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NHL Group Airs Injury Issues

The National Hockey League (NHL) went on the offensive in focusing on injury treatment and prevention in August in Toronto when it took part for the first time in an educational summit. The conference represented the second major effort by the league in recent years to address hockey injuries; in 1999 the NHL established a multidisciplinary 15-member panel to continually analyze injury data.

Charles J. Burke III, MD, cochair of the meeting and president of the NHL Team Physician's Society, said such broad-based efforts are needed to help physicians monitor changing injury profiles. Hockey, particularly the professional game, has changed over the years, says Burke, who is also head team physician for the Pittsburgh Penguins and assistant professor of orthopedic surgery at the University of Pittsburgh School of Medicine. "Equipment is more protective, and players are bigger, heavier, stronger, and better," he says. In response, physicians and league officials are constantly tweaking rule changes and other injury-prevention strategies.

Problems, Solutions

The conference agenda ranged from common musculoskeletal injuries to training and nutrition topics. The NHL Team Physicians Society and the American Orthopaedic Society for Sports Medicine sponsored the NHL-supported event. Burke says some topics stood out because they were controversial or included new information on treatment.

Concussions. Rates appear to have been stable in the NHL over the last decade, Burke says; however, lack of a clear definition of concussion has clouded the issue. "We're working on a standard definition so that a concussion at the [Los Angeles] Kings' rink is similar to one in Calgary or Pittsburgh," he says. The ability of mouth guards to reduce concussion severity was discussed, but there is still no definitive answer, Burke says.

Epidemiology. Speakers discussed various models that are used to collect hockey injury data and how groups can collect data in a way that makes the information comparable to other studies.

Groin injuries. "Sports hernia is a very hot topic now because it occurs in both hockey and soccer players," says Burke. Speakers discussed how to differentiate between a groin pull and a sports hernia and what physicians should know about mesh repair for athletic hernias.

Equipment. Many physicians who cover hockey teams believe developments in hockey equipment have made it too protective, Burke says. "Equipment has improved protection so that fear of injury is decreasing, and that can influence player behavior." Speakers presented background on how new hockey equipment is researched, developed, and tested. Controversy over head protection has subsided because older players who opted to use less protective helmet styles are retiring, and all current helmets are certified to meet protection standards.

Useful Information for Amateur Hockey?

The fact that the NHL initiated the conference underscores how seriously the league takes its responsibility to promote hockey safety at all levels, Burke notes. However, he emphasizes that differences between the professional and amateur game lead to different injury patterns and unique prevention challenges. For example, he notes that concussions became more of a problem in amateur hockey when face masks were required. "This protected the face, but it makes the face an area for an inadvertent hit," he says.

Once identified, safety initiatives at the amateur level are more likely to be instituted as formal rule changes (ie, penalties) rather than concerted enforcement of existing rules (the later approach is commonly taken by professional hockey). Burke says that the large scale of amateur hockey—about 65,000 coaches and 450,000 players—makes it impractical to hold joint meetings with coaches, referees, and players that would be required to tighten up rule enforcement. In contrast, Burke notes that the NHL was successful in its efforts to more stringently enforce slashing penalties, and that the league is now putting an emphasis on eliminating blows to the head by stricter enforcement of existing penalties for head hits, elbowing, high-sticking, and cross checks.

USA Hockey, the governing board for amateur hockey, has instituted rule changes for the 2021-2021 season. One is a penalty for checks to the head, and another is a modification of a rule to promote use of form-fitting mouth guards. Mouth guards can now be worn without being tethered to the face mask. Burke, who will be team physician for the US men's hockey team in the 2021 Winter Olympics, says the tether rule decreased the use of custom and form-fitted mouth guards, which he says provide superior protection, comfort, and breathing ability.

Medical teams can do only so much to make the game safer. Burke underscores the primary role of good coaching. "Especially body checking—a trend in Pee Wee hockey," he says. "Coaches can teach players about its proper role so that it continues to be an appropriate part of the game."

Lisa Schnirring

Field Notes

High Alert for Achilles Tendon Rupture?
A domino effect of the anthrax terrorism attacks might be greater numbers of patients seeking treatment for Achilles tendon rupture. According to media reports, fluoroquinolone antibiotics such as ciprofloxacin appear to be the most commonly prescribed drug for the prophylaxis and treatment for anthrax infection, and Achilles tendon rupture in patients taking the drugs is well known in the medical literature.

The effect, however, appears to be relatively rare. For example, a review of worldwide safety data for levofloxacin that appeared in a 2021 issue of Chemotherapy reveals that tendon rupture occurred fewer than four times per million prescriptions. One recent Dutch study noted a simultaneous increase in nontraumatic tendon ruptures and fluoroquinolone use; however, the authors stated that the increase was not likely to be solely explained by the increased use of the drugs. Another recent Dutch study suggests that fluoroquinolone-related tendon disorders are more common in patients older than age 60.

A study published in the May-June 2021 issue of the American Journal of Sports Medicine found that ciprofloxacin hydrochloride inhibited fibroblast metabolism in canine tendons, which may explain the ruptures that occur in patients who are on fluoroquinolone therapy. A German study of the drugs' effects on canine tendons, published in the August 2021 issue of Archives of Toxicology, suggests that tendon ruptures are caused by magnesium-antagonist effects of the medications.

Meningitis Outbreak in High School Football
Health officials in southeast Nebraska have linked a bacterial meningitis outbreak that spread among three high school football teams who played each other, according to a November 6 report that appeared in the Lincoln Journal Star.

At least four football players were hospitalized. Players were given antibiotics, and one of the schools disinfected all of its water sources. Parents of students at the schools were told to contact their physicians about prophylactic antibiotics for the children.