RECREATIONAL ICE HOCKEY INJURIES IN ADULT NON-CHECKING LEAGUES:
A UNITED STATES PERSPECTIVE
1St Elizabeth Medical Center, Trauma Center, 2209 Genesee St.,
Utica, NY, USA
2Department of Physical Therapy, Utica College, Utica, NY, USA
20 December 2004
© Journal of Sports Science
and Medicine (2005) 4, 58 - 65
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purpose of this study was to analyze injuries among adult recreational
ice hockey players. This was an observational prospective cohort study
with data collected on injuries sustained during one season in the
adult recreational ice hockey leagues of Oneida County, NY. The injury
incidence rate was found to be 12.2/1000 player-exposures. The most
common anatomic region injured was the head/neck/face (35%). Collisions
were most often reported as the mechanism of injury (44%). Fracture
was the most common diagnosis. Of players wearing face protection
(full cage or shield, or partial visor/half shield), none suffered
facial injuries, while all facial injuries reported were to players
not wearing facial protection. The concussion rate was 1.1/1000 player-exposures.
A lack of protective equipment was associated with 38% of injuries
and 24% of injuries involved penalties. A history of prior injuries
was found in 89% of injured players with 28% re-injuring the same
body part. This study's findings suggested various strategies to address
player injuries such as mandatory full facial protection and shoulder
pads, strict enforcement of game rules, and game rule modifications
(no body checking). Further research is needed on the role of preventive
rehabilitation in players with previous injury history.
WORDS: Ice hockey, recreational, adult, old-timer, United States.
the increasing popularity of professional ice hockey across the United
States (US) in recent years, there has also been an increase in the
number of adult recreational ice hockey players. The popularity of
adult recreational ice hockey was evident in Oneida County, NY as
seen by the growing number of participants in the leagues in operation.
Local league play consisted of a total of 23 teams in 4 separate leagues
and approximately 300 players.
The only study investigating the epidemiology of injuries in adult
recreational ice hockey has been done in Canada (Voaklander et al.,
No such studies have been conducted in the US to date. Furthermore,
no studies that we're aware of have investigated ice hockey under
the conditions distinctive to the adult leagues in Oneida County regarding
required hockey equipment and altered game rules.
The Canadian literature on adult recreational ice hockey has reported
a high incidence of facial injuries and injuries in part related to
lack of, or misuse of equipment (Deady et al., 1996
Voaklander et al., 1996a).
Puck related lower extremity injuries were also reported as frequently
occurring injuries (Voaklander et al., 1996b).
The purpose of this study was to analyze the incidence and nature
of injuries among US adult recreational ice hockey players.
Another important issue in adult recreational ice hockey is re-injury.
Many recreational players come from a competitive hockey background
and report injuries sustained during previous experience. Hence, it
can be hypothesized that previous injuries are a risk factor for sustaining
similar or related injuries.
Given the aim of this study to analyze the nature and incidence of
injury among adult recreational ice hockey players in Oneida County,
NY, it was hoped that the outcomes of this study contribute to ideas
for the development of injury prevention strategies to improve safety
in adult recreational ice hockey. This study population, also known
as "old-timer" ice hockey players, make up a distinct ice
hockey study population (with regards to use of protective equipment
or altered game rules) and has not received as much study as the professional,
collegiate, youth or other ice hockey players.
Approval for this study was obtained by the IRB/ethics committee
of the St Elizabeth Medical Center in Utica, NY. Subjects were recruited
from the four adult recreational ice hockey leagues in Oneida County,
NY, including the Clinton, New Hartford, Rome and Whitestown leagues.
All leagues had credentialed referees and all subjects signed the
study informed consent form. Permission to obtain injury data was
obtained from the league administrators prior to the start of the
study. The players were at least 18 years or older and all were
male. The age range was from 18 to 55 years of age with 45 players
less than 30 years of age and 152 players 30 years or older (of
which 44 were 40 years or older). The participants were former players
at the high school, college and minor professional league levels.
The games were played under modified ice hockey rules that prohibited
and penalized (minor penalty) body checking and slap shots. Also,
wearing face shields (except for goaltenders) and protective body
pads (such as shoulder pads) were not compulsory.
Players were recruited for the study in the dressing room prior
to the start of the first games for the 2001-2002 ice hockey season
by the authors. Enrollment and consent forms were completed as subjects
were recruited and injury forms were used to record injuries. Student
physical therapists attended all games and recorded player participation
and injury data on the injury forms. They were instructed and trained
in data collection prior to the beginning of the study. There were
only games and no practices for all the leagues. Additional data
from medical records for each injury sustained (including diagnosis
and treatment) were obtained from the treating medical facilities.
Participants agreed to the release of this information on the informed
consent/medical release form.
For the purposes of this study an injury was defined as an activity
related medical condition arising from ice hockey participation
that prevented a player from completing a game, caused a player
to miss a game, required a player to seek medical or dental care,
or was a concussion. The Vienna 2001 consensus statement definition
(Aubry et al., 2002) was used to describe
concussions when this diagnosis was encountered during data collection.
A pilot study (data not included in this study) was conducted from
January 5th through February 11th 2001, which
served to develop and test the injury forms as well as plan the
logistics of the study. The formal study period took place from
September through March during the 2001-2002 ice hockey season.
Incidence rates were calculated per player-exposure (defined as
a game attendance). Game attendance refers to actual participation
in play during a game by players without recording total ice time
per player. The incidence rate was calculated using the equation:
rate = total number of injuries/ sum of reported game attendance
for all players. Injury data were collected to compare facial injuries
in players with and without facial protection. Overall, the anatomic,
diagnostic and mechanistic distributions of injuries were analyzed.
A total of 196 players enrolled in the study from a pool of approximately
300 players participating in the leagues. All players were followed
by the study investigators to completion of the study. Of the medically
treated injuries, only one did not have verifiable documentation
to support the diagnosis. The player was able to recollect with
sufficient detail his rib fracture as diagnosed by his medical practitioner.
Data were compiled using the Statistical Package for Social Sciences
A total of 34 injuries to 28 players were reported during the 2001-2002
ice hockey season for the Oneida County adult recreational ice hockey
leagues. The total cumulative injury index was found to be 17.3%
(total number of injuries/ total population or 34/196). The total
injury incidence rate was found to be 12.2/1000 player-exposures
(total number of injuries/total player-exposures per 1000 or 34/2784).
The average age for injured players was 33.5 years. The percentage
of injured players less than 30 years of age was 25% (7) and those
30 and over was 75% (21). These numbers were similar for non- injured
players where the average age was 34.2 years and players less than
30 made up 22% (37) and those 30 and over 76% (128) with 2% (3)
not reporting their age. With respect to previous competitive experience
(varsity high school, college and professional level) for injured
players, 64% (18) played competitive hockey and 36% (10) did not.
As for non-injured players, 67% (113) played competitive hockey
and 18% (31) did not with 14% (24) not responding to the question.
The overall anatomic distribution, diagnostic frequencies and mechanism
of injury are listed in Table
1. The most frequent anatomic region injured was the head/neck/face
35% (12). Overall, the most frequent diagnosis was fracture 29%
(10) and the predominant mechanism of injury was collisions 44%
(15) (of which 60% (9) occurred with the boards, 20% (3) with players
and 20% (3) with the ice).
The head/neck/face injury data are summarized in Table
2. The most common diagnosis for the head/neck/face injuries
was laceration 42% (5) and the predominant mechanism of injury was
puck contact 50% (6). Of the 196 players in the study, 57% (111)
wore facial protection and 43% (85) did not. Facial protection use
was determined for each player at the beginning of the season and
after their injury occurred. All facial injuries were to players
not wearing facial protection. Players wearing full facial protection
(full cage or shield) and partial facial protection (visor or half
shield) suffered no facial injuries. The concussion rate was calculated
to be 1.1/1000 player- exposures. Two concussions were due to collisions
with the boards and one with a player, which ultimately resulted
in a collision with the ice (none were due to penalties). Loss of
consciousness occurred for two concussions. There was one rule infraction
involving illegal stick contact that resulted in a facial laceration.
Upper extremity injury analysis revealed the most frequent anatomic
region injured to be the shoulder 57% (4). The most frequent upper
diagnosis was sprain/strain 43% (3) and the predominant mechanism
of injury was collisions 86% (6). Two of the collisions were with
the ice and both a result of illegal activity (Table
3). Three of the upper extremity injuries (43%) were associated
with penalties (2 body checks and 1 illegal stick contact). Of the
players who suffered shoulder injuries, 50% were not wearing shoulder
pads and both injuries occurred as a result of unintentional collisions
with the boards.
most frequent anatomic distribution for torso injuries consisted
of the rib cage 71% (5). The most frequent diagnosis was rib fracture
43% (3) and the predominant mechanism of injury was collisions 57%
(4) (Table 4). Penalties were
associated with 57% (4) of the torso injuries. The penalties included
1 illegal stick usage, 1 collision with the boards (body check from
behind), 1 collision with the player (body check), and 1 fighting.
Of the rib cage injured players, 40% (2/5) were not wearing any
shoulder pads and 80% (4) of rib injuries were a result of illegal
extremity injuries revealed the ankle as the most frequent anatomic
region injured 38% (3). The most frequent diagnosis was sprain/strain
75% (6) with no predominant mechanism (Table
5). No lower extremity injuries were due to penalties.
Severity of injury (Table 6)
was classified as mild (resulting in < 8
days of absence from hockey play), moderate (resulting in 8
- 28 days of absence from hockey play), and severe (resulting in
days of absence from hockey play). Of the most debilitating injuries
(classified as severe), 71% (5) consisted of soft tissue injuries
(2 hamstring strains, 1 groin strain, 1 traumatic rotator cuff tendonitis
and 1 back pain due to muscle spasms). The remaining 29% (2) consisted
of fractures (1 bimalleolar ankle fracture and 1 distal fibular
fracture). Moderate injuries consisted of rib fractures 43% (3),
sprains 28% (2) (1 ankle and 1 acromioclavicular), facial laceration
14% (1) and concussion 14% (1).
of acute vs. chronic injury revealed that 88% (30) of the injuries
were acute and 12% (4) were chronic. Of the chronic injuries 75%
(3) were overuse injuries (1 hamstring strain, 1 spondylolysis,
and 1 low back pain), the other one was a recurrent shoulder dislocation.
The mechanism for chronic injuries included: routine play (2) and
collisions (2) (both unintended, 1 with a player and 1 with the
boards). Most of the overuse injuries (2) occurred during routine
The medical facility where initial treatment was sought was summarized
in Table 7. Hospitalization
occurred in 1 case of a bimalleolar ankle fracture (4 days).
injuries were reported in 89% (25) of the injured players, while
11% (3) never had previous
injuries. This was substantially different from the non-injured
players where 51% (86) had previous injuries and 48% (81) never
sustained an injury with 0.6% (1) not responding to the question.
Furthermore, 28% (8) of the injured players previously sustained
an injury to the same body part injured during the current study.
Analysis of injured players with respect to position played revealed
that 57% (16) were forwards, 36% (10) were defensemen and 7% (2)
were goaltenders. This distribution was similar for non-injured
players where forwards made up 64% (107), defensemen 32% (54) and
goaltenders 10% (17) with 1% (2) not reporting their positions.
Non-injured data does not add up to 100% because some players equally
played several positions.
Distribution of injuries according to period of play revealed that
32% (11) occurred during the first period, 21% (7) during the second
period, 44% (15) during the third period and 3% (1) during the pregame
Penalties were assessed in 24% (8) of the injuries according to
the following distribution: 12% (1) for head/neck/face, 38% (3)
for upper extremity, 50% (4) for torso and 0% (0) for lower extremity
injuries. Furthermore, 50% of injuries due to penalties (12% of
total injuries) involved body checking.
injury rate of 12.2/1000 player-exposures in this study was consistent
with similar work done in Canada (Voaklander et al., 1996b).
In our study, the use of direct observation with onsite and trained
personnel (student physical therapists) in addition to telephone
interviews and verification of medical records, decreased the self-reporting
bias for anatomic, diagnostic and mechanistic frequencies and distribution.
Also, by maintaining direct participation records, the self-reporting
bias for the player-exposure (denominator) was minimized. Comparison
with similar literature (Voaklander et al., 1996b)
was facilitated by using similar injury definition and denominator
(per 1000 player- exposures) in reporting injury rates.
The anatomic distribution of injuries in this study showed a higher
frequency of head/neck/face injuries (35% compared to 25%) and torso
injuries (21% compared to 10%) but a lower frequency of lower extremity
injuries (24% compared to 40%) to similar Canadian literature (Voaklander
et al., 1996b).
The old-timer league in the Canadian study had the same game rule
modifications (no slap shot and no body checking), and the same
rule not requiring facial protection (except for goaltenders) as
our study. The main difference was that shoulder pads were required
for the Canadian study but not for the leagues in our study. The
higher frequency of head/neck/face and torso injuries may be explained
by the combination of lack of protective equipment (all facial injuries
occurred to the unprotected face) and penalties (80% of the rib
The diagnostic distribution revealed similar trends to the Canadian
literature (Voaklander et al., 1996b),
with the exception of fracture, which was the most common diagnosis
(29%) in this study compared to 9%. In this study dental fractures
were included in the fracture diagnosis contributing to the overall
fracture frequency. The concussion rate of 1.1/1000 player-exposures
falls within the wide range reported for university and elite amateur
teams (Honey, 1998).
Concussion rates for adult recreational leagues are lacking in the
literature. Other common diagnoses such as sprains/strains, lacerations,
and contusions showed similar trends to past literature (Daly et
Deady et al., 1996).
Lacerations were previously found to occur mainly to the unprotected
face (Deady et al., 1996)
and was supported in this study given that 100% of the lacerations
reported were to the unprotected face area.
Collisions, comprised the predominant mechanism (44%) and most were
due to either unintended collisions with boards/players or intended
collisions (body checks). In fact, 50% of injuries due to penalties
involved body checking. Hence, body checking in a non-checking league
is associated with increased incidence of injury. This supports
the no body check game rule modification in old- timer recreational
ice hockey leagues, which needs to be enforced.
Penalties were associated with 24% of all injuries, similar to previous
research (Voaklander et al. , 1996b).
This supports strict enforcement of game rules. Perhaps, the awarding
of bonus league points for fair play to the team with fewer penalties
regardless of game outcome, may help reduce injuries as suggested
previously (Marcotte and Simard, 1993;
Voaklander et al., 1996b;
Roberts et al., 1996).
This needs further research in adult recreational ice hockey.
Lack of protective equipment was found in 38% of injuries. All facial
injuries involved lack of facial protection. Also, 50% of the players
who sustained shoulder injuries were not wearing shoulder pads and
40% of players who suffered rib injuries had no shoulder pads. In
this case, the shoulder pads could have possibly prevented these
injuries as most involved unintended collisions with the boards.
Most injuries (44%) occurred during the third period of play. This
is consistent with other research (Lorentzon et al., 1988;
Daly et al., 1990;
Stuart and Smith, 1995;
Voaklander et al., 1996b;
Molsa et al., 1997;
Pinto et al., 1999)
and may be due to lack of conditioning in once a week players with
no practices or conditioning. Of the injuries arising from penalties,
88% (7/8) occurred during the third period. Perhaps this is due
to more aggressive behavior and/or fatigue during the third period
when game outcomes are decided.
Most of the injuries classified as severe in this study, consisted
of potentially preventable recurrent soft tissue injuries (groin
and hamstring strains, and low back spasms). This suggests that
targeted injury prevention exercise programs prior to the start
of the hockey season may be warranted to reduce the chance for sustaining
these debilitating injuries. This requires further study with a
larger sample size to be able to determine the effect of such programs.
Only one injury in this study required player hospitalization, and
this finding is consistent with other research (Voaklander et al.,
Comparison of acute versus chronic injuries was similar to other
research (Daly et al., 1990;
Voaklander et al., 1996b).
The majority of injuries in this study were acute 88%. The chronic
injuries made up 12% of the total and were mainly due to overuse
The history of previous injury was found to be an important factor
in the injuries sustained in this study. It was found that 89% of
the injured players had sustained previous injuries and that 28%
of them re-injured the same body part. These data support the use
of a preseason screening procedure to identify players previously
The medical facilities where initial treatment was sought revealed
similar trends to the Canadian experience (Voaklander et al., 1996b).
Most injured players sought treatment at a doctor's office with
a second group seeking initial care in an emergency room. The difference
in this study was that a greater percentage of players opted not
to seek treatment or to self treat (35% versus 20%). One reason
for this difference may relate to medical coverage. The Canadian
players have access to universal healthcare whereas their American
counterparts do not, and some players need to rely on out of pocket
payment plans. In fact, it was reported that some players did not
have any medical coverage and asked about treatment options.
There were no injury patterns or trends with respect to player age,
position played or previous competitive experience when comparing
injured and non-injured players.
A limitation of this study is the relatively small sample size (196
subjects) with a 65% study participation rate. Another limitation
is the possibility of players underreporting chronic overuse injuries.
The lack of coordinated onsite medical services such as training
room facilities with an athletic trainer or team physician may contribute
to the underreporting of such injuries. Another possibility for
underreporting may be that the "hockey culture" mentality
- where rough aggressive play and not reporting injuries are traits
valued by the players.
aim of this study was to analyze the nature and incidence of injury
among adult recreational ice hockey players from a US perspective
in Oneida County, NY. The outcomes of this study have allowed us
to participate in the development of injury prevention strategies
that have the potential to lead to improved safety in adult recreational
ice hockey. The injury rate observed was consistent with similar
previous research in Canada (Voaklander et al., 1996b).
This study demonstrated that facial injuries are still common in
adult recreational ice hockey where full facial protection is not
required. Our data also suggested that a higher occurrence of injury
was associated with failure to wear shoulder pads, but further studies
are needed to demonstrate cause and effect. Penalty-related activity
was also associated with a higher injury occurrence. Given these
findings, it can be concluded that not wearing full facial protection
and shoulder pads can present risk factors for injury and that penalty-related
activities increase the likelihood of players sustaining injuries.
A concussion rate of 1.1/1000 player exposures poses a real injury
risk. It was not clear from this study how to reduce or eliminate
this, and further research on this subject is needed for this type
The high percentage of injured players with previous injury history,
and the potentially preventable chronic overuse soft tissue injuries
causing lengthy time loss from participation, raised the question
of what role a targeted preseason rehabilitation program could play
with these players. The answer to this question requires further
Several suggestions can be made from this study regarding injury
prevention strategies for the adult recreational ice hockey population.
facial protection should be compulsory for all players.
should be strict enforcement of game rules (such as no body checking)
with harsher penalties for rule infractions.
rule modifications eliminating body checks in reducing injuries
was supported in this study.
pads should be compulsory for all players.
care and emergency physicians are the frontline medical providers
for adult recreational ice hockey injuries and should have an
understanding of how to manage common ice hockey injuries including
above conclusions can potentially further reduce injuries and make
adult recreational ice hockey a safer and more enjoyable sport.
research study was funded by the St Elizabeth Medical Center (SEMC)
trauma department in Utica, NY. Many thanks to the SEMC trauma surgeons
who made this research possible by donating their fees for trauma
call. We would like to thank the Oneida County adult recreational
ice hockey league administrators and players for their participation.
We would also like to thank the Utica College physical therapy students
(Brian Kelley, Gabe Mattson, and Eric Stewart) for their involvement.
Finally, we would like to thank Mr Ralph Requa and Dr James Garrick
for their review of this manuscript and for providing useful suggestions.
injury incidence rate was found to be 12.2/1000 player-exposures,
similar to previous Canadian literature.
concussion rate was 1.1/1000 player-exposures.
of injuries involved a lack of protective equipment and 24% of
injuries involved penalties.
facial protection and shoulder pads should be compulsory.
enforcement of game rules is necessary.
of prior injuries was found in 89% of injured players.
Employment: Physician, Okeechobee County Health Department,
Okeechobee, FL, USA
Research interests: Primary care sports medicine
Douglas J. MATTSON
Employment: Physical therapist in private practice, Utica,
Degree: Research doctorate dissertation candidate,
Research interests: Biomechanics of shoulder and knee