In an effort to better understand the mechanisms that contribute to injury and to design better programs to make our players more durable on the ice, I’ve read a ton of research on hip injuries, such as hip flexor/adductor tears, sports hernias, osteitis pubis, femoroacetabular impingement (FAI), and labral tears over the last several years. While I recognize that every injury is multi-factorial, I always frame injuries within the context of “what can we do to minimize risk, if not prevent them?”

It’s become clear along this journey that hip injuries tend to coincide with one another and the issue is almost always much more complex than simply “overuse” or “we found a labral tear, which needs to be repaired.” This latter point was highlighted by a 2011 study from Silvis et al. that demonstrated that 77% of the 39 NCAA D1 and pro hockey players had abnormal hip/groin MRI findings that were indicative of pathology, despite being entirely asymptomatic (Read the abstract here: High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players). This is a hockey-specific example, but there are others looking at different joints and in different populations that support the idea that something appearing broken may not always lead to pain and may not always need to be repaired.

When I first started to read about how FAI (a bony overgrowth of either the femoral head/neck offset and/or the acetabular hood; image below) limited hip flexion ROM, I began including some assessments in our intake to help screen for those limitations and, over time, developed a better eye for seeing suspicious compensations throughout various exercises. Despite there not being clear research evidence in support of FAI being developmental (there was a thought that it was congenital and/or developed from a slipped capital epiphysis, both of which are explanations I believe hold merit in a minority of cases), I never really had any doubt that the majority of these cases are progressive, likely resulting from poor femoral head tracking and too much time or volume spent at or near end-range hip flexion. This is important, because if things are progressive there is an opportunity to intervene. Given that this bony overgrowth is associated with increased anterior-superior labral wear/tearing and eventual osteoarthritis (see Streit et al, 2013, among others), the need be proactive in minimizing risk is important from both a short- and long-term perspective.

Hockey Training-Femoroacetabular Impingement

A demonstration of the bony overgrowth illustrative of FAI

In the last few months, several interesting articles have been published that continue to shed light on this issue. First, Larson et al. (2013) published data on NFL prospects in college and found that 90% of the 125 athletes they looked at and 87% of the hips (an alarming statistic!) had findings consistent with FAI. Of these players, those with symptoms tended to have a greater prevalence of CAM or Mixed FAI and osteitis pubis, but the only independent predictor of groin pain was how progressive the bony overgrowth was (the “alpha angle”). This is interesting for a few different reasons. As I mentioned in the past (See: An Updated Look at Femoroacetabular Impingement), hockey players aren’t the only population affected by this hip “abnormality”. This is the first study I’ve seen (admittedly, I’m not looking for other sports) that has used an athletic population not typically put in the most “at risk for hip injury” bucket. As a backdrop, it suggests that as the bony overgrowth gets worse, the athlete is more likely to be symptomatic.

This latter fact is not surprising given a 2012 study from Birmingham et al. that concluded:

“Dynamic femoroacetabular impingement as caused by the presence of a cam lesion causes internal rotation motion at the pubic symphysis. Repetitive loading of the symphysis by cam impingement is thought to lead to increased symphyseal motion, which is one possible precursor to athletic pubalgia.”

As a follow up, increased motion at the pubic symphysis is also a risk factor for osteitis pubis (inflammation in the area), which is another cause of groin pain.

So what does this have to do with hockey players? I’ll get there!

A study published last month from Philippon et al. provided solid evidence that FAI is in fact developmental/progressive, at least in the hockey population. In short, they imaged the hips of 61 youth hockey players from 10-18 years old, and found that:

  1. In PeeWees (10-12 y/o), 37% had FAI and 48% had labral tears
  2. In Bantams (13-15 y/o), 63% had FAI and 63% had labral tears
  3. In Midgets (16-19 y/o), 93% had FAI and 93% had labral tears

While there will inevitably need to be follow up studies done, this provides some interesting information as to how these structures develop, and really highlights how important it is for hockey coaches, strength and conditioning coaches, and sports medicine professionals to be aware of their existence. In short, a player may not be skating lower because he/she physically does not possess the structure to achieve a deeper stance (remember this is a BONY block; it can’t be stretched), and he/she may not be able to squat/lunge/deadlift like textbooks suggest they should be able to for the same reason.

While slightly tangential to the previous conversation, a 2013 study from Jakoi et al. found that NHL players were less productive in the 2 years following sports hernia surgery than they were prior to the surgery. This was especially true for the “veteran” group (7 or more years in the league) as they played significantly less games per season (from 70.5 to 49.0), scored less goals per season (17.1 to 7.8), had less assists (25.4 to 13.1), and weren’t able to play as much time per game (from 18.6 to 15.2 minutes). While the declines in games played, goals and assists weren’t significant for the younger group (6 or less years in the league) there was still a decline despite playing more minutes per game (from 16.4 up to 18.4). When you factor in the total minutes played per season (games played x minutes per night), the younger group had almost equivalent minutes pre- and post- surgery (1077.48 vs. 1074.56), but still averaged less goals and assists following the surgery. This certainly isn’t to dismiss the potential benefits, and in some cases the necessity of the surgery, but instead should be taken as another argument for the importance of recognizing risk factors and intervening early.

There is a theme to this discussion. While it may not be possible to PREVENT 100% of injuries, it is important to do whatever is possible to screen/assess for risk factors, provide corrective strategies when appropriate, and coach around limitations that do exist so as to not exacerbate the problem. Given the data on how prevalent structural abnormalities are in athletes in a variety of sports, as well as the short- AND long-term implications of these injuries, taking the appropriate steps to improve an athlete’s durability may not just change your season (the two goal decrease in production could be the difference between making the playoffs or not, winning the championship or not), it may change his/her life.

Over the last several years, I’ve gotten a lot of questions about how I assess our players, what I’m finding, and how this influences my programming. In my new DVD Optimizing Movement, I cover these very topics in detail. For the first time ever, I discuss the exact assessment protocol I use (including videos of the assessments), how we integrate corrective strategies into group settings (and how you can too), how we alter exercise selection based on assessment findings, and the 4 things that underlie correctly performing almost every exercise. The DVD has gotten outstanding feedback from everyone ranging from personal trainers, to sports med professions in professional sports, to collegiate strength and conditioning coaches, to private physical therapists. Check it out at the link below!

Optimizing Movement DVD Package

Click here for more information and to watch the trailer! >> Optimizing Movement

To your success,

Kevin Neeld
UltimateHockeyTraining.com

References:

  1. Silvis, et al. (2011). High Prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players. American Journal of Sports Medicine, 39(4), 715-721.
  2. Streit, et al. (2013). The shape of the proximal femur influences acetabular wear patterns over time. Clinical Orthopaedics and Related Research, 471(2), 478-485.
  3. Larson, et al. (2013). Increasing alpha angle is predictive of athletic-related “hip” and “groin” pain in collegiate national football league prospects. Arthroscopy, 29(3), 405-410.
  4. Birmingham, et al. (2012). The effect of dynamic femoroacetabular impingement on pubic symphysis motion: a cadaveric study. American Journal of Sports Medicine, 40(5), 1113-1118.
  5. Philippon, et al. (2013). Prevalence of increased alpha angles as a measure of cam-type femoroacetabular impingement in youth ice hockey players. American Journal of Sports Medicine, 41(6), 1357-1362.
  6. Jakoi, et al. (2013). Sports hernia in National Hockey League players: does surgery affect performance? American Journal of Sports Medicine, 41(1), 107-110.

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A couple day’s back, I proposed the idea that the underlying assumption that hockey players (and athletes in general) are structurally and neurologically symmetrical was grossly misguided. In fact, structural asymmetries in conjunction with asymmetrical movement tendencies can be an underlying factor in a lot of the dysfunction our players present with and in common hockey injuries. This is true even of traumatic injuries; when a joint is in suboptimal alignment, stability is compromised. If you missed that post, I encourage you to check it out here: The Myth of Symmetry.

It’s no mystery to the hockey community that hip injuries are an epidemic. CAM impingement and sports hernias have been getting a lot of press over the last 5 years and adductor (“groin”) and hip flexor strains have become accepted as a necessary evil. I strongly believe that these injuries result because of a general lack of awareness of the predisposing factors that contribute to them and the necessary off-ice training strategies to prevent them. This belief isn’t at all theoretical; over the last two years we have completely eliminated adductor and hip flexor strains in our hockey players through off-season training alone. In other words, we have 2.5-4 months to “injury-proof” a player at Endeavor Sports Performance during the Summer, and then the player returns to his team and we don’t hear back from them until the next off-season. All of our players from last year have returned and we had ONE player sustain an injury to his hip flexors. It was a bilateral strain that resulted from an unexpected high speed collision to the back of his legs, which resulted in a rapid hip hyperextension and slight bilateral tear. It was a freak occurrence. This player will get struck by lightning on his way to cash in his winning lottery ticket before that happens again. Other than that, not a single game missed for hip-related injuries at all.

The overwhelming majority of hip injuries and nagging pains are completely unnecessary. Listen to one of our players describe his experience:

“Over the past few summers I have trained with Kevin in order to prepare my body for the rigors of professional ice hockey. Kevin was always organized and ready to lead our small group of elite athletes through intense, result-oriented workouts. Kevin’s ability to creatively and expertly create programs made training with Kevin at Endeavor Sports Performance a no brainer.

This past summer Kevin was also able to develop a program designed specifically for me to treat a sports hernia that prohibited me from doing most activities. Kevin was able to target the problematic area and not only strengthen it but got my body ready to perform at 100% and was the first season in a while that I was completely pain free.” – Jamie Carroll

When Jamie says “that prohibited me from doing most activities”, he means things like walking. He was generally able to lay in a bed pain free, but that was about the level of movement he could tolerate without pain, and getting out of bed was an unpleasant experience for him.

One of the keys in preventing unnecessary hip injuries is to have an in-depth understanding of the player’s anatomical/structural composition. In this regard, CAM impingement has received a lot of attention recently and rightfully so. Another frequent structural deviation that hasn’t received as much attention is femoral “version”. Femoral version is a measure of the angle of the femoral neck relative to a horizontal line through the two femoral condyles.

Demonstration of calculation of the angle of femoral version

While I think the above cartoon schematic is instructive for understanding how femoral version is calculated, I think this picture from my friend Bill Hartman’s post (Hip Mobility: Femoral Anteversion) better illustrates the contrast between “normal” and excessive anteversion.

Can you imagine how the orientation of the knee, lower leg, and foot would change if the femur on the right was re-oriented so that the femoral neck was the same as the one on the left?

Excessive femoral version, in either direction, will have a significant effect on the performance of the entire body and a failure to recognize the presence of such a structural deviation may result in off-ice training exercises that appear “correct” externally to be damaging internally. As a result, it is worth the time to assess for femoral version angles in hockey players. Check out the video below for a quick walk through on how you can assess for excessive hip ante- or retro-version in just a few minutes.

An idea that didn’t come through sufficiently in the video is that EVERY femur has properties of ante- or retro-version. 8-15° is considered within normal limits and “excess” is generally considered anteversion > 30° and retroversion less than 5°. That said, any deviation outside of normal limits is going to have an effect on the availability of rotational movement. When I mentioned that I was thinking Matt’s left femur was retroverted and the right was anteverted (outside of the normal limits in those directions specifically), I probably should have said that left femur was more retroverted than right, or that his right was more anteverted than his left. Following Craig’s Test, it was apparent that his left femur was in fact “normal” (version within normal limits), but the right femur was anteverted.

An important take home from this assessment is that the total rotation ROM is the true indicator of unilateral limitations. Matt had more expressed external rotation ROM on the left than right, and more internal on the right than left, but the total rotation ROM between the two sides was relatively equivocal. This indicates that differences in either internal or external rotation ROM from one side to the other are either:

  1. An ossessous adaptation that should be recognized and appreciated, but cannot be corrected; or
  2. A positional change in the pelvic structures that causes a change in the expression of rotational ROM direction tendencies

In the case of the latter, Craig’s Test rules out that the findings of a tendency of a hip to have more internal or external rotation ROM in comparison to the other hip is a result of a change in the orientation of the pelvis because Craig’s Test is strictly a measure of femoral bony orientation relative to other femoral landmarks (pelvis is taken out of it altogether).

The assumption that all hips are created equally and that ROM norms can be blindly imposed on all hockey players is dangerously misguided. Of the first 30 elite level hockey players (primarily USHL, OHL, NCAA D1, and professional players)  I’ve assessed at Endeavor Sports Performance over the last few weeks, 10 (33%) have either a unilateral or bilateral femoral version angle outside of the norm. Spotting these structural deviations early will help prevent unnecessary damage directly to the femoroacetabular joint structures and indirectly to adjacent structures affected by rotational limitations at the hip. This is true during both on- and off-ice activities. By providing the player with an understanding of what corrective exercises they can do to maintain joint integrity and what positions/movements they should avoid, the player can stay within his/her individual limits, optimizing performance and minimizing injury risk.

To your success,

Kevin Neeld

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Before jumping into today’s post, I just wanted to say a quick congratulations to several of our athletes from this off-season.

  • John Gaudreau (’93) is tied for 2nd on his team (Dubuque Fighting Saints) and tied for 3rd in the USHL for points, as a first year player!
  • Matt DiGirolamo was awarded the starting goalie position at UNH this year and is off to a great start. Check out this article: New Hampshire’s DiGirolamo a blast from the past for Umile
  • Colby Cohen played his first few games in the NHL over the last week and played quite well. Colby worked extremely hard with us at Endeavor all Summer. The gains he made are clearly helping him on the ice.
  • Eric Tangradi scored his first NHL goal a couple weeks back and looks bigger and faster on the ice than ever. great on the ice.

We’re really proud of the hard work these players have put in with us at Endeavor and also on the ice with their respective teams. Keep up the great work guys!

As you may know, I’ve spent a lot of time researching topics related to hip and lower abdominal injuries. Because injuries like hip flexor strains, groin strains, hip labral tears, and sports hernias are affecting an increasing number of players (and receiving an increasing amount of attention), I feel it’s important to do whatever I can do prevent these injuries in our players. Over the last couple years at Endeavor, we’ve pretty much eliminated hip flexor injuries altogether, and have been able to quickly restore balance in players suffering groin strains (almost always in players that refuse to take any time off the ice).

Sports hernias and labral tears can be a bit of a different scenario because surgery is an option, and one heavily pushed by most docs. This raises the debate, “Should ‘strength coaches’ be involved in these types of injuries at all or strictly leave them to surgeons/PTs?” It’s an interesting debate, but one we’ll leave for a different discussion. Over the Summer, we had a player come to us with the following situation:

  • LONG-term adductor/groin pain (several years!), in the area of the adductor longus (as expected)
  • Showed other symptoms of a sports hernia (notably painful during movements that stretch the rectus abdominis)
  • Painful during ALL movements, even jogging
  • No health insurance
  • 5 weeks to train


Goal # 1: Do everything you can to avoid this!

The reason I said we’ll leave the surgery debate for another time is because, without insurance (or shelling out $10,000 in cash), surgery wasn’t an option at all. Nor was seeing a physical therapist for that matter. Admittedly, the situationw as a little intimidating. He had 5 weeks to be symptom free AND to be ready to step on the ice for a new professional team in London, England. With that time course, there is no room for “I think this should work”; you get one shot. I spent quite a bit of time writing his program, and reached out to three incredibly bright coaches/mentors of mine: Eric Cressey, Michael Boyle, and Charlie Weingroff, all of whom provided invaluable insight into the situation.

A couple take homes were:

  • Don’t do ANYTHING that was painful (even mildly painful). In this situation, this meant NO lateral movement (including lateral squats, shuffling, slideboarding, amongst others), no reverse lunges or back leg raised split squats, and no skating!.
  • Focus on restoring balance across the hips. In this situation, this meant restoring length across the anterior hip, loosening up the glutes, and focusing most of the strength work on the posterior chain.

Compared to other off-season hockey training programs, this didn’t leave us with a ton of options. Naturally, we HAMMERED the soft-tissue work for the anterior and interior thigh compartments and also the glutes. We quickly progressed him from a foam roller to a PVC pipe, which gets a bit deeper because of it is so much denser.


PVC Pipe: An injured hockey player’s best friend.

The two areas I wanted to dive a bit deeper into are the stretching (geared towards adding length to the muscle) and the conditioning.

Stretching: Adding Sarcomeres in Series

Because one of the major focuses was to restore alignment, we used several stretches repeatedly:

  1. 1/2 Kneeling Hip Flexor Stretch w/ Downward Foot Press
  2. 2-Way Rectus Femoris Stretch w/ Downward Foot Press
  3. Stability Ball Internal Rotation Stretch
  4. Prone Active Hip Internal Rotation Holds
  5. Seated Glute Stretch
  6. Med Ball Loaded “Y” Stretch

Again, the goal here was to open up the anterior hip (remove some of the anterior tilt), improve hip internal rotation, and increase his ability to extend through the thoracic spine. The “Downward Foot Press” is a strategy we used to increase the tension in the stretched muscle in order to stimulate adding actual length (sarcomeres in series) to the muscle. We also had him hold the 1/2 Kneeling Hip Flexor Stretch for 5 mins on each side for the same reason. Stimulating actual muscle length is achieved through prolonged time in a stretched state and/or tension in a stretched state. After several weeks of this, he said his helps felt a lot looser, and his groin pain was starting to subside a bit.

Conditioning: How to stay in good shape when every movement hurts

How do you condition a hockey player when he can’t skate, run or slideboard, and you don’t want him to bike because of the concern of further exacerbating his already substantially shortened hip flexors? There are a couple options left, but the two that suited our purposes the best were:

  1. Forward Sled Marches
  2. Med Ball Circuits

On our sticky track, it typically takes around 25-30s to march a sled 25-yards to the end of the track. This made it pretty easy to build in an interval training component to his program. Because his body orientation while marching with the sled didn’t necessitate extreme hip flexion, he was able to perform the exercise pain free. Two wins.

Med Ball Circuits were a no brainer. High intensity, maximum velocity rotational movements are a must for off-season hockey training programs anyway. Devising a circuit to incorporate these was another great way to get some extra valuable work in while also improving his conditioning. The circuit was:

  1. Overhead Med Ball Slams: 12x
  2. Front Standing Med Ball Scoops: 10x/side
  3. Side Standing Med Ball Shot Put: 10x/side
  4. Underhand Med Ball Scoops: 12x

We’d have him perform the circuit anywhere from 3-5x, depending on the week.

At this point, you’re probably wondering what the outcome of all this was. After all, understanding these strategies is only worth your time if they worked. Last week he sent me a quick message to update me on how things are going. He said he’s been completely pain free all season (first time in years!), and he’s currently the second leading scorer on the Newcastle Vipers (EIHL).

A few important take homes from this experience:

  1. Many injuries that are typically thought to warrant surgery can be treated conservatively if done right
  2. A crucial factor in alleviating “soft-tissue” injuries is to avoid anything that irritates it
  3. EVERY PLAYER NEEDS TO TAKE TIME AWAY FROM THE ICE EVERY YEAR!
  4. Having a network of experienced professionals in your field is invaluable
  5. Studying injury risk factors can have a profound impact on your athlete’s careers. It’s worth your time.

To your success,

Kevin Neeld

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