Hockey Lacerations: Life in the NHL

As evidenced by Zach Werenski of the Columbus Blue jackets last week hockey players are tough and always want to come back and finish the game. Our job as team physicians is to protect the players and make sure there is no additional damage beyond the face laceration. Additional injuries can include eye damage, facial bone fractures, dental injuries and concussions.

With the St. Louis Blues we are fortunate to have excellent consultants to help me rule out any other injuries. We have a dentist (Ron Sherstoff) and oral surgeon (Ken Kram) present at every game. Additionally, we have opthalmologists (Gil Grand) and plastic surgeons (Tom Francel) available some nights in the arena, but always available for follow up exam.

With every facial laceration we do a neurological exam to rule out a concussion and if there is any doubt we will hold the player and do additional testing. 

To finish the story of Zach Werenski he returned for the game in a shield, but he developed significant bruising and swelling. He tweeted his own picture after the game below and then was diagnosed with a blowout fracture of his upper facial bones surrounding his eye.He missed the rest of the playoffs with Columbus

The Concussion Protocol

It is not uncommon to read in the sports pages that an NHL or NFL player sustained a concussion and is undergoing the concussion protocol. What is the concussion protocol? There are significant similarities and I will try to explain the big picture of what the protocol means without becoming too technical.

Once a player sustains trauma to the head in either league that is worrisome or suspicious for a concussion the player is removed from the game and taken to a quiet place for evaluation. This will include formal testing of the player and determining any symptoms the player may have. Testing will include cognition, memory and physical tests of balance.

If the player is determined to have sustained a concussion or if there is suspicion of a possible concussion the player is removed from the rest of the game and monitored.

At this point the player may need additional testing or close monitoring. Following the game and the next day the player’s symptoms are monitored. The player is encouraged to avoid activities that might exacerbate symptoms including video games, TV, computer and smart phone activities. As symptoms improve the next steps are taken to determine recovery. When the player’s symptoms have resolved then physical activity can be attempted which typically is a short exercise session of light stationary cycling, jogging or another aerobic activity. If symptoms return then the activity is stopped. If the player tolerates the increase in heart rate without symptoms then in following days the player will continue to slowly increase the activity level and will repeat the neuropsychological testing done previously ---before the season began.

If the neuropsychological testing has returned to baseline and the player has remained without symptoms then they will be allowed to return to practice and increase activity as tolerated. Once their functional skills and conditioning has returned to a level consistent with returning to game action they are released to play. All of this is contingent upon remaining asymptomatic during the progression of activities. As can be seen it can involve several days to protect the health of the player and avoid worsening symptoms or returning them to play prior to resolution of any concussion symptoms.

Frequently associated with concussion can be cervical spine musculature aggravation due to the trauma to the head. Local modalities, stretching and massage can sometimes relieve these symptoms which can be confused with concussion symptoms. Addressing these can help speed recovery and eliminate confusing symptoms.

Oblique Muscle Strains

Once again this season baseball players have been affected by oblique muscle strains. Most recently it impacted the St. Louis Cardinals when their All Star infielder Matt Carpenter sustained the injury missing a month of games including the All Star Game. Why are these such significant injuries for some sports and playing positions while you never hear about them in other sports?

The oblique muscles reside on both sides of the abdomen and chest running from the pelvis to the chest and ribs in the front and chest and spine in the back. There are 2 muscle groups on each side--- the internal and external obliques. Rather than running straight vertically or horizontally they run “obliquely” across the body and thus their name is derived.

These muscles are critical for rotational activities and that is why they are more impactful for certain sports. While challenging for any athlete an oblique muscle strain is the worst for those athletes that repetitively rotate. Thus baseball pitchers and hitters are highly affected. Hockey players are also bothered by it while shooting especially during slap shots.

We have had several with the St. Louis Blues over the years that resulted in several man games lost. It much less frequently affects sports that are more linear such as track, swimming, football or basketball. It is an infrequent injury even for quarterbacks and I can’t remember a significant oblique injury with loss of time for any of the Rams quarterbacks.

Treatment is similar to other muscle strains and involves conservative management with ice, NSAIDs and rehabilitation including stretching and strengthening. Nothing seems to shorten

the recovery which for baseball position players is typically a month. If anything more than a minor strain for a pitcher it can cost 6-8 weeks. Cortisone injections can be utilized, but still time is the best ally and cortisone is relatively a quick fix. These muscle strains typically are diffuse over a relatively large area and thus difficult to pinpoint for an injection. Likewise there is no scientific evidence that platelet rich plasma (PRP) or stem cell injections will speed recovery. That is why these are difficult injuries for the athletes and the fans that follow them. It is hard to be patient.