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Prevent Concussions

08/08/2013, 9:15am MDT
By USA Hockey

This information is from the recent cover article in The Journal of Musculoskeletal Medicine which will need to be referenced (Michael J. Stuart MD. Managing and Preventing Ice Hockey Injuries. J Musculoskeletal Med. January, p.37-44, 2005. Here is an excerpt on the head and face.

Mandatory use of standardized helmets has apparently reduced the incidence of skull fractures and intracranial hematoma. Despite helmet protection, concussions occur with alarming frequency. Concussions encompass a graded set of clinical syndromes that may or may not involve loss of consciousness. A direct blow to the head, face, neck or elsewhere on the body may cause a concussion by transmitting an impulsive force to the head. The resultant brain injury is due to a rapid onset, short-lived impairment of neurological function that resolves spontaneously.5 The acute symptoms reflect a functional disturbance rather than a structural injury. Players should always report symptoms such as prolonged headache, confusion, visual disturbance, and loss of memory or concentration. (Table 2) Health care professionals should look for concussion signs and maintain a high index of suspicion. (Table 2) A recurrent blow to the head can be serious, since repeated concussions cause cumulative damage and the severity can increase with each incident. After an initial concussion, the chance of a 2nd concussion is several times greater.
Physicians and athletic trainers should always rule out an associated neck injury when evaluating a player with a suspected concussion. Obtain a concussion history, since prior brain injury can affect severity and risk of recurrence. Perform a "sideline" evaluation, including a neurological examination, balance testing, and mental status assessment for orientation, attention, memory and concentration. Repeat the evaluation after 15 minutes both at rest and after exertion. No grading systems or return to play guidelines to date have been scientifically validated; therefore, common sense and caution should guide judgment. A symptomatic player should never return to play or be left alone. The player should be monitored regularly, medically evaluated after the injury and cleared for return to play by a physician. Neuropsychological testing, if available, may provide insight into concussion severity and recovery.
Facemasks have dramatically reduced the risk of eye injuries, including periorbital lacerations. Eye trauma from a stick, puck or elbow to players wearing partial or no protection can cause hyphema, orbit fracture, retinal detachment, or globe rupture. A blinding eye injury to a hockey player wearing full facial protection has never been reported. Full facial protection also reduces the risk of facial lacerations and dental fractures. A prospective cohort observational analysis in the United States Hockey League demonstrated a 4.7 times greater risk of eye injury with no protection compared to partial protection (visor or half-shield).6 No eye injuries occurred to players wearing full protection. This study demonstrated that both full and partial facial protection significantly reduce injuries to the eye and face without increasing concussions. All youth, high school and college players in the United States are required to wear full facial protection. USA Hockey rules now also mandates full facial protection for all Junior players. However, players 18 years of age and older may wear a half shield (visor) if they sign a waiver. The helmet and half shield must not be worn tilted back so that the bottom of the visor is above the tip of the nose. Improper positioning of the visor may direct a stick or puck toward the eye. A violation of this rule is a misconduct penalty. The helmet should be secured with a padded four-buckle chinstrap to prevent migration and protect the chin.
The mouth guard is a required piece of equipment for youth hockey in the United States, but is optional for college and junior players. A form-fit mouthguard not only protects the teeth, but may also prevent concussions and injuries to the temporomandibular joint.


Serious neck injuries (cervical spine fractures) are usually the result of a direct axial load to the top of the head with the cervical spine slightly flexed.7,8 This mechanism occurs in hockey when a player slides on the ice without control or is pushed or checked from behind and hits the boards. The risk of spinal cord injury, including quadriplegia, may be increasing and appears to be higher in hockey than football. Helmets and facemasks have been implicated in this apparent increased incidence of neck injuries because players feel invincible and officials are more lenient in calling penalties. No scientific research to date supports these contentions. However, a false sense of security may lead to violent attitudes and tactics. Prevention of catastrophic injuries involves the cooperation of players, coaches, and officials. Dangerous violent acts must not be disguised as aggressive physical play. Players should learn to protect themselves by making initial board contact with another part of their body other than their head. When sliding on the ice or being checked near the boards, attempt to make board contact with the shoulder blade or buttock areas. If head contact does occur, players should avoid the position of vulnerability by always keeping their "heads up" (in other words: "don't duck"). Coaches should teach body contact and control skills so that players can effectively and safely give and take checks. Athletes and coaches must always practice the objectives of sportsmanship, including respect for their opponents. Conditioning programs should include strengthening of the neck muscles. Existing rules, like checking from behind, charging, and boarding, must be strictly enforced. Non-officials (players, coaches, and fans) must support the on-ice officials who are trained to differentiate illegal from legal contact in order to eliminate dangerous actions. A larger ice surface ("Olympic-size" rink) may decrease player-board contact, which may decrease the risk of injury, especially to the head and neck.
Acute airway trauma to the larynx, hyoid and cervical soft tissues from a stick or puck blow to the throat may be life threatening. Beware of the "choking sign", stridor, hoarseness, hemoptysis, and subcutaneous emphysema. Any suspected airway injury should be evaluated at a hospital since luminal obstruction from edema or hematoma may be delayed. Diagnosis requires evaluation with flexible bronchoscopy and laryngoscopy followed by a CT scan.
Neck lacerations by the skate blade are potentially catastrophic, but uncommon.

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For the last 15 years, Ian Walsh has crisscrossed the United States as an NHL official. In this Part 2 of our conversation with Walsh, the 42-year-old Philadelphia native fielded a series of questions discussing life on the road, his conditioning schedule, mentors, on-ice struggles, the evolution of the game and advice for aspiring officials. 

USA Hockey: How do you think you've been able to maintain all of the officiating success you've had over the last 15 years?

Ian Walsh: I believe one of my strengths as an official is my work ethic. I come to the rink every night ready to work hard and give 100 percent. I also believe I am very coachable, and when I'm offered a suggestion for improvement, I try very hard to implement that advice into my game.  

USAH: What is your conditioning schedule like during the NHL season? How about during the off-season? 

Walsh: During the season, conditioning work is more about maintaining what you built up over the summer. The workouts aren't as intense but you must continue to take good care of your body. Game-day workouts usually include a 30-minute bike ride or a couple miles run at the hotel gym. I also like to do some core work and light strength training on top of that. 

The weather in Portland is amazing in the summer, and I prefer to be outside and on my road bike. I usually get in about four days a week of riding outdoors to help build my endurance and strength. I try to play hockey a few days a week as well to help work on my skating.

USAH: When did you realize you finally had cemented your career as an official? What was that feeling like?

Walsh: I don't know if you ever get that feeling. Every night is a different challenge in our league. It is a hard, hard league to officiate. The scrutiny of every call, every goal, ever non-call is such a challenge for all of us. The best players and coaches in the world expect us to perform at such a high level every night, and we have to be ready for anything that comes our way. It’s a privilege to be on the ice in the NHL, and I think that is something no official takes for granted.

USAH: What has been your biggest accomplishment to date as an official? 

Walsh: Being chosen to participate in four Stanley Cup playoffs is what I'm most proud of. It’s an incredible honor to be selected and that’s the goal for every official each year. Also, being part of the team that was chosen to represent the NHL at the 2014 Sochi Winter Olympics was a phenomenal experience and a great opportunity.

USAH: What has been the biggest hurdle/obstacle you've had to overcome in your officiating career? 

Walsh: I’ve been lucky so far, knock on wood, that I haven’t had any serious injuries. Other than some bumps and bruises, I’ve been relatively injury-free in my career. The biggest challenge is to be able to bounce back from calls you made that aren't correct. In this day and age, we usually know within minutes after the game if we made a wrong decision. When you make a call that impacts the game, it’s hard on the mind. Unfortunately, we make mistakes and what most people don't understand is that nobody takes it harder than the official making that mistake. Being able to bounce back from a mistake is something all officials must learn to do.

USAH: Who has had the most impact on your officiating career over the past 15 years? What has that person or those people taught you?  

Walsh: Nobody has helped me more over my NHL career than fellow referee Paul Devorski. I've worked a lot of games with Paul and we’ve had the opportunity to travel together on the road. As an elite, veteran referee, he has been able to pass down some of his knowledge to me to help me become a better official. Paul is retiring this year, and our staff will sorely miss him.

USAH: How has the game changed, besides speed, since you started in the early 2000s?

Walsh: I would say the biggest change besides the speed of the game would be the use of technology. It is amazing what you see at rink – teams have iPads on the bench, super slo-motion video replays, hi-def video scoreboards, etc. With all that technology, it makes the officials job appear easy. People forget that the official on the ice sees a play one time, in real time, and must make a split-second decision on that play. It often appears quite different when you see a replay in super slo-mo on hi-def after a game.

USAH: What advice can you give aspiring NHL/professional league officials as they progress in their career? 

Walsh: I would say make sure you have a backup plan. Making it to the NHL is everyone’s goal, but there are very few jobs available. There are so many factors that go into hiring an official and a lot of those are out of your control. Go and work the highest level available to you. Don't worry about other officials, if you are good enough, the NHL will find you. Also, control what you can control – always work on your skating, know your rules and come to the rink every night with a strong work ethic and a great attitude.

Tag(s): Concussion Information