ACL injuries in Ice Hockey & Return to Play Considerations

By Steve Chmielewski, PT, DPT, Level 5 USA Hockey Coach for Athletico Physical Therapy

Sport-specific training has become a larger component in athletics as coaches, parents and players strive to push the boundaries of athletes’ abilities for the betterment of players and teams. However the link between injury and high-level training is rarely discussed.

Take ACL (Anterior Cruciate Ligament) injuries for example. Although sports such as soccer, football and basketball typically dominate the conversation surrounding the recovery process of an ACL injury, these types of injuries also occur in ice hockey. The lack of discussion regarding ACL injuries in hockey can make it difficult for those rehabbing these injuries to know what to expect.

For instance, the immediate recovery from ACL surgery is consistent in both athletes and non-athletes alike. There is typically a long recovery period of 6 to 12 months before an athlete can return to sports that involve running and cutting. Range of motion into both flexion (bending the knee) and extension (straightening of the knee) are major priorities to ensure a progression toward strengthening at the appropriate pace. A proper health provider (physical therapist or athletic trainer) is trained to progress a patient through this difficult time with the guidance of a surgeon.

Most ACL injuries that occur in hockey are traumatic in nature by way of a collision with a player, the boards, or the ice and are complicated with the involvement of medial collateral ligament (MCL) and potentially the meniscus. Since ACL rehabilitation is a bit unique in ice hockey due to the nature of the sport and the demands it places on the knee, I have outlined some things that athletes should take into consideration when returning to play after this type of injury occurs.

Skating and Rehabilitation

When rehabbing after an ACL injury, the skating stride is a unique element of return to play because it requires the player to generate forces through the limb in all directions while the other knee is in deep flexion to provide stability and balance. These phases in skating are commonly divided into two categories: the push leg and the stance leg.

A transition in therapy from bilateral training to progressive single leg strength training is essential to ensure the knee is able to tolerate sustained holds in a deep knee bend through both legs to generate power during each of these phases while maintaining proper knee mechanics. The athlete will have to tolerate pushing off the affected leg repeatedly to move from one end of the ice and allow the individual to change directions quickly. This requires strong hip and quadriceps control to prevent compromising stresses to the knee (valgus forces). These stresses can be seen off the ice when a player is pushing off a slide board or with lateral cutting movements and can be viewed when the knee collapses inward. As the individual progresses through their therapy, this should be a key marker prior to their return to a return to the ice. This will allow the individual the opportunity to progress through their skating tasks with a reduced likelihood of swelling and pain later in their recovery. Prior to returning to competitive play, the individual should feel pain-free and stable with the following:

Forwards and Defenseman

  1. Stopping (snow plow->hockey stops)
  2. Long strides
  3. Backwards C-cuts
  4. Face-offs
  5. Shooting
  6. Quick starts (V-starts, cross over starts)
  7. Forward Crossovers
  8. Backward Crossovers
  9. Progressive simulated activities (board battles, puck protection, read and reaction drills)

Additional Goaltender Activities

  1. Side to side edge work (standing)
  2. Multidirectional positioning (T-push from post to angles)
  3. Stationary weight shifting in butterfly (no lateral movement)
  4. Lateral
  5. Standing <->butterfly training
  6. Game simulation drills

This list is great for players to focus on while progressing through their later stages of therapy and when cleared by their surgeon and their physical therapist/AT:

  • Dynamic warm ups (progress from single plane->multiplane-> multiplane plyometric training)
  • Progression in squat tolerance
  • Progressions in single leg strength training
  • Progressions in no weight bearing core strengthen from single plane ->multiplane
  • Progressions in weight bearing core strengthening
  • Single leg hoping forward ->diagonal hops

Make sure to consult your physical therapist if you have any questions about your recovery process or how to effectively return to sport during your journey. For information about Athletico’s ACL 3P Program, which can help athletes minimize the risk of ACL injury as well as help those who have experienced an ACL injury progress after surgery, please email ACL@athletico.com.

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MCL Injury Basics with ATI’s Hockey Injury Expert

 MCL Injury Basics with ATI’s Hockey Injury Expert

By Brian Rog with Contributions by: Andrew Grahovec and Katie Christopherson, ATC for ATI Physical Therapy.

To compete at the professional level in any sport requires the most athletic, highly skilled and mentally acute individuals in the world. With constant training, practice and exhibitions throughout a season, pushing your body to the utmost physical limits can take a toll on the body over time. In ice hockey, players, by nature, are regarded as some of the toughest athletes on a mental and physical level.

As one of the fastest sports, the conditions during play are dangerous and require sharp focus, balance and grit to compete at a high level. With the speed and physicality of the game, the risk of injury is significantly increased. It’s no surprise that one of the most common types of injuries sustained during play involve the knees.

To get a better feel for the inner workings of the MCL (Medial Collateral Ligament) and MCL injury insight, we teamed up with ATI athletic trainer and hockey injury expert, Katie Christopherson.

The role of the MCL

Considered one of the four primary stabilizing ligaments in the knee, the MCL is the innermost ligament of the knee designed to protect the knee joint’s stability and strength. It also plays a key role in preventing the leg from over-extending inward. For hockey players, the MCL is crucial in helping the knee manage the on-ice demands of skating, planting for contact and more.

Symptoms of an MCL injury

When an MCL becomes injured, you may experience pain on the inside edge of the knee, along with swelling and tenderness. Several hours after the injury, this discomfort may be coupled with difficulty moving and increased levels of pain. It’s also not uncommon to feel a ‘loose or wobbly’ feeling in the knee when walking. At this point, we recommend getting in touch with your primary doctor or local physical therapist to further assess the injury.MCL Injury assessment with ATI

Grades of MCL injuries

Since the MCL’s primary role is preventing the leg for overextending inward, naturally, it assumes a substantial amount of the body’s weight. Because of this, an athlete is more susceptible and likely to experience an injury to the MCL, rather than the LCL (Lateral Collateral Ligament), which is located on the outer side of the knee – opposite of the MCL.

MCL injuries are classified according to three different grades including:

·         Grade 1 (minor): results from a force strong enough to stretch the ligament, but not tear it.

·         Grade 2 (moderate): stretched ligament with some tearing involved

·         Grade 3 (severe): completely torn ligament – and most sever of the three grades

Which sprain is the most common among hockey players?

Given the fast-paced, high-contact nature of the sport, hockey players are at an increased risk of injuring their lower body structures. When looking at the MCL specifically, it’s more common to see Grade 1 MCL injuries resulting from less abrasive blows to the knee or mild twisting motions at the knee. For Grade 2 and 3 MCL injuries, we tend to attribute those to the more nefarious blows or extreme twists to the outside of the knee, which still happen, but not as often as the former.

Rehabbing an MCL Sprain

Among the three grades, a Grade 1 treatment is a more straightforward than the others. A Grade 1 sprain can take typically one to two weeks to heal, whereas a Grade 2 and 3 injuries may take two to four weeks and four to eight weeks, respectively.

MCL Physical TherapyIn rehabbing an MCL sprain or tear, your physical therapist or doctor first determines the grade of the injury and the effect it has on the knee during weight-bearing (the body’s ability to resist or support weight). They’ll also note how the knee joint moves through flexion (bending motion) and extension and how that force displacement is on the MCL. This will ultimately decide what treatments and strengthening methods to use.

Initially, an athlete’s treatment should consist of pain-free, range of motion exercises, such as knee slides on the table, wall slides, assisted slides and riding a stationary bike.

As pain subsides and range of motion increases, this usually indicates that an athlete is ready to incorporate flexion and extension exercises – like open-chain strengthening (hands or feet are not in a fixed position). But that’s not to say that an athlete should shy away from closed-chain strengthening (hands or feet are in a fixed or stationary position), as these are also effective exercises to build into a program.

Once an injured athlete progresses to the more advanced stages of rehabilitation, a concentration on functional activity will be introduced. This may include plyometric exercises and functional activities to ensure dynamic stability of the knee.

At this stage, a great tool for rehabbing a hockey player is a slide board, which is a slick surface that can mimic the motion of the athlete’s leg on ice.  

Dealing with a knee injury?

ATI experts strongly encourage athletes to take care of any minor aches and pains before they compound and get worse. This can be as simple as heating for 20 minutes before activity and icing for 20 minutes after activity when the athlete feels soreness in one particular area. If the pain persists, it might be a good idea to call your physician or visit your nearest ATI physical therapy clinic. In fact, at ATI, we offer complimentary injury screenings, so stop in and see what we can do for you.

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Youth Hockey and the NBA: Sports Injury Update

 

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Steve Kashul and Dr. Brian Cole talk about youth hockey injuries: how to compensate and recover from pain due to knee on knee impact; treatment of  ‘water-on-the-knee’; analysis of the ankle dislocation suffered by Caris LeVert with the Brooklyn Nets.

Sports Medicine Weekly on 670 The Score

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Former College Athlete Gives Unique Perspective on Knee Cartilage Injury

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It was a typical winter afternoon in southern California playing with his son at the park.

He stepped in a small hole, not unlike a hundred times before in the past without incident, so he brushed it off as just a temporary tweak or mild sprain. He then did a quick jog to the car and noticed a pinch of pain on the outside of his knee with every step forcing him to stop and walk.

Joshua grew up in Southern California playing about every sport imaginable sometimes playing hockey and football games in the same day. He was a varsity four sport athlete in high school, at one point even training with future professional Olympic and elite spartan runners running up ski slopes at the local resorts. In college, he ran under a coach who was an American record holder in the mile. No matter what sport or how many thousands of miles in training, he never suffered any major injuries.

The day after rolling his ankle he noticed he could not quite bend his knee as much and then when playing with his one-year old daughter his knee suddenly locked for a few minutes unable to straighten or bend at all. In the next couple days, Joshua was able to get a stat MRI.

He did know that since college he had put on about five pounds a year and this raised the risk of him having a knee injury or potentially damaging his cartilage.  With his ten years of experience as a Physicians Assistant (PA) in Orthopedic Surgery specializing in sports medicine, he started speculating on his diagnosis – quite possibly a bucket handle meniscus tear.

What he saw on the MRI scan immediately shocked him. He could see clearly that he had sheared off a chunk of his articular cartilage the size of a dime, which looked like a snow plow went through it. “I knew I was in big trouble,” Joshua explains, “…it’s such a bad injury because cartilage does not heal itself and doesn’t regenerate.”

Being dealt this curveball, Joshua started immediately reviewing and researching more about current cartilage surgeries to make the best decision on how to get it treated. Coincidentally, ten years earlier, while going through his graduate PA program, he chose as his master’s project “new treatment strategies in knee injuries for the prevention of knee arthritis.” As a PA in Orthopedic Surgery, he had scrubbed about a dozen cases throughout his ten-year career and knew the complexity of cartilage surgeries. After weighing the pros and cons, he eliminated a possible autograft or microfracture. He reached out to a renowned sports Orthopedic surgeon, Dr. Raffy Mirzayan, about performing a cartilage allograft transplantation.

A few months after the injury and finding a right match, Joshua went through with the two-hour outpatient surgery with no complications. Within six weeks he was walking with a cane and had full range of motion. Now, at five months after the surgery, he can walk normally and go up and down stairs; perhaps most importantly, he is able to play with is two kids again. His hope is to get back to running once his knee has healed (after about eight months) and to get back to running with his competitive college teammates.

He is eternally grateful to the donor and the family and he wants to do something special before he reaches out to them to thank them for the gift of donation. “I really enjoy helping others… I want to be able to pay it forward.

“I haven’t written a letter yet because I want to do something to thank them… I want to write a letter with me doing something (finishing a race) to show them how much of an impact it made for me.”

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For Hockey Players, Downtime Means Lacrosse Training Time

Dr. Brian Cole, @SteveKashul & Jason DeMaria owner of JD Strength Performance discuss training routine w/ hockey players during the off season and the growing popularity of #lacrosse training techniques.

Jason (Jay) De Maria attended Western Michigan University. While in college, Jay played ice hockey and volleyball.  As a student, he earned a Bachelor of Science Degree in the field of Exercise Science. Quickly looking to further his education, Jason became a Certified Strength and Conditioning Specialist from the National Strength and Conditioning Association and a Performance Enhancement Specialist through the National Academy of Sports Medicine.

With more than 10 years of experience behind him, Jason has successfully coached athletes in multiple sports.  Athletes of all levels have succeeded under Jason’s coaching, ranging from youth athletes all the way through the Collegiate and Professional ranks.  His dedication has earned him time working alongside strength and conditioning staffs in the USHL and the NHL.

More on Notable Athletes trained by Jason DeMaria

Sports Medicine Weekly on 670 The Score

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