Review of Field Hockey Injuries and Countermeasures for Prevention

Monash University Accident Research Centre – Report #143 - 1998

Authors: S. Sherker & E. Cassell

Full report in .pdf format [300KB]

Abstract:

Hockey is an ancient sport thought to be the forerunner of all ‘stick and ball’ games. The modern game of hockey is played in 132 countries around the world and is second only in popularity to soccer as a team sport. Epidemiological studies have consistently shown that injuries in hockey are numerous and can be serious. Most serious injuries result from being struck by the stick or the ball. Overuse injuries to the ankles and lower back are also frequently reported. Players aged between 10 and 19 years account for 50% of all Victorian hospital emergency department presentations for hockey injuries. Most injuries presenting to hospitals are to the upper limb (mostly injuries to the hand and forearm), face (mostly struck by stick or ball) and lower limb (mostly ankle, foot and knee injuries). Injuries to the eyes are infrequent, although tend to be severe.

The aim of this report is to critically review both formal research literature and informal sources of information in the context of the available epidemiological data, which describe preventive strategies and countermeasures to hockey injury. Countermeasures for preventing hockey injuries with some evidence to support effectiveness include: enforcing rules aimed at preventing dangerous use of the hockey stick and careless play of the ball; modifying rules for children; use of protective equipment (such as shin guards, eye wear and mouthguards); expert training of coaches and officials; adequate nutrition; pre-season conditioning; pre-game stretch and warm-up; prompt access to professional first aid and medical care; and full rehabilitation before returning to play. Potential countermeasures requiring further investigation include: risk management plans; prophylactic taping and bracing of ankles; altering the stick design to make it safer; the use of protective gloves; extending pre-season screening to include non-elite players; and improving injury data collection, especially for non-elite levels of play. A systematic program of epidemiological and biomechanical research is required to investigate these and other risk and preventive factors.

Executive Summary

Hockey is an ancient sport thought to be the forerunner of all ‘stick and ball’ games. The modern game of hockey is played in 132 countries around the world and is second only in popularity to soccer as a team sport.

The aim of this report is to critically review both formal research literature and informal sources of information that describe preventive strategies and countermeasures to hockey injury. This review is informed by the analysis of hockey injury data, which provides a context for the identification of potentially effective interventions.

Epidemiological studies in Australia and overseas have consistently shown that injuries in hockey are numerous and can be serious. The available evidence suggests that the majority of serious injuries result from being struck by the stick or the ball. Overuse injuries to the ankles and lower back are also frequently reported.

Victorian emergency department presentation data shows that players aged between 10 and 19 years account for 50% of all hockey injuries. Most injuries presenting to hospital ED are to the face, hands, and lower limb. Being struck by an object, usually the stick or the ball causes most of these injuries. Injuries to the eyes tend to be comparatively serious when they do occur.

There are few controlled evaluations of countermeasures to prevent hockey injury, so recommendations in this report are necessarily tentative. Potential countermeasures to injury are listed in Table 1. Where there is some supporting evidence for effectiveness, countermeasures for preventing hockey injuries include: penalties enforcing rules aimed at preventing dangerous use of the hockey stick and careless play of the ball; modified rules for children; use of protective equipment (such as shin guards and mouthguards); expert training of coaches and officials; pre-season conditioning; adequate nutrition; pre-game stretch and warm-up; prompt access to professional first aid and medical care; and full rehabilitation before returning to play.

Potential countermeasures requiring further investigation include: risk management plans; altering the stick design to make it safer; the use of protective eyewear; the use of protective gloves; prophylactic taping and bracing of ankles; extending pre-season screening to include non-elite players; and improving injury data collection, especially for non-elite levels of play.

Table 1: Potential countermeasures to hockey injury

Primary countermeasures
  • Coaching and expertise of coaches
  • Pre-participation screening
  • Pre-season conditioning and fitness program
  • Adequate nutrition and hydration
  • Adequate warm-up and pre-game stretch
  • Officiating and expertise of officials
  • Prophylactic taping and bracing
  • Devising rules aimed at preventing dangerous play
  • Safe playing environment (for example level surfaces)
  • Cool-down and post-game stretch
Secondary countermeasures
  • Wearing of proper footwear
  • Attention to biomechanics, technique
  • Control of dangerous play by officials and coach
  • Wearing protective equipment (for example shin guards, mouthguards)
Tertiary countermeasures
  • Prompt access to professional first aid and medical care
  • Availability of first aid equipment on site
  • Rest, Ice, Compression, Elevation, Referral (RICER)
  • Rehabilitation
  • Taping and bracing to prevent re-injury
  • Return to play only when fit

Hockey Injury Data Collection

A review of the current literature for hockey injury indicates a need to improve data collection at the club and association level to gain a more accurate picture of the incidence, pattern and severity of all hockey injuries. The use of consistent definitions of injury and standardised classification systems should be promoted. There is a need to include measures of exposure in hockey research (for example, injuries per 100 hours of match play and practice) so that findings from studies are more easily compared.

Recommendations:

  • Hockey injury data should be collected at all levels, including club and association.
  • Hockey injury data collection should be standardised to allow for easy comparison of reported findings.

Risk Management Plans

Risk management plans can assist sporting clubs, associations and facilities to provide a structure for sports safety. Components of a risk management plan may include: pre-participation screening; physical preparation; coaching; officiating; codes of conduct; policy and regulations; standards; equipment; health promotion; education; sports first aid and sports trainers; environmental and playing conditions; injury management and rehabilitation; injury surveillance; and insurance.

The effectiveness of risk management plans has not been formally evaluated. Few centre and clubs report that they have adopted a risk management plan. More formal evaluation of risk management plans is warranted. In addition, identifying and addressing barriers to implementing risk management plans at hockey clubs is needed.

Recommendations:

  • More formal evaluation of the effectiveness of risk management plans in the prevention of sports injury is warranted.
  • Identifying and addressing barriers to implementing risk management plans at hockey clubs is needed.

Pre Participation Screening

A person wanting to participate in sport needs to be of a minimum physical, physiological and psychological fitness in order to meet the demands of competition and to reduce the risk of injury . The overall goal of pre-participation screening is to identify people with conditions that may predispose them to serious injury and to refer them to appropriate specialists for further evaluation.

  • Pre-participation screening has been shown effectiveness in reducing the number of injuries in elite Victorian cricket players. On the basis of this evidence, it is recommended that all hockey players undergo at least a pre-season fitness screening for general strength, flexibility and endurance.

Recommendations:

  • All hockey players should undergo at least a pre-season fitness screening for general strength, flexibility and endurance.
  • Coaches should be trained to screen players and to refer them on to appropriate professionals if problems are evident.

Attention to Good Nutrition and Hydration

Hockey requires players to perform multiple work bouts at near maximal effort, punctuated by intervals of low intensity exercise or rest. This type of workload has been associated with a significant loss of water and fluid replacement strategies during training and competition should be followed. Given the high-energy demands of training and competition, athletes need also increase their total dietary energy intake.

There is evidence that elite female hockey players demonstrate a high level of body dissatisfaction and an elevated drive for thinness. Female athletes should be monitored for menstrual irregularities, as these have been associated with risk of osteoporosis which have been linked to an increased risk of stress fractures, especially in the lumbar region of the lower back.

Although there is evidence to show that diet can affect athletic performance, the link between diet and sports injury is not clear and further research is needed.

Recommendations:

  • The impact of diet on the incidence of injury, particularly in women, needs to be determined.
  • More research is needed to determine the role of menstrual irregularities and the risk of overuse injuries. In particular, the exact relationship between menstrual health, bone health and stress fractures is yet to be determined.

Pre-Season Conditioning and Fitness Program

Overuse injuries are common in hockey, affecting predominantly the ankles and lower back. Pre-season screening for pre-existing conditions, or for weaknesses in strength or flexibility is important to reducing the risk of injury.

Pre-season conditioning, with particular attention to improving strength, flexibility and endurance, can help the player prepare for the physical demands of the game. Warming-up and stretching, which are known to improve the range of motion of the joints and improve muscle elasticity, are recommended.

Recommendations:

  • All players should undergo at least a pre-season fitness screening for general strength, flexibility and endurance.
  • Further research is needed to determine the effectiveness and best methods of warm-up and stretching as injury prevention measures for hockey.
  • Players should undergo conditioning for general fitness before the start and throughout the season.
  • Players’ conditioning programs should be monitored for proper content and technique.
  • Coaches should be taught principles of sport-specific conditioning and fitness as part of their training.
  • More formal scientific evaluation of periodization training for injury prevention is needed.

Adequate Warm-Up, Stretch and Cool-Down

On the basis of current clinical and experimental evidence, it is reasonable to accept that warm-up plays a role in the reduction of the incidence and severity of musculoskeletal injuries. Well-controlled epidemiological and experimental studies are needed to fully evaluate the preventative effect of warm-up.

There is no epidemiological evidence to show that cooling down reduces the incidence of injury. However, on the basis of anecdotal evidence it is recommended that all participants should practice a slow gradual cool-down after strenuous activity, which can help to promote optimal recovery from strenuous exercise.

Recommendations:

  • Undertake research into the effectiveness and best methods of warm-up, stretching and cool-down as an injury prevention measure for hockey.
  • Develop and promote information about warm-up, stretching and cool-down techniques specifically for hockey.
  • Identify and address barriers to warm-up, stretching and cool-down among hockey players.

Coaching and Expertise of Coaches

The role of the coach is important to injury prevention. Coaches and leaders help to educate players in the fundamental playing techniques of the game, which should include tenets of injury prevention, controlled risk taking and disciplined play.

The National Coaching Accreditation Scheme (NCAS) of the Australian Coaching Council offers progressive hockey coach education programs at four levels of proficiency. It is recommended that all coaches should have at least a NCAS level 1 accreditation from a coaching course.

Sports Medicine Australia also recommends that coaches complete at least a sports medicine awareness course from their Safer Sport program. Coaches are usually present during training and games and are often the first to respond to an injured player. A coach with knowledge of basic sports first aid will ensure that a player receives prompt medical attention in case of an injury.

Recommendations:

  • All coaches should be provided with at least NCAS level I accredited coaching and sports medicine awareness training.
  • Coaches should be trained to screen players and to refer them on to appropriate professionals if problems are evident.
  • Coaches should be taught principles of sport-specific conditioning and fitness as part of their training.

Officiating and Expertise of Officials

Rules, and the way that officials interpret them are a key element in sports injury prevention . Determining what constitutes dangerous play is often left to the discretion of the officials, who have a duty of care to participants to ensure their safety during play .

The National Officiating Accreditation Scheme (NOAS) of the ACC offers umpires educational programs at progressive levels of proficiency. Training includes a module on risk management for sports officials . The program stresses that the health and safety of the participants is the most important factor to be considered in the official’s decision making process .

Recommendations:

  • It is recommended that all officials have at least NOAS level 1 accreditation

Rules and Penalties

To reduce some of the risk of injury, certain rules are applied and conventions observed to reduce dangerous play during a match. Rules that limit the use of the stick and the ball are adopted in order to reduce the risk of stick and ball type injuries, which are frequently reported. The effectiveness of these rules in reducing injury is dependent on the strict and consistent interpretation by the umpires.

Modified hockey rules for children gives younger players a chance to develop basic skills before progressing to a more competitive level of play. By gradually introducing and developing more formal skills, children’s entry level playing ability is far greater when they start to play hockey with standard rules.

The FIH has adopted a "no blood rule" which states that an injured player must leave the pitch in case of an injury that causes bleeding. Players with bloodstains on body or clothing are not to be allowed to start or continue to play in this condition. Wounds must be covered and the bleeding stopped before the player may re-enter the game.

Recommendations:

  • Young children should be progressively introduced to hockey through Minkey and ‘half-field’ hockey.
  • Umpires should be continuously trained so that there is consistent interpretation of rules to minimise unsafe play.
  • Strict penalties should be consistently invoked for deliberate fouls and player dissension.
  • It is recommended that clubs and organisations adopt and enforce an infectious disease policy.

Prophylactic Taping and Bracing

There is increasing interest in prophylactic taping and bracing as a means of protecting players against ankle sprains which probably account for the greatest loss of playing time of any injury. The effectiveness of taping and bracing in the prevention of ankle injuries in hockey has not been investigated, although it has been shown effective in reducing the incidence of acute ankle injuries in other sports (basketball and US football).

The concept of taping and bracing implies that the ankle joint is inherently ‘weak’, and requires added support to sustain the forces involved in play. One alternate theory is that these injuries are due to poor tactile sensory cues and not from a lack of mechanical support to the ankle. Further controlled research is needed to determine the exact mechanism of ankle injury and whether taping or bracing can prevent ankle sprains and strains in hockey.

Recommendations:

  • Improve ankle stability by including flexibility and strength exercises in the pre-season training
  • Ensure full recovery of ankle function before returning to play in order to prevent recurrent ankle injuries
  • Investigate the effectiveness of different prophylactic stabilising methods for the ankle in hockey players in controlled studies
  • Investigate the relationship between footwear and ankle injuries in hockey.

Protective Equipment

The effectiveness of protective equipment in preventing hockey injuries has not been fully evaluated. Shin guards have been proven effective in preventing kick-type injuries to the lower leg, although the force of a swung hockey stick is much greater than the force of a kick. Nevertheless, shin guards are recommended for use by hockey players.

Mouthguards are effective in protecting the teeth from fracture, preventing lacerations to the lips and cheeks, decreasing the risk of jaw fracture and reducing the risk of concussion. Mouthguards should be worn by all players during games and training.

The use of protective eyewear and gloves to protect against hand and especially finger injuries requires further investigation.

Recommendations:

  • Enforce the rule that all goalkeepers wear helmets and other protective gear during games and at training.
  • Promote the use of well-fitted shin guards during training and games.
  • Undertake further research into the design and effectiveness of shin guards for use in hockey.
  • Players are strongly advised to wear mouthguards during training and games.
  • Mouthguards should be properly fitted and of good quality in order to maximise player comfort and compliance.
  • Mouthguard use should be encouraged at an early age so that it becomes a habit.
  • Mouthguards should be replaced at the first sign of wear (cracks or splits) or loss of resilience.
  • Undertake controlled studies into the effectiveness of protective gloves in preventing hand and particularly finger injuries in hockey.
  • Undertake further research into the effectiveness of protective eyewear in the prevention of hockey eye injuries, with a view to introducing protective eyewear if indicated by research findings.

Environmental Conditions

There are practical advantages to the use of synthetic surfaces in hockey. The International Hockey Federation (FIH) has developed performance standards for hockey pitches based on ball rebound, ball run and deviation, impact response, surface friction, dimensions, slope, smoothness, colour, gloss, watering, porosity and surface health.

Anecdotal evidence suggests that ankle inversion injuries, meniscal problems and the prevalence of shin soreness, knee pain and lower back problems have increased with the more widespread use of synthetic surfaces. The abrasive nature of synthetic playing surfaces has meant that lacerations are also more frequent.

The natural grass surface contributes to a greater cushioning effect and less strain to the lower limbs by absorbing 10% more energy on impact than synthetic turf . The only study to compare the rate of injury on synthetic surface to that of grass is Jamison and Lee (1989). The authors reported that although the overall number of injuries sustained on Astroturf was greater than on grass, the joint injuries to the lower limb were more prevalent on grass surfaces (53%) than on Astroturf (37%). More research is needed to determine whether synthetic surfaces put the joints of the lower limb at greater risk of injury.

No specific evidence of preventative measures for climate-related hockey injuries were identified in this review. Injury prevention strategies are based on general thermoregulatory recommendations, such as wearing appropriate clothing, using sunscreen, maintaining hydration and undergoing a process of acclimatisation in extreme temperatures. Coaches, sports trainers and officials should be familiar with the potential dangers of playing or competing under inclement weather conditions, including high heat and humidity, extreme cold, or during electrical storms . In such situations, practice or competition should be restricted, altered or possibly cancelled to reduce the risk of injury.

Recommendations:

  • Testing of new surfaces for hockey pitches should include controlled studies of changes in frequency, pattern and severity of injury.
  • The relationship between playing surface, footwear and ankle injuries in hockey needs to be investigated
  • Hockey players should maintain adequate fluid intake, especially in hot weather.
  • Hockey players should wear a broad-spectrum sunscreen in high ultra-violet conditions.
  • Risk management plans should be developed and implemented by hockey associations to control for environmental hazards such as thunderstorms and extreme climatic conditions.

Treatment and Rehabilitation

Emergency care of hockey soft tissue injuries includes immediate rest, ice, compression, elevation and referral (RICER). The RICER method of treatment is believed to reduce the possibility of further damage to the injured soft tissue by reducing the swelling in the area.

The goal of a rehabilitation program is for the athlete to be free from pain and for the muscle strength and joint flexibility to return to pre-injury levels. It is important for a player to undergo a full recovery before returning to play. A premature return to play may exacerbate the injury and result in further time off the field.

Recommendations:

  • Players should seek prompt attention for their injuries from a professional with first aid qualifications.
  • Organisers of events should ensure that there are qualified professional first aid personnel at all events.
  • Players should allow enough time for adequate rehabilitation of injuries, especially full recovery of ankle function, before returning to pre-injury levels of play.
  • More controlled research into the effectiveness of different rehabilitation programs should be undertaken.

Sponsoring Organisation: Sport and Recreation Victoria