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Its always a pleasure to be able to sit down with individuals who’ve “been there, done that”, but anytime I’m able to sit down with someone associated with hockey, this becomes a privilege. Rather than give you Sean’s bio, I’ll just refer you to this link.

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Sean Skahan

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The reason I’m writing about this rendezvous is because of some of the topics we chatted about. Here, in point form, was the jist of our conversation.

• The importance of working hard to create opportunities – Sean isn’t where he is today because he spent 8 hours on the computer and one hour of training clients per day. Sean was in the trenches, interning with one of the best, and jumping on any opportunity awarded to him from his great work. He stated that sometimes these opportunities come in different and unexpected forms (he’s always wanted to work with football), but it was important that he both recognized and pursued them.

• The difference between American and Canadian hockey players - One thing I shed some light on, to which he agreed, was the difference between players north and south of the border. Here, in Canada, hockey schools are a dime a dozen. Our players have a fantastic skill set and our young players spend almost as much time on the ice than they do in school. Unfortunately, this creates a problem. Many, if not most, of our players do not know how to train. In contrast, if you look at American youth, plenty of time and money is devoted to athletic development. In fact, the sporting culture down south is an industry. From full time strength coaches and athletic trainers/therapists in high schools to athletic scholarships in college and university, young American athletes know how to train. One example I provided Sean with was with regards to Olympic lifting. I asked him to compare his Canadian prospects and rookies with his American counter parts. If you’re in professional hockey, ask yourself the same question and I guarantee you’ll come to the same conclusion: Canadians spend too much time on the ice and not enough time developing themselves as athletes.

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Canada - 3 : USA - 2

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• The contribution of track and field – Those of you in the field of strength and conditioning, regardless of sport, should spend some time working with track and field athletes and coaches. Luckily I was fortunate to work closely with the University of Toronto Track Club for a number of years. Some of the lessons I’ve taken away from this opportunity were the importance of a thorough warm up and cool down to training, the creativity utilized by coaches when cueing, and the precise form utilized when training in the weight room. Sean agreed that we can all learn a lot from spending some time working with athletes in this sport.

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For more information about Sean Skahan, please visit seanskahan.com. He also posted an excellent article on Dragon Door and recently released his DVDs on Kettlebell Lifting for Ice Hockey which can be found here.

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So far, experts, non-experts, and wanna-be-experts have all shared their opinions on what should and could be done to curtail the incidence of head injuries and concussions in the NHL. From eliminating fighting to modifying equipment to tactical rule changes, there have been countless ideas rendered of what the league can do differently to protect their players as well as the game itself.

Unfortunately, making changes isn’t easy. We all know that. Even the NHL’s arm-chair executives (the fans) know that. But collectively, I believe most if not all of us can agree that something must be done. Or else…

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While our knowledge base is still relatively limited with respect to the ramifications of sustained concussions, let alone early return to play from head injuries, we do know, as Mr Dryden stated, that:

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“Better helmets, more muscular necks and shoulders, MRIs and Rule 48 haven’t offered the answer to 220-plus-pound players moving 30 miles an hour.”

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220-plus pound players moving 30 miles an hour? Really?

The game of ice hockey has changed dramatically over the last 30 years, but what hasn’t changed, and perhaps what has been staring at us in the face the entire time, is the size of the rink. Simple physics will tell you that an ice rink measuring 200 feet by 85 feet containing the same amount of players (let alone one extra referee) that now weigh an approximate average of 20 pounds heavier and travelling approximately 15 more miles per hour may no longer be the appropriate size.

So maybe…just maybe…we need a larger fish tank.

When our pet koi outgrow their tank, we get a larger tank. And when our children outgrow their skuuts, we get them a bike.

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Now I’ll admit that I do not have the epidemiological data on concussions over in Europe where they play on larger ice surfaces, but only because of the simple reason that there hasn’t really been any significant studies published in recent times. Remember, studies take several years before the collected data turns into published research. And the only studies currently available are ones published the 90s. A lot has changed since then.

Surely, some will argue that the European game is completely different than the North American game. And I would agree. But I would also counter that there are many North Americans playing over in Europe, with my brother-in-law as an example. But I would also state that perhaps the difference in style of play across the ocean may actually be secondary to rink size more than any other significant reason. Perhaps?

Now others would argue that it would cost millions and millions of dollars to alter the ice rinks in each of the 30 North American cities where teams are located. Again I would agree. But I would also counter that millions and millions of dollars are equally spent on player salaries as well. And what good is the NHL when its highest paid players are sitting on the sidelines suffering from concussions?

So Gary Bettman states,

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“I will go where science takes me”

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As a health care practitioner, that exact statement is what I am trained to follow. But in the case of the NHL, what if the scientists are asking the wrong question? Or, maybe they are asking the right questions, but what if other specific questions aren’t being asked?

Perhaps science can take us down the path that soccer (football) in Europe and other countries around the world have taken for several years and study the area covered by players during 60 minutes of regulation play. Total distance as well as peak and average speeds can be determined via global positioning systems relative to the area of play to determine whether a need for a larger ice surface is actually necessary. And sound science must utilize comparative data so perhaps the exact same study (or studies) can be performed in the KHL, DEL, Swedish Elite leagues to name a few. Simply put, I would hypothesize that players would a) cover the same total amount of ice, travelling at the same current speed, but in a less confined area or b) cover less amount of ice in total, travelling at the same current speed, AND in a less confined area. Further, I would also hypothesize that the puck would change directions with less frequency on the larger ice surface leading to more predictable play.

And should these types of studies conversely reveal that a larger ice sheet results in a greater total amount of ice covered, then perhaps this may equate to less frequency of collisions.

I know this may seem far fetched but it is an idea. One that, in my humble opinion, may have at least an ounce of sound merit to it.

*UPDATE*

A colleague directed me to this research study. Seems as though my thoughts are not too far off!

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For more information on concussions, please check out ThinkFirst Smart Hockey’s online education program or their resource page.

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This video exposes the most common speed training faults of hockey players and reveals a new system for designing off-ice exercises that actually transfer to on-ice speed improvements. To watch the video, just click the affiliate link below:

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Speed Training for Hockey by Kevin Neeld

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Over the last couple of years, I have utilized the FMS to screen each of my players prior to the commencement of the season. Having both tracked and treated their injuries year-long, it looks like one of the seven screens may be a powerful predictor of AC joint separations. Traditionally thought of as an injury that occurs due to the physical nature of the sport, AC separations are one of the most common injuries in ice hockey. In fact, shoulder injuries in general consistently rank quite high in epidemiological studies (see studies by Benson and Emery).

As per the FMS manual, “The shoulder mobility screen assesses bilateral shoulder range of motion, combining internal rotation with adduction and extension, and external rotation with abduction and flexion. It also requires normal scapular mobility and thoracic spine extension.” A loss of such normal scapular mobility and thoracic spine extension often results in any of the following presentations: sick scapula, upper crossed syndrome, scapular protraction, etc. And as a result, a shoulder girdle that may be more prone to injury.

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When thinking about AC joint separations, it is important to note that often it is the acromion that translates in a downward fashion rather than the clavicle moving superiorly. In each of the above faulty presentations, it is not uncommon for the acromion to already be trending toward an anterior-inferior position. Now when presented with trauma such as a seemingly benign body check, a protracted shoulder may indeed not be able to “cushion the blow” as well as one that is retracted, and may sustain an AC injury.

At least this is my take on it.

But what can we do to “better position” our players for increased resiliency?

Personally, I prefer dynamic and loaded correctives over manual stretching and therapy. Indeed soft tissue work may be necessary, but experience has demonstrated to me that the following correctives give me a bigger bang for my buck.

Try these out with your 1′s and 2′s and let me know what you think!

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I studied the HITs system too!

Study Title: Does cervical muscle strength in youth ice hockey players affect head impact biomechanics?

Authors: JP. Mihalik, KM. Guskiewicz, SW. Marshall et al.

Journal: Clinical Journal of Sport Medicine

Date: September 2011

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Summary:

• Some of you are aware that Hockey Canada recently instituted their new Head Contact Rule in an attempt to minimize head and neck injuries, including concussions. While I think this is certainly a giant leap in the right direction, there are also many other factors to consider when it comes to injury prevention. In this particular study, Mihalik and his group of researchers looked at the role of more “internal factors” for head injury prevention, specifically cervical muscle strength. The rationale for this paper was based on the speculation that the neck can be strengthened to reduce the risk of mild traumatic brain injuries by way of tension to withstand and distribute the force of head impact.
• This prospective cohort study utilized AAA hockey players (aged 15 + 1 year) wearing helmets equipped with Head Impact Telemetry to record impact force data (linear, rotational and HIT severity profile) in real-time. Using a handheld dynamometer, body relative cervical muscle strength (as described by Kendall) of the anterior neck flexors, anterolateral neck flexors, cervical rotators, posterolateral neck extensors, and upper trapezius were measured. These results were then used to categorize the players into three groups based on strength (weak, moderate and strong) for the purposes of comparative analysis.
• Of the 7770 total impacts recorded over the course of one season, it was revealed that increased isometric cervical strength did not reduce the severity of head impacts. In fact, those players with weaker upper trapezius muscles experienced lower impact severity scores than those with the strongest recordings.
• Personally, I am not prepared to discredit the role of neck strengthening as a potential protective mechanism but I do think some things (relevant to this aspect of injury prevention) need to be considered. First, I am not quite sure how the results from a shrugging maneuver (as used to test the upper trapezius) can be relevant regardless of the findings. I would put more weight into those results from each of the other testing procedures. Second, I’m more of a quality of muscle activation kind of guy rather than a quantity. Does quantity matter? Of course, but I do think that the ability to reflexively stabilize a joint upon impact is more important than absolute strength. I would liked to have seen Janda’s and Jull’s tests rather than the ones used. Finally, we should remember that the results of this paper are demographic specific. At this age, the players are not only still developing physically, but they are also still learning the art of both rendering and receiving contact. Therefore, I would like to see a similar study performed at higher levels and at the very least, in junior age players.

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Mihalik, JP et al. (2011). Does cervical muscle strength in youth ice hockey players affect head impact biomechanics? Clinical Journal of Sport Medicine, vol 21(5); 416-421
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Rinkside Reading: Off-Season Training Tips

Unfortunately, many people still aren’t getting the message. Last night, I was watching the local news and perked up when a segment about the Edmonton Oil Kings‘ fitness testing day was aired…until I heard a message about Early Specialization. Go directly to 35:35 for the segment.

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I think we’re still missing the boat. How is it that the message of healthy, long term athlete development is being completely forgotten? Is it Hockey Canada? I doubt it. Is it the media? Perhaps. Or is it the trainers? Maybe, maybe not. I know Body By Bennet has plenty of room in their facility for fundamental skill development and I know they’re doing the right things, but somewhere, somehow some parents are getting the wrong message. I really don’t know what’s going on in other, less established facilities. At least here in Canada anyway. Read this discussion I had with Sean Skahan early in 2011.

One of my graduate supervisors, Dr. Joe Baker, recently released his new book “Talent Identification and Development in Sport” and in a recent article in the Toronto Star he states,

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“Playing many sports…is a sign of general athletic prowess and a source of useful skills for the one a youngster will eventually choose.”

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Anyway, young Canadian children need to be children first. They need to be athletes second. It’s okay to be a “hockey player” and I encourage young children to get out on the ice and play, but most importantly, they need to participate in a wide range of athletic and playful activities.

Because mark my words, 10 years from now the U.S. will be a power house in international and professional hockey.

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Video streaming by Ustream

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If you're not a member, you're missing out!

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For those of you unfamiliar with FAI, make sure you read Kevin’s post before reading any further. But for those of you who are, you’ll know that there are a million orthopaedic tests that all look the same.

So what do you do when these tests are positive? We already know that many professionals who suffer from FAI also have labral tears, but what about those young athletes who have no labral pathology? And what about those who do have labral pathology but for some reason or other, may not be candidates for surgery?

Well some of you soft tissue the heck out of it on a weekly basis but do you truly get the results you’re after? Maybe, maybe not. And if not, why not?

To answer that question, we have to ask ourselves what, from a non-osteological perspective, may be contributing to this presentation in the first place? Well Shirley Sahrmann may have the answer to this one. And her likely answer will probably fall somewhere along the lines of the anterofemoral glide syndrome (check out Eric Cressey’s post for some info on this presentation).

But back to my question, as a manual and rehabilitation therapist what can you do about it?

We know that the deep posterior hip structures are often stiff and shortened, so the first thing I would do is mobilize these structures.

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We also may notice that the adductor musculature likely need some soft tissue work as well, so I would pistol (perhaps a simultaneous and combined ART / contract relax strategy – using the elbow as resistance) my way through these structures as well.

Personally, I prefer a more gentler and slow approach than his technique.

I’d also probably use a foam roller as well to save my hands.

I would likely then do some trigger point work in the anterior portion of the gluteus medius region at this point. Sorry I don’t have a video recorded for this one but only because its my secret weapon . Actually, you can do some needling here (and the TFL) as well, if you want even faster results.

Hit 'em RIGHT behind the ASIS.

But next I’d get them to do some self mobilizations, again for the deep posterior hip structures:

Then I’d throw down some “Sister Kenny” action (but more for the glute max rather than the glute med). Take a gander through Craig Liebenson’s ROS to see what I’m talking about (just click on the image).

And finally, I’d lock it down with the most appropriate, glute-dominant hip extension pattern that their exercise progression continuum calls for. This can be the lumbar-locked glute bridge:

It can be the hip extension portion (12:00 direction) of the Valslide Quadruped Hip Stability Clock Slide:

Or it can be the hip airplane:

As always, you’re free to choose whatever exercise you wish, just make sure its appropriate!

Happy treating!

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With the off-season underway for the majority of families, many are asking themselves what they can be doing to prepare their young one(s) for next fall. Certainly there are no shortage of hockey camps, schools, and tournaments available but if your son or daughter plays minor hockey, then I highly suggest you take a look at my recommendations in the “Rinkside Reading” section of the Hockey Centre.

Just click on the image above.

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Authors: W. Meehan

Journal: Clinics in Sports Medicine

Date: 2011

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Summary:

• Here is a little review of potential interventions in one of the most influential and highly discussed injuries in ice hockey today, concussion. While the current state of the literature may still be in its infancy, each incident of this “traumatic brain injury”, particularly in professional hockey, seems to make front page news and cast a shadow of doubt on the safety of our sport. This paper by Meehan discusses various therapeutic options that may be rendered in the presence of such injury.

• First introduced is the role of physical rest in the recovery process. The stepwise return to play protocol is discussed although it is mentioned that studies have begun investigating the role of light physical activity during recovery. Since quantitative cognitive deficits have been demonstrated in the presence of such injury, academic accommodations via cognitive rest were suggested for student athletes.

• Often considered an “invisible injury”, Meehan proposes that education regarding the typical recovery process be one of the mainstays of therapeutic intervention. Studies have demonstrated fewer symptoms at follow up in those that were informed about their symptoms, coping strategies, and the likely course of recovery.

• While most athletes achieve spontaneous recovery of symptoms within days to weeks, some experience prolonged recovery to which pharmaceutical intervention may be warranted. It should be noted that the evidence for such interventions is very minimal and the following information should be taken as a summary rather than a recommendation of care. Meehan suggests that pharmacologic treatment only be considered in the presence of the following:

1. Symptoms exceeding the typical recovery period,
2. Symptoms negatively affecting quality of life to the degree that the treatment benefits outweigh its risks, and
3. The clinician rendering treatment is both knowledgeable and experienced in the management of (sport) concussion.

• Meehan asserts that pharmacologic treatment has yet to be demonstrated to speed the recovery process and that standard approaches are lacking. Instead, he reports that medications are utilized for the treatment of its signs and symptoms. Since previous literature has grouped symptoms related to sport concussion in the categories of sleep disturbance, somatic (i.e. headache), emotional, and cognitive, chosen medications must be specific to the symptom experienced.

• In the presence of sleep disturbance, sleep hygiene that includes the elimination of constant stimuli (i.e. television, computers, caffeine, etc) is strongly considered. Medically, Meehan’s first line of defence for the presence of sleep disturbance is Melatonin. Other considerations are discussed although benzodiazepines seem to be advocated against due to their negative arousal and cognition effects.

• Somatic symptoms such as headaches are common in the presence of sport concussion. Meehan discusses the potential roles of antidepressants (i.e. amitriptyline – his preferred treatment) as well as the potential negative effects (“rebound”) of analgesics such as ibuprofen. Other medications are introduced as well as physical therapy, psychotherapy, and trigger point injections.

• For athletes suffering from emotional disturbance, for example stemming from participation restrictions, Meehan suggests tricyclic antidepressants and serotonin reuptake inhibitors as a complementary intervention to coping strategies, familial support and psychological counseling.

• Finally, since cognitive symptoms are common complaints in those suffering from sport concussion, potential pharmacologic treatment may include methylphenidate for attention and speed processing deficits as well as the domaminergic agent amantadine for executive function and prefrontal cortex glucose metabolism, in addition to cognitive rehabilitation.

• It should be noted that the majority of athletes recovery both spontaneously and quickly from sport concussions. The preceding review merely discusses potential medical interventions that may have complementary roles to physical and cognitive rest and rehabilitation. It must be reiterated that the above MUST NOT be taken as prescription but merely as a review of Meehan’s academic paper, intended for medical professionals. If you or your family member has sustained a concussion, you MUST consult a physician for care.
  

Meehan WP. (2011). Medical therapies for concussion. Clinics in Sports Medicine, 30; 115-124.

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Um, not really!

A high ankle sprain can be an injury to any or all of the following:

• The distal anterior tibiofibular ligament (ATIFL)
• The distal posterior tibiofibular ligament (PTIFL)
• The transverse ligament
• The interosseus ligament
• The syndesmotic recess
• The synovium
• The plica
• The intermalleolar ligament
• and may include a fracture to any of the osseous structures

There are certainly no shortage of structures in this area and therefore, assumption that the injury is sustained solely by the ATIFL is simply a dart thrown with a blindfold.

For example, upon suspicion of a syndesmotic injury, it is important that specific clinical tests are utilized to determine in fact whether or not such injury was sustained. Dr. Pajaczkowski does a nice job in this case report of summarizing four orthopaedic tests including the squeeze test, the external rotation stress test, ligament palpation, and passive dorsiflexion. It is also important to assess the proximal tibiofibular joint to determine the possible presence of a fracture or ligamentous injury.

Following this, should imaging be required, an x-ray is commonly the first line of defense to determine the presence of osseous damage. Among the studies required, the entire tibia and fibula must be examined to identify whether or not a fracture of the proximal fibula is present. Additionally, stress views are commonly performed since traditional anterior-posterior and oblique views may not fully demonstrate an increased tibiofibular clear space. One specific injury commonly missed is a fracture of the posterior malleolus.

While access to MRI may be limited for some, its clinical utility is generally of extreme importance for optimal management since specificity of diagnosis = specificity of treatment. This imaging modality will likely provide the medical team with direction of care through the identification of the specific tissue(s) involved (as per above). Since there are too many structures to discuss, more information on diagnostic imaging of these injuries can be obtained from the articles by Molinari et al, Williams et al, and Hermans et al.

From a rehabilitation perspective, treatment is typically a product of the specific grade of injury sustained. Naturally, the P.R.I.C.E principle, medication, and modalities may take precedence although it is not uncommon for early active range of motion to be employed. Certainly, addressing dysfunctional and non-painful patterns will prove valuable yet the focus must not be taken away from basic tissue healing principles. To my knowledge, a randomized control trial for the rehabilitation of such injury has yet to be performed although several papers have identified successful rehabilitation protocols in the management of this injury. For a detailed outline of rehabilitation protocols for this and other orthopaedic injuries, you may be interested in obtaining Clinical Orthopaedic Rehabilitation by Brotzman and Manske.

A must have for rehabilitation clinicians

Unfortunately, the recovery time line for high ankle sprains are longer than that of “traditional” ankle sprains but hopefully the above information will facilitate a more optimal approach to the management of this injury. Certainly, T.D. Forss and Chris Davie have their work cut out for them but I have no doubt they are more than familiar with such injuries (they are very common in ice hockey) and will have Taylor ready to go for the 2011-2012 season.

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Study Title: Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study.

Authors: A. Robb & J. Pajaczkowski

Journal: Journal of Bodywork & Movement Therapies

Date: January 2011

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Summary:

• Here is a nice little pilot study by two of my colleagues from Toronto on the effect of Active Release Techniques on immediate pain thresholds in elite ice hockey players. Using 9 players from AAA to the major junior level, they studied the influence of this popular manual therapy technique on its ability to modulate reported pain pressure thresholds (PPT) in acute adductor muscle strains. Up until now, the majority of the current literature on this technique had looked at the beneficial application of ART through case studies, however, few if any have looked deeper into the therapeutic effect of such protocols. PPT, “the minimal amount of pressure applied to the tissue to change the pressure sensation to discomfort or pain”,  was assessed both pre- and post-treatment via a hand-held mechanical pressure algometer. A significant improvement in PPT was demonstrated in this study. Since the painful experience involves both a bottom-up and top-down process, this study sheds some light into the potential positive effects manual therapy may have in acute pain patients. While the authors disclose that it is still difficult to conclude with certainty the exact pathophysiological and histological mechanisms responsible for these outcomes, they do provide some potential mechanisms for such reduction of pain. Certainly this study lacked a large sample size and randomization (hence a pilot study), however, the work of Drs. Robb and Pajaczkowski do pave the way for further research to validate a therapy that carries with it an extreme wealth of anecdotal evidence.

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Robb, A. & Pajaczkowski, J. (2011). Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study. Journal of Bodywork and Movement Therapies, 15, 57-62

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