade ACJ injuries is debated due to the risk of reinjury. A recent meta-analysis comparing operative to nonoperative Grade III-V ACJ dislocations showed no clinical differences in functional outcome scores between the approaches.20 Recovery rates following ACJ separation in ice hockey players is typically around 2–4 weeks, 6–8 weeks, and 4–6 months following Grade I, II-III, and IV-VI respectively.21 Grade II injuries are the most common in ice hockey while Grade III injuries result in more games missed compared to Grade I-II injuries.22 For athletes injured in the middle of their seasons, corticosteroid injections can be a good option for pain and inflammatory relief.23 In contact sports such as hockey, precautions need to be taken to prevent reinjury, such as additional padding/bracing (e.g., Sully brace, donut pad) upon RTP. Future considerations and research should focus on integrating this additional bracing into shoulder equipment to prevent initial and reinjury of the ACJ.
4.2.2. Shoulder instability
In general, shoulder instability occurs when there is some degree of disconnection at the glenohumeral joint. This could be in the form of subluxation, dislocation, or cartilaginous/ligament tear. Although the definition is somewhat inconsistent, shoulder instability is highly documented in the literature on ice hockey related shoulder injuries.9,13,24, 25, 26 In a report on 24 junior and professional hockey players, Dwyer et al. defined instability to include dislocation, subluxation, labral lesions, rotator cuff tears, and chondral defects.24 Alternatively, Swindell et al. used dislocations requiring reduction as the inclusion criteria for shoulder instability while Castle et al. used labral tears.13,27 Future literature would benefit from more nuanced definitions of “shoulder instability” in order to draw definitive conclusions on injury rates and RTP given the drastically different treatment methods by injury type. This is especially important as career longevity differs based on injury type.27 Rehabilitation protocols that include functional and psychological components have achieved improvements in shoulder functionality, pain, and range of motion in collision sport athletes.26 Moreover, some reports have described a role for chiropractic management in refractory cases and elastic bands/body blade programs, however increased evidence is needed to determine their efficacies.28,29
4.2.3. Clavicle fractures
Clavicle fractures are a common UE injury in ice hockey. A recent study by McCarthy et al. reported a rate of 1.8 clavicular fractures per 100,000 AEs among athletes in high school, which is the most at-risk age for sport-related clavicle fractures. When comparing injury rates across different sports, ice hockey was noted to have the highest rate of clavicular fracture at 5.3, higher even than other full-contact sports (e.g., American football).30 Non-surgical management is generally accepted for non-displaced fractures, but for certain types of displaced fractures, current literature supports operative intervention.31 Players being treated nonoperatively can expect an 8–10-week recovery period, during which time they should use a sling, figure-of-eight splint, or other modality for stabilization.32,33 Moreover, while unstable distal clavicle fractures have long been treated operatively, recent literature found that plate fixation of displaced midshaft fractures may also lead to improved long-term functional outcomes.33 Vander Have et al. also found benefits to operative treatment of such fractures in the adolescent population.34 No study to our knowledge has analyzed the impact clavicle fractures have on RTP or production following the appropriate recovery period in ice hockey.
4.3. Recovery and return to play
When an athlete experiences injury, the most common follow-up question is, “when can I play again?”. The answer depends on a variety of factors including injury type, injury grade, and management. For example, NHL players suffering from Grade I ACJ injuries treated with conservative management were able to RTP in three weeks while NHL players who underwent arthroscopic shoulder labral repair returned to play in 4.3 months.22,35 However, there is no definitive RTP schedule for each injury type and severity because athletic factors also play a role in recovery time length. Post-injury performance, recurrent injury risk, time of seasons, and career longevity must be weighed by both athlete and clinician in determining an optimally safe and effective RTP strategy.
In NHL players with shoulder instability, 98.5% were able to RTP after missing an average of 26.3 regular season games. Those managed both operatively and nonoperatively experienced decreases in points/game, but this was greater for nonoperatively managed patients. While nonoperatively managed players returned to play sooner, they missed more career games on average due to a higher prevalence of recurrent injuries.13 Following shoulder arthroscopy, NHL athletes experienced a 67.6% decrease in performance in their first season back from injury; this metric returned to baseline in postoperative season two.36 Amongst the four major North American sports, NHL players experience the largest reduction in performance following shoulder arthroscopy.36 Compared to healthy controls, NHL players who underwent shoulder arthroscopy for labral repair in particular had significant reductions in goals per 60 games (0.2 goals/game difference), points per 60 games (0.5 points/game difference), and shooting percentage (2.0% difference) compared to their previous year; production returned to preoperative levels after three years.27 These players ultimately experienced shorter careers compared with controls (1.6 season difference).27 Noninstability shoulder arthroscopy procedures likewise have the greatest negative effect on NHL careers after surgery with an average of 2.1 seasons played following intervention.25
It has been demonstrated that rehabilitation programs are effective in stabilizing operatively and non-operatively managed shoulder injuries, including those suffered from playing high-impact sports such as hockey.29 However, the immense forces placed on the previously injured shoulder joint in hockey players are large enough to overcome an adequately rehabilitated joint. One strategy for minimizing recurrent injuries is to incorporate functional testing, psychological testing, and specific RTP criteria as part of rehabilitation programs, aspects which have demonstrated a low reinjury rate two years after follow-up; similar programs have reported improved patient reported outcomes and RTP within 6.5 months of injury (6.5%).26 Such a rehabilitation program would likely lengthen initial RTP, but ultimately decrease total games missed due to fewer recurrent injuries.
5. Conclusion
UE injuries in ice hockey players have become exceedingly prevalent. The majority of research at present focuses on the epidemiology of hockey injuries, yet few address the impact such a high-speed collision sport with shoulder checking has on the UE. At present, ACJ sprains, shoulder instability, and clavicle fractures are amongst the most common shoulder injuries experienced by ice hockey athletes. To this end, the type of injury has a significant impact on a player's RTP. Ultimately, it remains unclear the extent to which these repercussions differ by sex and level of play as the majority of studies at present focus on professional male athletes. With ice hockey developing into a worldwide sport, future research should focus on the differences in injury rates and type by sex and level of play, with efforts made to curtail standard equipment to commonly experienced injuries.
Author contributions
Christopher White – conceptualization, data curation, project administration, investigation, methodology, writing original draft, review & editing.
Stephen J. O'Connor – conceptualization, data curation, investigation, methodology, writing original draft.
Timothy R. Sestak – data curation, investigation, methodology, review & editing.
E. Spencer Fox – data curation, investigation, methodology, review & editing.
Paul Cagle – conceptualization, investigation, methodology, project administration, resources, review & editing, validation, visualization.
Conflict of interest
None.
Funding/sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Informed consent
N/a.
Institutional ethical committee approval
The Institutional Review Board at our institution reviewed and approved this study prior to the investigation.
Declaration of competing interest
The following individuals have no conflicts of interest or sources of support that require acknowledgement: Christopher A. White, Stephen J. O'Connor, Timothy R. Sestak, E. Spencer Fox.
Acknowledgments
None.
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