A review of the prevention of head, neck and facial injuries in ice hockey


MSL Webb, G R McLatchie

Department of Sports Medicine, University Hospital of Hartlepool, UK

Abstract
Ice hockey is one of the fastest and most physical team sports. With projectiles (pucks) travelling at over 100mph and players travelling at up to 30mph wielding sticks and skating on razor sharp blades, there is potential for significant injury.1

In 1961, an insurance survey reported over 100 closed head injuries, with one death. This led to research into helmets and subsequent mandatory use.

Facial protection was first developed in 1972 initially for goalkeepers. By 1976 all amateur players were required to wear full facial protection.

Key Words: Ice hockey, head, neck and facial injuries, prevention

The potential for significant head, neck and facial injuries is high in ice hockey.1 This led to research into helmets and their mandatory use in Sweden.2 Helmets became mandatory in youth ice hockey in Canada in 1965, shortly followed by the Amateur Hockey Association of the United States (AHAUS). In 1969, the Canadian Standards Association (CSA) was put in charge of ensuring the safety of hockey helmets. In 1975 the Canadian Amateur Hockey Association (CAHA) decided that amateur players should wear approved helmets only.2 Helmets and facemasks worn must be certified by the International Organisation for Standardisation (ISO).3 Although helmets were made mandatory in 1979 in the National Hockey League (NHL) in North America, players are not required to wear facial protection.

Since the introduction of helmets and facial protection, facial and eye injuries have been reduced by 75% (1972 to 1983). 6 Players aged 20-34 constitute the largest age group injured.7 The most common injury is due to contact with a stick or puck whilst wearing a helmet with no facial protection. Protection must be properly worn to be effective. (7)

A Finnish study found that 10 out of 1437 9-18 year olds (age range where full facemasks are mandatory) were injured involving the head and neck region. Four of these were probably due to defective facemasks. The study demonstrates the importance of proper use and standard maintenance. Data from this large study show that facemasks prevent facial injuries in this age group.10

In a study published in 2002 injuries in elite amateur ice hockey players were examined, recording the type of injury, severity and type of facial protection.4 The aim was to see if specific injuries were associated with different forms of facial protection. Players wearing no facial protection suffered fifty-two injuries (158.9 per 1000 player-game hours). The number of players wearing half visors (shields) who were injured was 45 (73.5 per 1000 player-game hours) and the number of players wearing full facial protection (cage or shield) injured was 16 (23.2 per 1000 player-game hours).4 The conclusion was that players wearing no facial protection were twice as likely to be injured as players wearing a half-visor, and seven times more likely than a player wearing full facial protection. The risk of eye injury in players wearing no protection was 4.7 times higher than players wearing partial protection. No eye injuries occurred in players wearing full protection.4

The importance of gumshields has also been emphasised in various studies. A dental arch form fitting mouthguard helps to protect teeth as well as preventing concussion.11, 13 A recent article in the British Journal of Sports Medicine advises the use of mouthguards in high impact contact sports such as ice hockey. The study called for a grading system for mouthguards so that athletes can make informed decisions about the form of protection they use.12 IIHF Rule 227 recommends that all players wear a custom made mouthguard.3 Hockey helmets alone have not reduced the number of concussions as dramatically as expected.15

Castaldi reported that although minor maxillofacial injuries have decreased there is a ‘recent almost epidemic increase in catastrophic spinal cord injuries’.9 Cervical spinal injuries are usually caused by a player hitting the boards with their head which can occur due to a check from behind or sliding into the boards uncontrollably.13 Castaldi noted that the likely reasons for the increase in spinal injuries are:
Playing rules not being enforced constantly especially those involving checking from behind or tripping an opponent onto the boards.
Compared to 10 years ago, players are much bigger.
There are no safety standards for rinks.
If a player collides with the boards, or goal post, with their head in a flexed position, this mechanism exceeds the protection offered by any certified helmet.9

The increase in neck and spinal injuries is believed to be related to the introduction of helmets and full facial protection themselves. It is claimed that players believe that they are protected from injury and are therefore willing to risk their safety as well as that of their opponents. This style of play has become more pre-eminent as referees have become increasingly lenient.8 In one study, all the players injured by illegal body checks were within the age group where full facial protection is required.7 This suggests that helmets with facemasks may produce a rougher and more dangerous style of play. In comparison, the 2002 study showed that there were no statistically different rates of concussion between the three groups. This study demonstrated that wearing both partial and full facial protection reduced the risk of eye injury whilst not increasing the risk of concussion or spinal injury4 suggesting that facial protection may not increase the risk of cervical spinal injuries significantly.7

Sustaining an injury in ice hockey, whether it be to the head, neck or face, or any other region of the body, is multifactorial.13 Protective equipment such as helmets, facial protection and mouthguards play only a small role in preventing head, neck and facial injuries. Rule changes and re-enforcing the existing rules of the game are the key to reducing injuries.13 Lacerations, contusions, strains, and sprains are by far the commonest injuries and educating players, coaches, officials, parents and fans is essential to promoting safe play. USA Hockey stresses that players should :
Never deliver a hit to the head
Never check from behind
Never drop your head near the boards
Never leave your feet to give a check
Never use your stick as a weapon
The importance of recognising head injuries is highlighted and even though the use of certified helmets has reduced severe head injuries, concussions still occur.13 A list of symptoms and signs along with educating the hockey community in what to do in case of a head/neck injury is the key to reducing the sequelae.

Each governing body may also wish to look into the safety at ice rinks within their own countries using the IIHF rules that govern rinks for international competition. Castaldi highlighted rink safety as a possible reason for the increase in cervical spine injuries in 1991.9 Without specific rules or safety standards, the potential for injury is high. Players’ safety is everyone’s responsibility and making rinks safer would help to reduce preventable injuries.

Conclusion
The reduction of head, neck and facial injuries is still an important issue for the international ice hockey community. The evolution of helmets and facial protection has been beneficial to player safety by decreasing the risk of maxillofacial and eye injuries, but at the same time head and neck injuries have been on the increase. Further research should be undertaken to establish all the possibilities that may remain to explain the increase in head and neck injuries. Educating the hockey community is key, along with enforcing the existing rules to make sure that players wear the appropriate protective equipment, wear it properly, and ensure a safe playing environment.
Acknowledgements
I wish to acknowledge the assistance given by the Sports Medicine Staff at University Hospital of Hartlepool and to Eve Jackson, Undergraduate Rotation Organiser, for her help and support.


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