Ice hockey is widely known as one of the world’s fastest and most dangerous sports. With the game’s popularity growing at record levels, participation in ice hockey in the United States has experienced substantial growth over the last decade. Over 400,000 male players and 40,000 female players participate under the auspices of USA Hockey (the national hockey governing body), compared to about 190,000 male and 6,300 female players ten years ago.
With the increased participation in hockey has come an increasing number of injuries. The potential for hockey injuries stem from razor sharp skates, 30 mph skating speeds, 100 mph slap shots with a frozen 6-ounce rubber puck, unyielding boards, long wooden or metal sticks and legal body checking.
Hockey injuries fall into two broad groups: the high speed, low mass injuries caused by a puck or stick which result in contusions, lacerations and concussions; and the low speed, high mass injuries caused by collisions with bodies or boards, frequently resulting in sprains and fractures. Lower extremity injuries account for approximately 27 percent of all hockey injuries with 11 percent occurring in the foot.
Recognizing And Treating Hockey-Related Ankle Injuries
Ankle sprains are a common problem in most sports. However, in hockey, the common ankle sprain caused by plantar flexion, inversion and internal rotation is a relatively rare occurrence. This is due to the protection afforded by the modern stiff skating boot and because there is relatively little jumping and landing, which is a frequent cause of inversion injuries in other sports. More frequent and much more troublesome in skating is the dorsiflection-eversion-external rotation ankle sprain.
There are two principal etiologies for this sprain. The first and most common injury occurs when a player catches his or her support blade in an ice rut, causing the skate to follow the rut, forcefully rotating and everting the ankle. The second etiology is a fall over the front of the skates, with the foot being caught in an externally rotated, dorsiflexed position under the body. Both cases result in a strain of the deltoid ligament followed by progressive loading of the tibiofibular ligament and interosseous ligament.
This type of sprain results in immediate pain which is localized in two distinct areas, the medial aspect of the ankle over the deltoid ligament and the anterolateral aspect of the ankle over the anterior inferior tibiofibular ligament and distal interosseous ligament. The pain is increased with eversion-external rotation stress of the dorsiflexed ankle. Inversion-internal rotation of the plantar flexed ankle is relatively painless. When the mechanism of injury and clinical examination are consistent with an eversion sprain, you should perform stress X-rays to rule out a diastasis of the ankle syndesmosis. Be sure to include the entire tibia and fibula on the film in order to avoid missing a proximal fibular fracture.
Immediate treatment for these sprains should include prompt compression, ice and elevation since the amount of swelling predicts the amount of ankle pain and the length of recovery you can expect. When the radiograph demonstrates evidence of mortise widening or instability, consider performing open fixation with a syndesmodic screw in order to reduce and hold the ankle anatomically. If the stress X-rays are negative for diastasis, continue with crutches and a compression dressing until the initial injury pain subsides. At that point, you can allow weightbearing as tolerated and proceed to emphasize ankle rehabilitation.
The initial focus of the ankle rehabilitation program should concentrate on return of motion. An exercise bicycle and an ankle board are valuable in this early phase. As the tenderness over the anterior tib-fib ligament and interosseous space begins to subside, have the patient initiate inversion-eversion strengthening and heel cord stretching. Encourage proprioception training, using a tilt board or other balance device, in conjunction with the stretch and motion program.
Once the patient can tolerate full weightbearing, ankle strengthening, range of motion and proprioception well, you can allow the patient to proceed to straight ahead running. The final, most difficult phase of the rehabilitation is returning to skating because of the inherent external rotation, everson forces placed across the ankle with normal skating stride. To help protect the ankle against excessive stress in this period, apply immobilization taping. In nonoperative cases, return to function occurs within three to six weeks after the injury while a surgical case will require 15 to 18 weeks for functional recovery.
Be Aware Of Skate Bites
The skate bite — an inflammation of the sheath that covers the tendons that cross the anterior ankle and dorsum of the foot — is another common ankle injury you would see among hockey players. Skate bites are caused by pressure from skate laces. In lacing skates, it is usual to make the distal and upper laces very tight, while leaving the throat area lacing looser for flexibility. However, the tightness of the upper boot lacing sometimes causes extensor tenosynovial reactions and even painful thromboses of the superficial veins.
The player may first feel an aching discomfort when he or she puts on the skates. The player may not even feel pain or discomfort after warming up. However, after playing, the ankle and foot will swell and become painful.
Initial treatment consists of ice and NSAIDs as well as adding a protective cushion to the skate. As the skate tongue softens or molds to the foot and ankle, you’ll often be able to achieve decreased pressure and reduced irritation. Emphasize to hockey playing patients that skate bite injuries, if left untreated, could become chronic, leading to scar tissue formation. The scar tissue will cause compression of the structures in the area and may require surgery. To prevent skate bite, some players wear padding over the area where their laces cross while others shave the inside of the tongue of their skate.
Other hockey players leave the skate tongue down for greater flexibility and comfort. This has lead to an incidence of lacerations of the anterior of the ankle caused by skate blades. These “boot top” injuries have caused damage to the anterior tibial tendon, extensor hallucis and digitorum longus tendons, and the dorsalis pedis artery, vein and nerve.
Expert Pointers On Treating Foot And Toe Fractures
Although the foot is protected by a solid boot made of leather and plastic, foot injuries still occur frequently in hockey. Fractures and contusions account for most of the foot injuries. Fractures of the feet are almost invariably the result of impact by the puck or stick.
The most commonly fractured bones are the navicular and the base of the fifth metatarsal (styloid process). The first through fourth metatarsals are fractured much less frequently. These fractures are usually oblique but can appear comminuted or spiral. When these fractures are not displaced, players often “play through the pain.” Treatment for these fractures consists of four to eight weeks of immobilization, depending on the injury. If the fracture is displaced and cannot be closed or reduced, it may be necessary to perform ORIF.
Toe fractures are not very common in hockey due to the hard toe of the skate. However, these fractures do occur occasionally due to direct trauma from a puck or stick. You may see a subungual hematoma with these injuries and the fracture will usually be comminuted. The player will present with pain, edema and ecchymosis of the affected toe.
Treatment of nondisplaced toe fractures consists of immobilization splinting to the neighboring toe with tape, felt or prefabricated splints. With these cases, you can expect a return to action in a matter of days. If the fracture is displaced, depending on severity, you should perform a closed or ORIF. Return to play will then take a couple of weeks, depending on the degree of displacement and the amount of reduction and stabilization you perform on the area.
Dr.Caselli (shown on the right) is Vice-President of the Greater New York Regional Chapter of the American College of Sports Medicine and is a Professor in the Department of Orthopedic Sciences at the New York College of Podiatric Medicine (NYCPM). Ms. Gagne and Mr. Kaplan are both senior students at NYCPM.
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