Part 1 of this series described anatomical asymmetries that all humans have, and how they can lead to predictable patterns and functional asymmetries. Part 2, below, will dive into how these patterns directly affect hockey performance and how they may contribute to common hockey injuries.

Influence on Hockey Performance
These positions are not inherently harmful. In fact, everyone should possess the ability to get into and out of these positions, bilaterally. Problems arise when an athlete gets stuck in a pattern and is unable to achieve the reciprocal position. This causes a shift in neutrality and increases the likelihood the athlete will need to push past joint end-range to achieve a functional outcome.  Specific to skating in hockey:

  1. A left hip positioned in a state of external rotation and abduction will make it more likely that the athlete will drive through end rage to achieve the desired stride length, which can cause compensatory SI joint stress and/or movement in forward skating.
  2. A left hip positioned in a state of flexion will make it difficult to recover the leg fully under the body without standing up higher, which may cause some players to recover this leg slightly outside of their hips.
  3. During crossover strides to the left, the left hip will be unable to adduct and drive under the right leg, a huge source of power.
  4. During crossover strides to the right, the right hip will be more likely to drive through end range internal rotation and adduction, which can also cause a resultant gapping stress to the right SI joint.

Application to Common Hockey Injuries
Interestingly, femoroacetabular impingement (FAI) which affects the overwhelming majority of elite level hockey players involves a loss of hip flexion, adduction, and internal rotation. While the two types of FAI, CAM and pincer, differ in the site of bony overgrowth, it’s clear that these injuries can become worse over time as players continue to push through joint end range and force bone on bone contact. Referring to the list above, it’s apparent that a left hip positioned in a state of flexion will increase the probability that a player will drive through end range hip flexion on that side; likewise, a right hip positioned in adduction and internal rotation provides a mechanism for excessive bony contact on that side. In other words, this same pattern provides a mechanism through which hockey players can develop FAI on both sides.

Similarly, because the left hip is positioned in a state of external rotation and abduction, the adductors are positioned long. As the stride leg is extended, these adductors are forced to decelerate the leg near their end-range, making it more likely that these muscles will become overstretched/strained and tear. In addition to the compensatory SI joint movement that the forward stride can create on the left side, driving through end-range external rotation can also cause a forward migration of the femoral head within the joint, causing excessive strain and laxity across the anterior hip capsule. Both adductor strain and anterior hip capsule laxity are common causes of “groin pain” in hockey players. Laxity in the capsule also allows for excessive accessory motion within the joint, which can cause labral damage and eventual osteoarthritis.

On the opposite side, the right adductors are positioned short and can become extremely dense and fibrotic. The predominant thought currently is that sports hernias are caused in large part because of a tug of war across the pubic symphysis between dense adductors and weak abdominals. The adductors progressively win this battle in an erosion-like fashion, which causes a fraying of the structures in the area of the superior surface of the pubic bone. Not surprisingly, sports hernias are more commonly found on the right side.

Naturally, early recognition is key. Indeed, while not every hockey player I’ve tested falls into one of PRI’s patterns, every hockey player with a history of hip injuries that I’ve tested does.

Subjectively, players may report having a more difficult time turning or crossing over to one side compared to the other. Similarly, they may have a preference for or feel more explosive when stopping and/or pivoting on one side compared to the other. While structure clearly influences function, function similarly influences structure. Simply, as players bias toward a certain position or pattern, all of their body’s systems, most notably their nervous and musculoskeletal systems, will adapt to the stresses. Often times, a small bias can snowball into a glaring asymmetry later down the road. This process may take years to develop, but can have dire consequences on a player’s health, performance, and career longevity.

Superimposed Occupational Biases
The discussion on structural and functional asymmetries is further complicated by occupational biases. In this sense, “occupation” simply refers to the asymmetrical patterns that players of different handedness and positions perform regularly throughout their seasons. For example, a right-handed player will likely perform THOUSANDS of high velocity, high power rotations toward the left (think slap shot) that they will not perform toward the right during a season. A goalie will likely bias toward a side-bent positioned on his stick side. These occupational tendencies are superimposed upon the asymmetries discussed above, and can help alleviate or further exacerbate some of the aforementioned consequences.

Wrapping Up
In addressing these issues, it’s necessary to keep the player’s injury history, current structural and functional presentation, and current and future occupational demands in mind. Often times, it is wise address asymmetries secondary to a loss of joint neutrality first, as it is impossible for muscles to function optimally if they are positioned poorly. Using repositioning techniques from PRI, typically breath-driven exercises involving asymmetrical targeting of specific muscles, can help restore and reinforce neutrality, and interrupt a downward spiral of compensatory adaptations.  The off-season is an appropriate time to assess players for these imbalances, and to increase the volume of strategically asymmetrical exercises. Players should be monitored periodically throughout the season to help minimize the cumulative damage a season of play from a non-neutral position can create. Ultimately, following this approach can help fend off many of the acute, progressive, and chronic non-contact injuries players face throughout their careers.

To your success,

Kevin Neeld

Please enter your first name and email below to sign up for my FREE Athletic Development and Hockey Training Newsletter!

Over the weekend I posted a video at HockeyStrengthandConditioning.com of a former (and hopefully future) division 1 lacrosse player that I’ve worked with over the last few months at Endeavor Sports Performance. What makes this player unique is that he’s undergone 4 hip surgeries (2 on each side) secondary to femoroacetabular impingement (FAI) and bilateral sports hernia surgery. The video alludes to the importance of recognizing individual limitations and teaching the athlete how to move within his or her own confines.

Working with this athlete also highlights the importance of understanding these so-called abnormalities. When he first came to Endeavor, light jogging wasn’t even an option. In other words, his range of motion was so poor, damage so significant, and overall comfort level with athletic movements so degraded that we really had to start slow. A few months later, he’s sprinting, cutting, and jumping explosively and without pain; he’ll be the first to tell you that he’s never felt better. My ability to effectively work with athletes like this stems directly from the amount of time I’ve spent studying the relevant research. I think this information is valuable for anyone that trains anyone, but if you work with hockey players, it’s absolutely essential. The amount of research in this area has exploded over the last decade; understanding the causes and implications of FAI will help you more effectively train players that present with these injuries (which is most) and help to prevent unnecessary complications.

Illustrating “normal” hip joint anatomy and FAI abnormalities

Below is a brief review of some of the current literature:

High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players

  • MRI findings from 21 professional and 18 NCAA D1 players; all were asymptomatic
  • 14 (39%) dysfunction of adductor-rectus abdominis insertions
  • 25 (64%) hip pathologic changes
  • 30 (77%) have MRI finding of hip or groin pathologic abnormalities

The prevalence of cam-type femoroacetabular deformity in asymptomatic adults

  • Retrospective analysis of CT scans from 419 randomly selected patients from 2004-2009 that were taken for problems unrelated to the hip
  • Of the 215 male hips (108 patients) analyzed, a total of 30 hips (13.95%) were defined as pathological, 32 (14.88%) as borderline and 153 (71.16%) as normal.
  • Of the 540 female hips (272 patients) analyzed, 30 hips (5.56%) defined as pathological, 33 (6.11%) as borderline and 477 (88.33%) as normal.
  • This highlights the prevalence of these injuries in asymptomatic individuals, especially men. This means that, in the general population, roughly 1 in every 3-4 men that you train will have an underlying hip abnormality. The prevalence of these findings in hockey players is drastically higher (see above).

Prevalence of cam-type femoroacetabular impingement morphology in asymptomatic volunteers

  • 200 asymptomatic individuals (111 females, 89 males; average age 29.4 years) had an MRI taken of their hips.
  • 14% of the volunteers had at least one hip with CAM impingement
  • 10.5% had CAM on either the right or the left side; 3.5% had CAM in both hips
  • 22 of 28 individuals (79%) who had CAM were men; only 6 (21%) were women.
  • 22 of 89 (24.7%) men had CAM impingement, compared with only 6 (5.4%) of 111 women.

Hip flexor muscle fatigue in patients with symptomatic femoroacetabular impingement

  • Comparison of hip flexor strength during submaximal isometric and repeated maximal dynamic contractions in those with and without FAI.
  • FAI participants exhibited significant hip flexor weakness compared to the controls
  • No changes were noted in fatigue indices between the two groups
  • Authors noted that those with FAI tend to have adductor and hip flexor weakness. It’s easy to look at these weaknesses and point to them as potential causes of FAI secondary to poor femoral head control. That said, it’s also worth noting that the bony overgrowth limits hip adduction and hip flexion and may cause weakness secondary to neurological inhibition, especially as bony end-range is approached.

Can we predict the natural course of femoroacetabular impingement?

  • Because FAI is so strongly associated with future osteoarthritis, these authors sought to determine whether age of total hip arthroplasty was related to certain radiographic findings and/or activities.
  • Given the complex and dynamic nature of these injuries, it’s not surprising that they weren’t able to find a relationship through their methods. That said, I think they hit the nail on the head with their conclusion: “Hence, considering the high prevalence of FAI-related radiographic findings, we conclude that not every radiographic abnormality requires treatment.”
  • This highlights the importance of not taking every positive radiographic finding and shipping the player off to the surgical table!

Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: a case series

  • Analyzed 37 hips (average age: 25 years) with BOTH a sports hernia and FAI. Patients were athletes competing at the pro (8), college (15) elite high school (5) and competitive club (9) levels.
  • Evaluation occurred at an average of 29 months post surgery (wide range of 12-78 months though)
  • Of 16 hips that had athletic pubalgia (sports hernia) surgery as the index procedure, 4 (25%) returned to sports without limitations, and 11 (69%) subsequently had hip arthroscopy at a mean of 20 months after pubalgia surgery.
  • Of 8 hips managed initially with hip arthroscopy alone, 4 (50%) returned to sports without limitations, and 3 (43%) had subsequent pubalgia surgery at a mean of 6 months after hip arthroscopy.
  • Thirteen hips had athletic pubalgia surgery and hip arthroscopy at one setting. Concurrent or eventual surgical treatment of both disorders led to improved postoperative outcomes scores (P < .05) and an unrestricted return to sporting activity in 89% of hips (24 of 27).
  • While it’s impossible to make any accurate inferences, I’d be interested to see how these numbers may differ if the athletes were in sport programs with medical professionals that truly understood the implications of the abnormalities and could teach the players how to move within their limits.

In my experience, most players do very well when they understand the limitations in their joint anatomy and are taught how to move within these confines. Because the primary suggested mechanism underlying athletic pubalgia involves a tug of war across the pubic symphysis between the adductors and abdominals AND because those with FAI tend to have very dense/fibrotic adductors, many players will benefit from some soft-tissue work in this region, especially in the area of the proximal adductor magnus attachment. Also, because posterior capsule density can push the femoral head forward in the joint and put excess stress on the anterior/superior labrum, this is another area worth having a manual therapist look at. The manual method itself is less important than the proficiency of the therapist. It can be tough to find someone that is comfortable working in that area, but it is well worth the trouble when you do!

To your success,

Kevin Neeld

P.S. If you’re interested in learning more about hockey hip injuries and associated assessments and corrective strategies, I highly encourage you to check out my presentation “Hockey Hip Assessments: An In-Depth Look at Structural Abnormalities and Common Hip Injuries”, which is now available at Hockey Strength and Conditioning

Please enter your first name and email below to sign up for my FREE Athletic Development and Hockey Training Newsletter!

With 2011 officially upon us, I can’t help but reflect on what a great year 2010 was. A few of the highlights:

  1. We had an extraordinary Summer at Endeavor (awesome to watch Eric Tangradi score his first NHL goal and Colby Cohen play his first NHL game).
  2. I was able to make a trip out to San Jose to spend some time with my friend Mike Potenza, and another trip down to Raleigh to meet Pete Friesen and attend his Physio-Fitness Summit (which I recapped for a HockeyStrengthandConditioning.com article).
  3. My Ultimate Hockey Development Coaching Program was not only a big success, it was a lot of fun to do. The thing I like about doing “interviews” is that I pick up a lot of new stuff too. Joe Heiler, Jeff Cubos, Brijesh Patel and Jared Beach’s talks were especially enlightening to me, but I’ve heard great feedback about all the other talks as well.

  4. Along those same lines, the launch of HockeyStrengthandConditioning.com was particularly exciting. When I was growing up as a player, it was nearly impossible to get access to NHL coaches, players, trainers, etc. Now, the internet has made this exceptionally easy. The fact that you can now make a nominal investment and get immediate access to the guys that have help develop elite level hockey players at all ages doesn’t only appeal to me as a professional, it excites me as a former player. And the networking possibilities are unreal. When I was a senior at the University of Delaware, I wrote a letter to every US-based NHL Strength and Conditioning coaches inquiring about internship opportunities. While I wasn’t able to grab an internship out of their effort, there were a few NHL Strength Coaches that called me and spent some time giving me advice on how to break into the industry (Mike Kadar, who is now with the Pittsburgh Penguins was especially helpful). At HockeyStrengthandConditioning.com, you can post an inquiry on the forum and get responses from many of the top hockey strength and conditionign professionals in the world (including several that work in the NHL or with NHL players). Awesome.
  5. Emily and I made the move from Baltimore to Philadelphia at the end of August. My commute to Endeavor has dwindled to measly 25 minutes from what was a grueling 2 hour trek. It’s still enough time that I can go through an audio book every week, but short enough that I don’t need to wake up at 5:30 and drink 3 coffees and a spike just to make it to work (awake) by 8:30.

And finally, I’ve gotten terrific feedback on many of the posts on this site over the last year. It’s certainly come a long way from when I first started a few years back. As you continue to spread the word about this information to people you know, I continue to get more feedback to cater the content to your interests.

With all that said, here are the top Hockey Development posts of 2010!

7. Hockey Injuries: Sports Hernia Case Study

6. Hockey Training Tip to Prevent Shoulder Injuries

5. Hockey Training with the Vertimax

4. Randy Pausch, Will Smith, Kevin Neeld?

3. Video Reveals Secret to Developing Elite Level Hockey Players!

2. No One Conditions Alone

1. The Truth About Sidney Crosby

To your success,

Kevin Neeld

P.S. If you haven’t yet, go sign up for the 2011 Sports Rehab to Sports Performance Teleseminar. It’s free, and the speaker line-up is incredible!

Please enter your first name and email below to sign up for my FREE Athletic Development and Hockey Training Newsletter!

Between writing the blogs and newsletters for my site AND Endeavor’s site, I’ve been doing a lot of writing recently. Usually when I write, I try to not rehash on things I’ve already talked about. I’d hate for anyone to ever refer to me as monotonous. The other day I was rereading a few articles I had read before and it hit me that it’s helpful to hear QUALITY information over and over. It helps make it more concrete in your mind.

With that said, I’ve created a list of a few articles and interviews that I’ve been a part of that I think EVERYONE should read. These articles outline much of the scientific foundation that I base my hockey training programs on. Spend a day or two re-reading these articles and post your comments below!

Maximal Force: Cracking the Nervous System Code

3 Tricks to Increase Maximal Strength

Fight the Injury Blues: Keep Lifting

Rethinking Bilateral Training

Dissecting the Sports Hernia

Battling Anatomy: Implications for Effective Squatting

Rapid Rate of Force Development

To your success,

Kevin Neeld

P.S. In the next week, I’ll be announcing the official launch of my Ultimate Hockey Development Coaching Program. Stay tuned!

Please enter your first name and email below to sign up for my FREE Athletic Development and Hockey Training Newsletter!

This was a post from Endeavor’s website that got such a great response that I wanted to share it with you.

As you know, I’ve recently teamed up with Michael Boyle (Boston University), Sean Skahan (Anaheim Ducks) and Mike Potenza (San Jose Sharks) to launch an incredible hockey training website: HockeyStrengthandConditioning.com.

Hockey Strength and Conditioning

On the site, U of Minnesota Strength Coach Cal Dietz shared an interesting article with us. The article outlined research with groundbreaking results. If you value your hockey career, you’ll read carefully!

This article outlined a study that took MRI’s of the hips of 39 NHL and NCAA Division I hockey players. Of the 39 players, twenty-one (54%) had labral tears, twelve (31%) had muscle strains, and 2 (5%) had tendinosis (degeneration of the tendon) of the hips. Overall, 70% of the players had irregular findings on their MRIs. Interestingly, the majority of these players were considered “healthy” at the time of the study, meaning they were okay to play.

As shocking as these results may appear, I wasn’t at all surprised. Similar results have been found in the shoulders of baseball players, and hockey players completely abuse their hips. Most players spend no time doing the stretches they need to (because they’re either too lazy or don’t know which ones they should do), have poor motor control of muscles around the hips (which tears up the joint and labrum!), and spend WAY too much time on the ice.

A couple weeks ago, I was on the phone with Mike Potenza (San Jose Sharks); he mentioned that in over 90% of cases, the players he sees that have sports hernias do little to nothing in terms of training. Everyone at the collegiate and professional strength and conditioning levels understand that good training can improve a player’s performance, lengthen their career, and keep them out of the surgeon’s office. Hopefully youth players and parents will get the message.

To your continued health and success,

Kevin Neeld

P.S. If you’re looking for a step-by-step training system to use this off-season, check out my Off-Ice Performance Training course. I continue to get incredible feedback about the exercises and progressions in the course, from NCAA D1 Strength and Conditioning Coaches down through parents of youth players (e.g. peewees). Download your copy today!

Off-Ice Performance Training

Please enter your first name and email below to sign up for my FREE Athletic Development and Hockey Training Newsletter!