From a performance standpoint, hockey has always been a few steps behind baseball. This applies with everything from performance tracking technology to analytics. Although this might not seem ideal from an injury prevention standpoint, some tendencies in player development leading to injury may be more common in baseball than in hockey. For now. If hockey can gain insights from baseball’s elbow problems, we could potentially decrease or at the very least delay hockey players from experiencing hip issues before it becomes a major problem.
As a physiotherapy student, I was very fortunate to have had the opportunity to work alongside guys like Mike Reinold and Lenny Macrina at Champion PT & Performance during my final clinical rotation. I learned A TON about baseball injuries from them. With my background as a hockey player, when I returned to Canada my focus turned to hockey injuries.
Having spent some time working with and researching hip injuries in hockey players, I’ve noticed some particular similarities between baseball’s elbow injuries and hip injuries in hockey. These parallels seem so similar between sports that we may be able to learn from best practices in baseball for reducing the risk of elbow injuries and apply similar practices in hockey to reduce the risk of hip injuries.
Comparing Elbow Injuries in Baseball to Hip Injuries in Hockey
In Mike Reinold’s article “10 Things You Need to Know About Tommy John Injuries”, he discussed how elbow injuries are occurring as a result of tissue overload leading to overuse injury. Based on S&C principles, we know we can change stress on a tissue by manipulating things like intensity, duration, frequency and load. From Mike’s article, some of the variables leading to increased elbow stress in youth baseball are:
Intensity – players are throwing with more velocity
Duration – players are throwing longer throughout the year, with less time off
Frequency – players are throwing more frequently with multiple leagues, teams, and showcases
Load – players are throwing with over- and under-weighted balls
Similarly, hockey players are being pushed towards the limits of the same stress variables. The extension, abduction and external rotation followed by flexion, adduction and internal rotation motion of skating has been shown to increase stress on some of the structures of the hip (labrum study, upjohn study). Most hip issues in hockey are a simply a result of the low load repetitive nature of skating leading to overuse. We can look at tissue stress at the hip in hockey through the same lens as that baseball:
Intensity – The game is faster, and players are faster
Duration – Players are on the ice longer throughout the year with less time off (playing more months/year)
Frequency – Players are on the ice more often with multiple teams/seasons, camps and showcases (more ice times/week/month/year)
Load – Players are training using resistance/assistance sprint training on-ice
Since hockey is behind in research and science compared to baseball, there is not yet solid evidence for the causes of hip problems in hockey players. There is, however, promising research that is beginning to piece together answers to these important questions. The purpose of this article is to investigate the parallels and share some of my observations between baseball’s elbow epidemic and hockey’s growing pool of hip injury.
Trends in Baseball and Hockey Surgery
Ulnar collateral ligament reconstruction (Tommy John surgery) was first performed in 1974 by Dr. Frank Jobe (Jensen et al. 2020) and was performed on the first MLB player in 1986 (Erickson et al., 2015). Over the next 15 years, the rate of Tommy John surgery performed on high school athletes ranged between 8%-13% (Erickson et al., 2015) with the large majority of surgeries being performed on either college or professional players. By 2011, the rate of Tommy John surgeries performed on patients between 15-19 years old was over 50% and continues to rise (Erickson et al., 2015).
Comparing hip arthroscopy trends, we can see some similarities. Hip arthroscopy was first described in the 1930’s but wasn’t discussed again until the mid 1970’s (Kandil & Safran, 2016). Arthroscopic techniques advanced from a diagnostic tool, to simple procedures like removal of loose bodies and debridement, to now labral repairs and reconstructions, microfractures and osteoplasty which are some of the more common procedures performed on hockey players’ hips.
As surgical procedures have evolved, there has also been an explosion in the use of hip surgery with an increase of 600% between 2006-2010 in the US (Bozic et al., 2013). The exact rate of hip arthroscopy in hockey specifically has not been reported, but with increasing hip and groin issues in hockey players (Worner et al., 2019), more players are having hip surgery. Studies of hip arthroscopy in hockey players typically focus on individuals around 25-30 years old (Philippon et al., 2009; MacDonald et al., 2013;Larson et al., 2017). This suggests that the majority of hockey players electing for hip surgery are moving into the later stages of their careers. That being said, this pattern may be soon changing.
I’ve been seeing more junior/college players needing surgery and have even seen some minor hockey players who have needed hip surgery. Similar to Tommy John surgery in baseball, where we are seeing younger athletes needing elbow surgery, we are now starting to see a similar trend in hockey, where hockey players are having hip surgery earlier in their careers. If we can learn from baseball, perhaps we can decrease the rate of hip surgeries, or at the very least, slow down the development of hip problems in hockey players.
3 things that can be learned from elbow injuries to reduce the risk of hip injuries in hockey are:
- Early Sport Specialization
- Higher Velocities, Increased Load
- Implementing proactive joint specific care programs
1) Effects of Early Specialization
In a review on preventing elbow injuries in youth baseball players (9-14 years old), Fleisig & Andrews (2012) found that the strongest correlation of elbow injuries was pitch volume. In particular, youth players who developed elbow injuries requiring surgery had greater pitches/game, pitched more innings/year, pitched more games/year, and pitched more months/year. Part of the problem is that most youth sports are no longer seasonal, they are year-round sports. In baseball, on top of playing summer baseball, there are opportunities for travel teams, showcases, lessons and camps, etc. This leads to youth players not having time to play other sports and focusing just on baseball.
Recommended guidelines for preventing elbow injuries in youth baseball pitchersShepperd et al., (2020) recently found that NCAA hockey players who specialized before high school (<15 years old) had higher rates of hip and groin problems than those who specialized later. Again, hockey players who had higher volumes of ice time at younger ages experienced more issues. Just like other popular youth sports, hockey is no longer a winter sport. Young hockey players often play minor hockey throughout the winter, followed by opportunities to play travel hockey in the spring and showcases or camps through the summer before returning for tryouts in the early fall. With such a year-round schedule, this leaves little time for young hockey players to let their bodies rest and experience other sports and/or activities that would benefit their development as people and athletes.
Although there is still lots to learn about the cause of some of these hip problems in hockey players, a couple of the recommendations made by Fleisig & Andrews could also be implemented in youth hockey (<15 years old): players should not play for more than one team in overlapping seasons and should refrain from on-ice activities for a minimum 2 months per year. This would prevent accumulating high frequency of skating in short amounts of time as well as long duration of skating over the course of a year.
2) Higher Velocities, Increased Load
Another common trend in baseball and hockey that is likely contributing to both injury issues is increases in velocity. In baseball, there has been an increase in throwing velocity over the years. Research by Keller et al. (2016) found that MLB pitchers who threw more fastballs had a higher risk of elbow injury. This suggests that throwing more high velocity pitches (fastballs) increases the risk of elbow injuries in major league players. There is also evidence suggesting that pitchers who throw at higher velocities may be at a greater risk of elbow injuries than those who throw at lower velocities (Chalmers et al., 2016).With the increase in pitching velocity, and pitch velocity being a factor in elbow injuries, it is no surprise that we are seeing an increase in elbow injuries.
In hockey, the game has shifted from a mix of skilled players and grinders to a mix of skilled players and highly skilled players. This is perhaps best visualized by the evolution of the NHL’s Fastest Skater Competition times over the past 20 years. Now this is not something that we can change: The game will only continue to get faster. It makes the game more exciting to watch. However, from a health and longevity standpoint, we have to adapt to these changes.
Research by Upjohn et al. (2009) shows that as players increase their skating velocity, there is a corresponding increase in muscle activity around the hip. This suggests that as players skate faster, there is greater demand on the hip muscles. Thus, they also require greater hip muscle strength and endurance to tolerate the increased demand over the course of a season, which may not be developed at younger ages. Although there may not be any evidence, this could also increase the strain on static structures like ligaments and the labrum. If young players are getting faster and are putting increasingly greater demand on their hips, we have to allow the body to recover from these loads.
By pushing the limits of multiple training variables, hockey players are putting high stress on the hips. Youth players are playing hockey at higher frequencies (more ice times during the year) at a high intensity (faster speeds) for longer durations (on the ice longer through the year). This leaves little time for recovery–which is now even more important due to higher demands–leading to unwanted adaptations (overuse). One possible solution could be implementing concepts from a periodization theory. Within this programming theory, it is suggested that athletes perform a mix of high volume-low intensity work and high intensity-low volume work over the course of a week. Incorporating a mix of high intensity-low volume ice times and high volume-low intensity ice sessions with multiple rest days throughout the week in-season can allow young players’ hips to properly recover and adapt by better managing the stress of skating. Further, allowing players to have a true off-season would allow their bodies time to recover from the stresses of a full hockey season.
Typical periodization schemeTo change this, we need to manipulate these stress variables to work in our favor. By decreasing the frequency/volume (avoiding playing on more than one team in overlapping seasons) and decreasing the duration (taking 2-3 months off from on-ice activities per year) we can better manage the higher intensity skating from a faster game.
3) Implementing Proactive Joint Specific Care Programs
Today, you can show up to a ball field on any given night to find kids doing shoulder and forearm activation and mobility drills, also known as “arm care”. This type of warmup specific to the shoulder and elbow is often used by the pros in order to maintain good shoulder and elbow health which are both heavily taxed from pitching over the course of a season. A lot of youth baseball coaches will have some form of arm care program in place for the pitchers and players to perform prior to throwing. This type of methodical, deliberate, and preparative warmup is not something commonly done in hockey.
These are not meant to be injury prevention programs; they are meant to oppose and prepare for the effects of playing. We know the repetitive motion of skating can leave players with tight and fatigued hip muscles. Thus, mobility and activation drills specifically targeting the hip can help maintain healthy and strong tissues around the hip.
Implementing these types of programs does not need to be complicated. It can be as simple as choosing 2-3 mobility drills and 2-3 activation drills for athletes to do during their off-ice warm up. For ideas on designing hip care programs, you can check out some hip mobility and activation drills here and/or read my previous article on muscle activation for common glute exercises here.
How Can We Improve Hip Injury Rates in Hockey?
If you’ve read this far, I would greatly appreciate you sharing this article with parents, friends and coaches who you think may be interested in this information.
Unfortunately, most young hockey players will begin to develop these hip issues during their minor hockey years but will not show signs until they’re older, making it challenging to see the link between cause and effect. However, if hockey is in fact on the same path of youth athlete injuries as baseball, we need to make changes BEFORE it turns into a much larger issue.