Hockey Doc

The Hockey Doc: Evaluating and removing injured players from the ice

By Dr. Rob LaPrade

Question: What is the best protocol to evaluate and remove injured athletes from the ice?

Answer: This is a very important topic because the initial treatment of an injured athlete can be very important to their ultimate outcome. At a college hockey game in Grand Forks in 2010, proper training and attention to detail saved the life of a player with a C2 neck fracture, which is usually 95% fatal. In the evaluation of an injured athlete, especially one that may have been checked from behind or  tripped into the boards, it is first important to do a basic safety evaluation starting with an ABC evaluation.

A.B.C. stands for Airway, Breathing, and Circulation. If an athlete is unconscious, it is important to verify they are breathing and also to check their pulse. For any athlete who does not appear to have the normal ABC’s, the basics of CPR should be initiated by qualified providers.

For those athletes who are conscious and alert, one of the first and most important things to ask them about is where they hurt before moving them. Athletes with any head, neck, or back pain should be evaluated very carefully and not moved without stabilization of the spine. One of the most important things to do in injured hockey players, when they are unconscious or alert with neck or head pain, is not to remove their helmet. This is because the helmet provides important support to their spine and if they do have a neck fracture, it can cause motion of the fracture which could lead to permanent nerve damage or paralysis.

We have done studies which demonstrate that the most significant risk of increased motion in the cervical spine occurs at the mid-level of the neck when the helmet is removed. This is the exact level at which the majority of ice hockey spinal fractures occur. Thus, it is important to leave the helmet on to make sure that if the athlete does have a neck fracture, that the fracture does not move and cause paralysis. In athletes who have neck pain and are on their face in the prone position, they should not be moved until people trained and comfortable with proper log rolling technique can help move them onto their back. At all times, the neck should be stabilized and the helmet should be left in place. This same protocol should be followed in athletes who have low back pain because they may have a thoracic or lumbar spine injury also.

For those athletes who have no head or neck pain, but may have lost their breath or have extremity pain, it is reasonable at this point to assist them with rolling onto their back so that they can be better evaluated. If a significant extremity injury is suspected on initial assessment, it is often best to remove the player from the rink before doing a more complete assessment.

It is reasonable to assume that anyone who has hit their head has a concussion until proven otherwise. Athletes who have a headache, neck pain, who are disoriented and appear confused should not be allowed to be back into competition. It is important to ask them if they know which rink they are in, what period it is, what the score is and other questions which help to determine how alert and oriented they are.

To summarize this important topic, in any athlete who may have had a head or neck injury, it is important to leave their helmet on. For athletes who may have isolated extremity pain, splinting of the extremity and/or assisting them off the ice could be considered. In any athlete who may have head or neck pain, however trivial it may seem, it is reasonable to wait for emergency medical services to assist them off of the ice to make sure that there are no significant neck or skull injuries present.

Robert F. LaPrade, M.D., Ph.D. is a complex knee surgeon at The Steadman Clinic in Vail, Colorado.  He is very active in research for the prevention and treatment of ice hockey injuries. Dr. LaPrade is also the Chief Medical Research Officer at the Steadman Philippon Research Institute. Formerly, he was the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the U of M. If you have a question for the Hockey Doc, e-mail it to This email address is being protected from spambots. You need JavaScript enabled to view it..