Improving sudden cardiac arrest (SCA) outcomes in hockey

By Rick Garner CEP, Team Paramedic Arizona Coyotes and Arizona State University Athletics

Firefighters, Paramedics, and EMT’s see and treat more out of hospital cardiac arrests than anyone else. These scenes are much different than in-hospital arrests. I’ve responded to 100’s of arrests during my career with the Phoenix Fire Department, and every scene and circumstance were different. Aside from a pediatric drowning, cardiac arrests are one of the most emotionally traumatic scenes a First Responder will ever face. Due to the unexpectedness of SCA’s, the pain and collateral damage experienced by family/friends is heart wrenching. They realize that just minutes ago their friend or family member was alive and well, and now they lay lifeless on the floor. Like a player who comes off the ice after a shift, then suddenly collapses, becoming apneic and pulseless. Cardiac arrests can happen to anyone, anywhere, at any time. SCA’s leave bystanders in a state of disbelief and shock.                                                                 

From an emergency medicine standpoint how well we manage an arrest depends largely on how well we’ve prepared for them, and how calm we can stay during them.                                       

If you’ve ever participated in a successful resuscitation you know it’s an incredible feeling to see life return to a lifeless body. Sadly, if you do it for a living, you soon realize that no matter how well you perform during an arrest many times people just don’t survive.  It’s out of our hands.

Sudden cardiac arrests (SCA’s) are commonly referred to as “witnessed” or “unwitnessed”, and as “in-hospital” or “out of hospital”. Game time SCA’s are considered “witnessed, out of hospital” arrests.  There are over 1000 out of hospital cardiac arrests (OOHCA) each day in the U.S. The current survival rate is less than 6%. That means less than 60 out of every 1000 will survive. However, during a game we have the potential to achieve much higher survival rates if we’re prepared to manage our patients quickly and effectively.

Sudden Cardiac Arrest (SCA) *Estimates suggest that cardiac arrest is the 3rd leading cause of death in the U.S. behind cancer and heart disease. Every year in the U.S., approximately 395,000 cases of cardiac arrest occur outside of a hospital setting, in which less than 6% survive. In hospital cardiac arrests have a 24% survival rate. Survival rates depend greatly on where the cardiac arrest occurs.

*Source: The National Academies of Sciences Engineering Medicine

How can we achieve the best outcomes if/when a SCA happens during a game?

Over the past 6 professional hockey seasons we’ve had 3 game time “witnessed” cardiac arrests. In each of these cases the athlete survived. How did the pre-hospital care of these patients beat the odds and contribute to their survival?

  1. 2014 Rich Peverley – Dallas Stars
  2. 2016 Craig Cunningham – Tucson Roadrunners
  3. 2020 Jay Bouwmeester – St Louis Blues

I’ve been asked how hockey has managed to achieve a 100% survival rate for game time cardiac arrests? My response: “It didn’t happen by accident.” These cases had special advantages. The patients were in great shape, the healthcare providers on scene (along with the emergency departments/hospitals) did an excellent job in managing these arrests, and the game time emergency action plan (EAP) for SCA worked.

Some Keys we’ve learned to having a successful resuscitation:

In each of the arrests I’ve responded to with the Phoenix Fire Department, not a single incident happened at the fire station with crew and equipment ready. Each time we responded 4-8 minutes with lights and sirens before reaching our patient. This response time combined with the time it takes bystanders on scene to recognize the severity of the situation and call 911, negatively effects patient survivability. It can ultimately end up being 10 minutes after the arrest before First Responders arrive.                                                                                                                                                                    

In each player arrest we had “Luck by Location” and “Early Recognition”. Each arrest happened during a game and was “witnessed” by healthcare providers who could immediately start providing care. Luckily each arrest happened in just about the best possible place it could, outside of an ER or hospital. All of the medical resources needed for a successful resuscitation were already in place and ready to respond. If these arrests would have happened at home, at a restaurant, while driving, or on a plane, the outcome most likely would have been much different.

Unfortunately, I have also been witness to either poor quality CPR or NO CPR on a SCA patient upon EMS arrival. More lives could be saved if people would immediately become hands-on and start doing hard and fast chest compressions prior to the arrival of 911/EMS resources. CPR is a take home skill we should all have.

Effective CPR was started immediately on each player. It’s important to note, these incidents involved elite athletes in great physical condition, and who’s blood was well oxygenated at the time of their arrest. Chest compressions were started immediately to circulate the oxygenated blood to the brain. Without these compressions the brain does not receive the oxygen it needs to survive.  This is a learned skill that is practiced each year during the PHATS/NHLTPS conference.

Each year at the annual PHATS/NHLTPS conference the following courses are offered:

1) CPR/AED certification with a focus on high-performance CPR                                         

2) ACLS Refresher course for team physicians                                                                  

3) Sports Med Team Based EMS training session

During a cardiac arrest it’s important to remain calm and focused on the immediate priorities. We need to get EMS resources coming, clear the patient’s chest for AED pad placement, and begin high-quality CPR. We need to quickly apply an AED to determine if the patient’s heart needs to be shocked. The AED should be applied without stopping chest compressions. The compressions are only stopped when the AED advises “do not touch the patient”. Remember, for every minute it takes to administer a shock the chance of survival goes down by 10%. If the patient’s heart needs to be shocked, the AED will advise to do so. The shock allows the patient’s heart to reboot and start up again on its own, hopefully in a rhythm that will push pulses and create a blood pressure. This is called “Return of Spontaneous Circulation” or (ROSC). The sooner we apply an AED after a cardiac arrest the better chance we have for achieving ROSC and patient survival. *Always remember to say “Clear” and look to make sure nobody is touching the patient prior to pressing the shock button. It’s a good practice to have everyone working close to the patient acknowledge the “Clear” command by also saying “Clear”.

In each arrest a shock was provided in under 2 minutes. In doing this we gave our patients better than an 80% chance of survival.

After achieving ROSC, we still need to manage our patient. This includes assessing vitals, providing oxygen/airway management, administering ACLS medications, providing safe transport, and advising the hospital of the patient’s status. Successfully managing a cardiac arrest is a fluid production and takes an entire team effort to get a win.

Team Practice of the EAP worked. Professional hockey’s medical personnel have put in a great deal of time and effort when it comes to player safety and planning for EMS incidents. SCA scenarios are constantly being reviewed and discussed by Sports Med staffs throughout hockey. You need to practice how you want to play. This is a major contributor to hockey’s success in managing cardiac arrest patients. Each Sports Med team member knows how the play is supposed to be run and how they fit into the play.

 At the annual PHATS/NHLTPS conference attendees have the opportunity to participate in a Sports Med Team Based EMS training session.This session is highly attended with excellent hands-on participation from the group. I believe the positive outcomes we’re seeing is a reflection of the work that’s being put in on the front end. During these sessions we have AT’s and team physicians going through EMS scenarios together. The sessions are being led by the paramedics and emergency medicine physicians who cover the games. This educational formula promotes collaboration, discussion, and team building. Ultimately, this model has created a high-performance CPR EAP that appears to be on track.

Moving Forward, we need to remain proactive and prepared for the cardiac arrest patient that doesn’t achieve ROSC on the scene. Remember, maintaining blood flow to the brain is crucial for survivability. If ROSC isn’t achieved, the use of mechanical CPR devices should be considered. They can provide quality chest compressions in the ambulance while advanced airway management and ACLS care is being provided. They will also create a much safer environment in the back of the ambulance while transporting Code 3 to the hospital. At the end of the day patient and provider safety are always the top priority.  

 “Improving Player Safety through Emergency Medical Preparedness

By Derek M. Hansen, CSCS @derekmhansen RunningMechanics.com SprintCoach.com

I have been working as a coach and consultant for speed and sprint-based athletes for over 30 years beginning in the sport of Track and Field.  As an athlete, I was always competing in sprinting and jumping events from a very young age and was also very capable in a multitude of sports.  As such, I have always used sprinting as a foundational element in all of my training programs, regardless of the sport.  For the most part, athletes continued to improve as long as we were making them sprint maximally a few sessions per week in their off-season preparation. 

It was not until I started to work with Olympic level speed skaters that I realized that the same could be said for athletes who wanted to skate at high velocities.  Much of the off-season preparation for these skaters was sprint-based on a conventional rubberized track surface using track spikes.  The faster skaters were also fast sprinters.  And many of the tendencies – good and bad – they demonstrated in dry-land scenarios, also came out when they were on the ice.  When I started to use the same approach with ice hockey players, we had similar outcomes and the players enjoyed the change from all of the conventional on-ice and gym work they were accustomed to during the off-season.  As we made the transition to a more comprehensive sprint-based program, in some cases eliminating on-ice work for a significant period of the off-season, we experienced even better results.

We know that over-training a specific movement or activity can quickly lead to a training plateau and diminishing returns, as well as a whole array of over-use problems, particularly in the hip and groin area of the ice hockey athlete.  This article reviews an extremely productive alternative to developing on-ice speed without all of the negative side effects of excessive on-ice work.

Distinguishing Between Specific and General Adaptations

Most sport coaches want more of what happens during games and competition.  If the game is played on ice, the practice will take place on the ice and any supportive skill work or drills will also occur on the ice.  It only makes sense.  However, there are many good reasons to consider dry-land solutions to on-ice demands.  There are specific aspects of dry-land sprinting that mirror the actions of skating acceleration as we will identify in this article.  Additionally, there are a whole host of systemic, general adaptations that occur in maximal sprinting that can contribute to improved on-ice performance.  Shorter ground contact times, more profound elastic responses and greater central nervous system demands are just a few of the reasons to sprint maximally at specific times of the year to build a faster and more resilient ice hockey athlete.  Chasing specificity can have immediate positive effects, but coaches and trainers must support this work with general activities that bolster physical resiliency, improve overall fitness and performance, and minimize both physical and mental burnout in ice hockey athletes of all ages and levels of ability.

The Myth of ‘First-Step’ Quickness

Many a physical preparation coach have staked their reputation on the importance of ‘first-step’ quickness.  It makes sense!  Going back to Neil Armstrong’s first ground contact on the moon back in 1969, we were inundated with the “One small step for man… one giant leap for mankind!” and we were hooked.  Strength coaches have promoted their weight room routines or plyometric exercises as part of their ‘first-step quickness’ program, rather than placing equal importance on every step and every contributing training element.  But even though a journey of a thousand miles begins with one step, the quality of all of those steps is critically important.  I’ve seen amazing first movements and initial steps decimated by horrible execution of steps 2, 3 and 4.  In fact, if an athlete is encouraged to do something sensational with their first step, chances are they will over-commit to that acyclical effort and ruin the smooth execution of the cyclical action of sprinting or skating.

Because both sprint and skating acceleration are cyclical activities, the distribution of effort must be balanced between each stride.  Too much emphasis on one stride can rob the other strides of proper position, frequency, range and, ultimately, power.  Finding the optimal cadence for any cyclical activity is critical for acceleration performance whether you are on a track or on ice.  In ice hockey scenarios, it is more common to initiate three to five strides before gliding on two skates, so it may be unnecessary to sprint far in dry land scenarios.  There are a few good reasons to sprint to maximum velocity that we will address later in the article.

The Biomechanics of Sprinting and Acceleration

Sprint – and in particular – acceleration mechanics can be simplified in a manner that divides up the action of the upper and lower extremities into front-side and back-side contributions.  Movement along the sagittal plane by the arms and legs about the frontal axis will involve the rapid flexion and extension of joints.  While many athletes are initially taught to ‘push’ out back to create propulsion, most of the top sprint athletes understand the importance of attaining range on the front-side of the body.  While some coaches may refer to a lifting of the knees, ideally the athlete is bringing their foot to the front side of the body at a height that allows them to accelerate the leg downward forcefully toward the ground to create both vertical and horizontal propulsion.  Any extension to the backside of the body is simply a byproduct of front side intent, ground preparation and overall force production.  When combined with a stride frequency of approximately 4.5 steps per second (in sprinters) good things can happen.

Some basic statistics on sprinting will help to illustrate what is clearly happening ‘on the ground’ and how this data can support a sprint-based approach to on-ice performance both specifically and generally.  Credit is provided to Dr. Ralph Mann and his research work with elite sprinters, documented in his book, “The Mechanics of Sprinting and Hurdling.”


Figure 1 – Horizontal sprint velocity in world-class male sprinters (Source: Ralph Mann)

It doesn’t take many steps for an athlete to approach top-speed as illustrated in Figure 1.  Horizontal speed is achieved not by first-step quickness, but a well-coordinated array of successive steps.  Over-striding, stumbling or standing up too quickly can all significantly impact acceleration rate.  This information does allow us to understand that short sprints and accelerations of even three to seven steps can contribute toward overall speed abilities of an athlete.  In ice-hockey players, this plays an even more significant role, as more than three to five skating strides are required in game-specific scenarios before a bilateral glide phase is employed.  While ice-hockey athletes do not accelerate at the same rate as sprinters in the early phase of a sprint – primarily due to the ice surface itself – a steady rate of acceleration is similarly experience by on-ice athletes.

Examination of athlete ground contact times during a maximal acceleration in an elite sprinter reveals that the amount of time on the ground quickly diminishes as velocity is increased.  Figure 2 illustrates the fact that world-class sprinters can quickly achieve ground contact times of no more than 1/10th of a second.  While ice-hockey players do not utilize the stretch-reflex in the lower leg complex as much as a dry-land sprinter, the initial steps in an on-ice acceleration will display similarly short ground contact times until the athlete begins to enter a unilateral glide phase.  As mentioned previously, this may happen as quickly as the fourth or fifth skating stride.


Figure 2 – Ground contact times in world-class male sprinters (Source: Ralph Mann)

Once we start to look at the stride/step frequency element of sprinting, we see that consistency is imperative.  There are no sweeping variations in stride frequency.  Sprint athletes quickly achieve their optimal stride frequency from step one and continue that pattern for their entire race.  This is important to realize for dry-land sprinting applications, as athletes must be taught to relax and maintain fast and consistent strides.  Athletes that can rapidly cycle through strides will often have better acceleration abilities whether on the track or on the ice.  While excessive stride frequency can diminish power, much like a car spinning its wheels without moving, it is recommended that training sessions focus on attaining maximal frequency with a measured amount of relaxation to allow for optimal stride length.  Once again, the ice skating athlete will peak in stride frequency much earlier than the sprinting athlete due to the nature of skating mechanics.   However, hitting a high frequency as soon as possible should still remain one of the goals of acceleration training regardless of the training environment.   Higher stride frequencies also allows for more accessible direction change abilities due to the fact that a step is always ready for force application on the ice.


Figure 3 – Stride frequency in world-class male sprinters (Source: Ralph Mann)

We have always been taught that good sprinting is the result of the optimal combination of stride frequency and stride length.  This is no different for the skating athlete.  The only difference is in how the stride length is attained in sprinting versus skating.  In sprinting, athletes drive more force into the ground for shorter instances of time to take advantage of elasticity so that the athlete is vaulted further and faster forward on each stride as shown in Figure 4.  In skating, athletes modify their stride mechanics to push laterally to essentially move up to larger ‘gears’ to create higher velocities of movement.  While stride frequency remains constant in sprinters over a six to seven second duration, stride frequency is skaters will actually slow down to accommodate a modified and more efficient stride mechanic.  Pushing laterally and crossing-over substitute bigger gears for high stride frequencies as proven by both science and practice.


Figure 4 – Stride length in world-class male sprinters (Source: Ralph Mann)

Application

So how do we modify sprinting to fit the parameters of ice skating?  Fortunately we don’t have to answer that question.  When on solid ground, sprint!  When on the ice, skate!  This may sound all too easy, but it works perfectly.  When athletes enter the initial start and early acceleration phase, they assume the same positions.  Figures 5a and 5b are of former Canadian Olympic speed skaters (500m distance) in their initial acceleration for both dry-land (inset) and on-ice scenarios.


Figure 5a:  Canadian Olympic Speed Skater – Jamie Gregg

In both cases, the off-ice posture and limb placements closely resemble the on-ice positions.  While these similarities may only last for three to four strides, sprinting still represents a more than suitable means of simulating the positions and stresses of on-ice early acceleration from a pure specificity point of view.  Skating will typically have a lower heel recovery position – during the swing phase of the stride – due to a lower elastic contribution from the foot at toe-off and the weight of the skate versus a sprint spike or running shoe.  As was mentioned previously, off-ice errors will typically manifest themselves as on-ice errors.  This reinforces the concept of ‘fixing’ mechanical errors in dry-land training sessions where more reps are possible, less equipment is required and facility accessibility is not an issue.  If you can fix it on dry land, you may not have to fix it once you hit the ice.  I believe this is one of the more compelling specificity arguments for dry-land sprinting.  And, I would argue that the stretch-reflex throughout all musculo-tendo structures in the lower extremities play a larger role in skating speed than most people would like to admit.

Figure 5b:  Canadian Olympic Speed Skater – Mike Ireland

For those of you that are not speed skating aficionados, fortunately, this tendency can also be seen in some of the faster ice hockey players.  Fast skaters have to produce adequate force into the ice at a high enough frequency to produce fast locomotion in a limited amount of space in game scenarios.  Figure 6 depicts one of the faster NHL players executing a powerful acceleration at an All-Star event competition that looks very similar to the positions of a dry-land sprinter.  I superimpose my proprietary “Be the Hashtag” symbol on sprinters and skater videos and photos to show how the posture and limbs should line up during acceleration and maximum velocity sprinting.  All good sprinters and accelerating skaters exhibit this posture, and it is a very simple way to convey optimal positions to athletes – particularly younger athletes – with a simple smartphone camera and app such as Dartfish Express.

Figure 6:  Connor McDavid accelerating in an All-Star speed competition

Figures 7 and 8 show examples of former NHL athletes accelerating maximally on a rubberized track.   In both cases, their off-season dry-land preparation was comprised of no less than two sessions per week on the track focusing on starts, accelerations and – in some instances – maximum velocity sprinting.  It is also important to note that both athletes readily enjoyed the training sessions, as it was a significant departure from the higher volumes of on-ice work that they were accustomed to during the off-season period.  There were no instances of muscle strains or other injuries during the course of the training periods and, if anything, the athletes exhibited a much lower incidence of injury once they resumed their on-ice activities and regular season commitments.


Figure 7:  Jason Garrison accelerating over 20 meters

Figure 8:  Manny Malhotra sprinting out of starting blocks

While maximal upright sprinting may not specifically address the requirements of ice skating, hitting higher velocities beyond 20 meters of sprint distance allows athletes to benefit from the greater forces required to run fast.  In Figure 9, you can see this former NHL player hitting top speed with maximal velocity mechanics over 40 meters with relatively good technique.  This approach is supported by the research of Nagahara et al. in Figure 10 demonstrating that ground reaction forces increase dramatically as athletes hit higher running speeds.


Figure 9:  Manny Malhotra sprinting maximally over a 40-meter distance
Figure 10: “Step-to-step spatiotemporal variables and ground reaction forces of
intra-individual fastest sprinting in a single session”  Nagahara et al.  2018. 

Return-to-Play Protocols

Another one of the benefits of employing a dry-land, sprint-based approach to training is that you also create another means of strengthening the athletes should they have the misfortune of getting injured.  Most of my lower body rehabilitation protocols involve the significant integration of sprint drills and accelerations on a daily basis.   I have presented on two occasions in the last five years at the NFL Combine for PFATS on the subject of a sprint-based approach to hamstring injury prevention and rehabilitation, and my methods have been adopted by a majority of teams. 

The same approach can easily be adopted for ice hockey players as part of a transitional ‘step’ between the clinical rehabilitation phase and return to on-ice activities.  Sprint drills and dry-land acceleration work will safely strengthen the muscles and connective tissues to the demands of on-ice locomotion.  We even use sprint accelerations for upper extremity injuries to maintain the strength of the upper body, as many athletes comment on how sore they are in the shoulders, biceps, traps and upper back, with some even commenting on hypertrophy gains after as little as three weeks of sprint work.

Concluding Remarks

One of the symptoms of presenting this type of information is that you will get the hecklers from the back row chiming in with, “Well, you can’t take a sprinter and put him in skates expecting him to be an NHL level player!”  I would never assert that this is the case, just as I wouldn’t suggest that sprinters would make great basketball, football or tennis players.  We all understand that sport specific skill is critical to success in every sport.  However, integrating some of the valuable qualities that dry-land sprinting brings to the table for most athletes in various sports – without creating significant over-use issues – is a compelling option for players and teams looking for easy-to-implement solutions for off-season preparation, in-season maintenance and year round return-to-play protocols. 

I am not proposing a massive shift towards excessive dry-land training, but simply a subtle re-orientation to some very effective off-ice solutions that don’t require significant equipment or training to implement on a consistent basis.  Once all professionals attain a level of comfort and competence around this modality, significant benefits can be made available to all players from the development levels all the way up to the elite performers.


Derek M. Hansen is an International Sport Performance Consultant that has been working with athletes all ages and abilities in speed, strength and power sports since 1988.  He has worked closely with some of the top performers in the world as a coach and a consultant – including Olympic medalists, world record holders, Canadian National team athletes, and professional athletes from numerous sports. Most recently, he worked progressively over the last five years on speed development and sprint integration with the Super Bowl Champion Kansas City Chiefs.  He worked as the Head Strength and Conditioning Coach for Simon Fraser University for 14 years, the first non-US member of the NCAA.  He also serves as a performance consultant to numerous professional teams in the NFL, NBA, MLB, NHL and MLS, as well as NCAA Division 1 programs throughout North America, specializing in speed development, strategic performance planning, return-to-competition protocols and neuromuscular electrical stimulation programming.  Derek also offers continuing education courses around sprint-based solutions via his Running Mechanics Professional curriculum at RunningMechanics.com.

By Jason McMaster, Head Equipment Manager, Winnipeg Jets

The 2019 Heritage Classic in Regina was a great experience for our whole organization.  Saskatchewan is a very passionate hockey province, and embraced the opportunity to have an NHL outdoor game there. The city of Regina was a great host.  

The Saskatchewan Roughriders were generous enough to allow the Jets to use their home dressing room.  The Riders dressing room is outstanding.  They did a great job on their dressing room complex design when Mosaic stadium was built.

With the Riders dressing room facility being so large, with great stalls, we were able to dress the room up really nice with Jets signage.  I would like to personally thank Rob Baker from Pakmark who did an amazing job with all the decals and signage.

The atmosphere at the game could not have been any better.  From the fighter jets fly over after the national anthem, to the consistent snow fall throughout the game, and the chilly -12C temperature all making the game feel like a true Canadian outdoor experience.

This event would not have been possible without the help of the Saskatchewan Roughrider training staff, Winnipeg Jets Game night attendants, the Calgary Flames, and the NHL staff.  Thank you all!

Photos courtesy of Jason McMaster & the Winnipeg Jets.

By Hayley Wickenheiser, Assistant Director, Player Development, Toronto Maple Leafs

A year prior to the 2014 Sochi Olympics, I took a slap shot off my foot in practice with the national team. My foot was sore, and it ached for a while, so I went to see a sports medical doctor. They did an x-ray and it was negative. The advice I was given was to not load the foot, there may be a small crack and let it heal with no impact but playing should be ok. The injury kept nagging me and finally I went back to a different doctor, who did a CT only to find I had a crack in my navicular. First lesson here, suspected Navicular Fx needs a CT not a X Ray!! Don?t mess around with the feet. 

There?s currently no set standard of care for whether a board or scoop should be used to remove a player from the ice. The method used for SMR is usually determined by the City, State, Provence, Fire Department, Ambulance Company or a local Authority. As healthcare providers in sports we can still pre-plan for injuries and have what we need ready to treat them. We can also take advantage of some of the differences between treating patients in the field and treating our players on the ice.

By this point, the crack was not going to approximate, and my frustration was through the roof. I played through the Sochi 2014 Olympics in a lot of pain, modifying my training and surviving thanks to the Incredible medical staff on the national team. After the Olympics finished, I went to see renowned foot surgeon Dr. John Lau at Toronto Western Hospital. Dr. Lau decided I needed a screw in my foot to try to pull the bone back together. 3 months later and doing everything I was told to do and I returned to the ice. Two games back, I remember taking a sharp tight turn and my foot literally crumbling under the screw. I went from one crack to a navicular that was in 4 pieces and my career in jeopardy. I don?t think anyone realized the amount of torque a foot undergoes, even in a hockey skate. 

Back to Dr. Lau I went, who had to do a complete fixation using a bone graft from my hip, with a plate and 8 screws. He also gave me strict orders that if I touched my foot to the ground for even a moment before 4 months, I may never walk right again let alone skate. I took his advice to heart and went back to Calgary to begin my rehab. 

I started rehab on day 10 post-surgery with a plan led by my amazing friend, and trainer Dr. Syl Corbett. Syl devised a plan that would see me work backwards from the day we projected me to skate again. Day one for me started with a garbage bag taped around my giant cast I had on, so I could start swimming. Ever seen a hockey player swim? It is not pretty, let alone with a cast on. That is where I lived for the first 2 months, in the pool! Fast forward to 4 months later and 10 months before I was playing again, I came back with personal bests in almost every area of my fitness testing and with more drive and appreciation of being a pro-athlete and what my health meant to me. To this day, it has been a long road to say the least, but without Dr. Lau?s great hands and Dr. Corbett working 5 hours every day with me, I?m not sure I would have ever played again. Dr. Lau would tell me it was one of the top 3 worst breaks of the navicular he had ever seen. Great!! 

Today I am happy to say he saved my career, I am back to running and training normally and I am able to stay on the ice, this time in my role with the Toronto Maple Leafs. There were countless days I wasn?t sure I?d be able to do either. Here is what I know from that experience that may help all of you when working with any athlete, whether it be a pro or weekend warrior: 

  1. Every athlete is an individual case: there is no box or timeline for certainty in recovery and athletes will do remarkable things in healing and recovery that defy all ?normal people? rules. In saying that, your job more often than not, is to pull the reigns back, but keep in mind how driven athletes really are. 
  2. Start with a goal of return to play and work BACKWARDS from that date to formulate a plan. I always felt better when I knew where I was going and the plan to get there. Yes, swimming sucked but I knew I would be fit and strong and keep progressing for when I hit land. I slept better, had less anxiety and felt calm knowing my team had a plan and believed in it. 
  3. It?s about who can keep their head on: much of injury rehab is physical yes, but once the physical rehab is over, the mental rehab of return to play is more crucial. Even though I couldn?t play hockey, I could watch it, visualize it, and continue to work on my game when not on the ice. Within my rehab I incorporated game simulations as much as I could so when I stepped back on the ice, I felt less behind. Athletes will often want to stay close to their sport. 
  4. There will be THOSE DAYS…when either you or your athlete want to choke each other out! Stay Positive. Rehabbing injuries, especially big ones are very scary and uncertain for maybe both of you. Be honest with them, talk about the valleys and plateaus they will hit, let them vent and don?t fall into the dark black hole when they do. Remember, it?s not about you, it?s the fear and uncertainty that grips so many and makes us all crazy at times. 
  5. Find the silver linings in every day: there is always something that can be worked on ?always a way forwards. Stay creative and be prepared when your athlete comes to work with you. The best way to keep athletes following your plan and on side with you is to show you are as committed and invested in their rehab as they are. 
  6. Ask for help if you need it. I always had tremendous respect and I do to this day studying medicine, when I work with health professionals who admit it when they don?t know something. We can?t know everything there is to know in rehab, research or the latest and greatest training. If you don?t know, say so! Your athletes will trust and respect you more in the end. This is not a sign of weakness but strength in knowing your limitations. I will be forever grateful to those doctors and therapists who kept me on the ice relatively injury free through my career. My navicular injury was the worst I have ever experienced, but with a great team of folks on my side, I was able to return to the ice and more importantly, feel that I can have a long life after hockey with a relatively healthy foot to live an active life.

Hayley Wickenheiser is the Assistant Director of Player Development with the Toronto Maple Leafs, a second-year medical student at the University of Calgary and a four-time Olympic Gold Medalist with Canada?s Women?s Hockey Team.  She has partnered with Dr. Syl Corbett to create an athletic balm, Rock on Clay*.   She?s pleased to offer our readers 10% off until Dec 15. with the code: navicular.  You can purchase the balm by visiting her site here, http://www.rockonclay.com/

Photos courtesy of Jon Sanderson & Hayley Wickenheiser

* The appearance of advertisements or promotions is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality, or safety by PHATS/SPHEM.

By Brian Papineau, Head Equipment Manager, Toronto Maple Leafs

Why did the organization choose Newfoundland for their training camp location?

With our ECHL team (Newfoundland Growlers) based in St. John?s and the older AHL affiliation (St. John?s Maple Leafs from 1991-2005), the organization decided it was best to hold training camp there.

Is this the first time your team has held their training camp off-site?

Every year, the Maple Leafs like to hold training camp off-site to give the many fans from all over a chance to watch up close as the team prepares for another season. We have traveled to Halifax, NS twice and to Niagara Falls, ON as well. It also allows the players a chance to get away from our normal surroundings that we spend so much time at during the season and allows them to interact with the community as well as take in the sites and do some team bonding.

How much time did you have to prepare?

Originally, two members of our organization traveled to St. John?s 10 months prior to see the possibilities of holding training camp there. They viewed arena options and hotels and then about 6 or 7 of our staff from different departments went for a site visit around August 1st and that was a chance to meet some of the key contacts at the arenas, hotels, restaurants as well as the head of all the volunteers. We went through logistics and what our needs would be when we arrived in St. John?s.

What was the biggest challenge?

The biggest challenge was getting everything out there and making sure that we had enough room on the two chartered planes that we flew on. We pre-shipped many supplies like Gatorade and medical supplies early to free up space on the aircraft. We also ordered some of our supplies (water, tape and pucks) to be shipped directly to St. John?s so that we didn?t have to worry about taking it with us. The day we left, we had our Media Day in Toronto at our practice facility, so we had players wear their practice gear for the Media portion so that we had all the game gear packed ahead of time so that we could pre-load the planes and allow for a timely departure.

Would you do anything different having gone thru it?

I think everything went smooth for the most part as we spent the first three days at the practice facility in Paradise, NL and then moved into Mile One Stadium for three days and an exhibition game against the Ottawa Senators. Our day to day schedule is pretty much the same the past five years, so we kind of know what to expect and that makes planning easier while away.

What surprised you most about Newfoundland?

We have been to Newfoundland a few times over the years and we held a small portion of our training camp there back in 2001 during 9/11. You hear how wonderful and friendly the people are and how much they love their hockey and that was shown daily. The hockey office staff and trainers (Neil Davidson and Andrew Koch) from the Growlers were great hosts and took care of many details leading up to training camp. It also never hurts to have David Roper from Mount Pearl, NL on staff with the Maple Leafs. It didn?t matter what was needed, Ropes got it done.

Did you have a chance to tour Newfoundland? 

As I mentioned earlier, we did a site visit previously so I was able to tour around the area and I didn?t realize how beautiful St. John?s is and the many attractions it has to offer. The people, the food and the sites were outstanding.

What advice would you give to an Equipment Manager who?s team is holding their training camp off-site for the first time? 

I think the biggest thing is go out ahead of time and check out the arena and hotel and meet the people that you will be dealing with. They along with volunteers will help you in so many ways. Take pictures of your locker rooms and working environment and think about the electrical requirements, the heat and drying of equipment, laundry facilities and more that will be needed to ensure that camp runs smoothly.

Photos courtesy of Brian Papineau.

By Chris Davidson-Adams
Head Equipment Manager, Vegas Golden Knights

Blocking shots is something every player is now asked to do.  It?s not like the ?old days? where rugged, skilled players wouldn?t think about it, it?s a necessity.  It?s even a player statistic you can look up! With that, we as equipment managers are tasked with protecting the players so they aren?t scared of blocking shots. 

When I was first hired as Head Equipment Manager of the Vegas Golden Knights, one of my first tasks was to go over policies and culture with our General Manager, George McPhee.  It was an easy decision by both of us to encourage all players to wear hand and foot protection.  All players were very receptive and understanding of this. 

With so many great products and a variety of applications you can accommodate players how they see fit.  We use several products for foot protection ranging from Ultra Stop by Custom Skates Works, Helskore Skate Armour, No Shifts Missed, to Laboratoire Orthopediques.  All the manufacturers of gloves have options for hand protection which makes it easier now.  Custom Pro Repair makes great specialized products for those more challenging pads and injury protection.  From full foot to sides only, from full hand to knuckles only, if a player can dream it we do it.

Photos courtesy of Chris Davidson-Adams

By Rick Garner CEP, Team Paramedic Arizona Coyotes and Arizona State University

Backboard vs. Scoop / Log Roll vs. Lift and Slide


It?s Game Time, you?re on the road, and you see your player take a big hit into the boards. He?s lying motionless on the ice, and players are waving you out. When you get to him, he?s awake, but a little disoriented. As you check him out, he?s complaining of some neck pain, with some numbness and tingling in his arms and hands. You decide he needs SMR and your fist goes in the air. As the home team?s medical staff comes on the ice to assist, you also see EMS coming with their gurney and equipment. When EMS gets to you, they remove their equipment from the gurney and lay a scoop stretcher next to your player. You see the scoop and think where?s the board? Because at home you practice using a board for these situations. Don?t worry, it?s going to be OK, take a deep breath, and trust the home team?s EAP to help you through this. Make this an educational session and learn from this experience.

SMR is designed to do no harm and create as little motion to the spine as possible during the removal of someone from their current position to a gurney and then to the next level of care.            
The least amount of movement to the patient the better.

There?s currently no set standard of care for whether a board or scoop should be used to remove a player from the ice. The method used for SMR is usually determined by the City, State, Provence, Fire Department, Ambulance Company or a local Authority. As healthcare providers in sports we can still pre-plan for injuries and have what we need ready to treat them. We can also take advantage of some of the differences between treating patients in the field and treating our players on the ice.

Let?s take advantage of what we already know:

Our potential patients are hockey players.  Our players are wearing helmets, pads, and skates, which adds to their height, size and weight, especially goalies. Know the challenges during treatment because of the hockey equipment.                                                        

You will get to see the mechanism of injury. Paramedics and EMT?s in the field usually don?t. The take-away, is we should be using a board/scoop that fits our patients instead of the standard 6-foot board first responders use in the field.   The board we use should be larger, and if you are using a scoop it should have the ability to expand large enough to fit the player. Let?s make things easier.

Log Roll or Lift and Slide – Most EMS providers use a board with a log roll.This method has been used for decades because it?s versatile, convenient, and quick. It also allows for EMT?s/Paramedics to visualize the patient?s back for trauma/abnormalities prior to putting them on the board.This is why a board and log roll is the most preferred and commonly used method by first responders for stabilizing players on the ice. This does not mean a board and log roll is always the best or most effective way for SMR. It?s simply the most familiar to EMS providers.

The NATA recommends having a ?Time Out? meeting with EMS prior to the start of each event. It?s during this time that we should find out if a board or scoop is the preferred method used locally for SMR. If the local method is not your staff?s preferred method, then we should have the discussion on how this is going to work come game time. Another topic of discussion should be how SMR will be done if the player is in a prone position. Current recommendations support using a log roll with a board for this type of incident. How will we handle this if a scoop is this only option? Will a board also be available for this scenario? If the patient is supine and we?re using a board, we should also determine if we?re going to use the log roll or lift and slide method. Both methods work well, however, the lift and slide has recent data to support less movement of the spine, which is ideal. Both methods take practice as a team, with the lift and slide needing additional personnel in a more coordinated effort. At the end of the day we want to do both, the method that is best for the patient, and the one our group has the most confidence in using.

During the 2018 football season at Arizona State University,Gerry Garcia, ASU?s Head AT, scheduled our EMS ?Time Out? meetings 90 minutes prior to the start of each game. In attendance were the AT?s, physicians from both teams, the X-ray tech, spotters and interns. As the discussion went around the room, we always made a point to let the visiting staff know that we used a larger backboard. We would also ask which method they preferred to use if they have a player who needs SMR, the log roll or lift and slide? At the end of the season the response was split 50-50. Some teams even brought their own backboard and straps to be used on their player. In each meeting we let them know our EMS team would use whatever SMR method they were most comfortable with.

As the lift and slide method becomes more popular, we need to insure we have a solid commitment to regular training, using a consistent staff. The lift and slide works very well when you have enough staff who are familiar with the procedure and can perform it in a coordinated fashion.

While on the road if your staff prefers to use the lift and slide, then we should communicate that to the EMS crew prior to the event. It?s not the best timing when you?re meeting an EMS crew for the first time on the ice to inform them, we?re going to lift the patient and slide the board under them. Especially when the last patient they boarded in the field they used a log roll. The home team?s medical staff should also be informed of your preferred method because they?ll be needed to assist.  If our staffs can get comfortable using both methods, we will have less surprises on the ice.

While at home if your staff prefers the lift and slidemethod, and your EMS providers use the log roll, then we need to practice the lift and slide with our EMS staff. This can be challenging if teams don?t have regular EMS providers covering the ice each game. With different personnel rotating through each night, the method they used on their last call in the field will be their go to method on the ice. So, only if your EMS staff uses the lift and slide method in the field, will it translate perfectly to the ice.

Game time EMS incidents are low frequency/high profile events. Knowing this we need to continue working with and developing our EMS team. The more consistency we have in our game time EMS staff, the more opportunities we have to establish a team-based EMS standard of care. The closer working relationship we have with our EMS team, the better the chance we have for a positive outcome. When it comes to EMS, we need to be Proactive instead of Reactive.

By Toby Palmiscno
Equipment Manager, Bemidji State

Bemidji State University participated in the 13th annual Hockey Day in Minnesota.  The Bemidji State men?s team outlasted Michigan Tech on Friday night with a 4-3 overtime win, and the women?s team fell to Minnesota State on Saturday afternoon by a score of 2-1.  Both games played outdoors on the south shore of Lake Bemidji; a quarter mile from the Sanford Center, which is the home arena for both programs.

As the head equipment manager for both the men?s and women?s hockey programs at Bemidji State, I can tell you that hosting this sort of an event was a ton of work; but it was the coolest thing I have ever been a part of.

The planning process for me began four months prior to the official announcement, ten months before the first game. Unlike a NHL stadium series outdoor game, our budget is small, so it was important to take the time to prioritize the basic player needs and still spend as little as possible. 

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Annual Hockey Day In Minnesota

Annual Hockey Day In Minnesota

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January in Bemidji, MN is typically very cold; but the game temperature reached 15 below zero both days; colder than anyone may have expected.  Originally, we had provided base layer tops and balaclavas for our players, but with the new forecast a few days prior, additional neck warmers, glove liners, and dozens of hand and toe warmers were added to the supply list.

The players? benches did have some heat, but out in the cold, I quickly found out that dry erase markers don?t work, neither did any type of hockey tape. My stopwatch malfunctioned, and our Howie?s visor spray froze in less than seven minutes.  Ironically, the only player from both teams that did not switch from a clear face shield to a cage scored the game winner in overtime. 

Changing steel wasn?t an issue; although I wore a pair of black gloves (two pairs for a $1 at the local Dollar Tree) under my winter choppers, because bare skin became very cold in a matter of minutes.  I kept a whistle in my pocket for the linesman; and he switched it out with me every four of five shifts because it started to freeze up on him.  I changed a goalie cowling on Friday for one of the high school players; he took a puck to it at practice and it shattered quite easily.

In addition to the college games, four high school games and numerous youth games took place during the event.? Teams would get dressed at the locker rooms in the Sanford Center, then bus to the outdoor rink where four 30?x10? construction trailers served as locker rooms for intermissions.? Teams then bused back to the Sanford Center to shower and hang their gear.? The four members of my student staff spent countless hours helping transport supplies, setting up locker rooms at both sites, and pushing laundry through.

The Bemidji Hockey Day committee and its 300 plus volunteers were vital in the success of the event.? Carly, Tommy, Monty, Chad Pie, and Scrambie were five of the volunteers that braved the cold for endless shifts all weekend, to ensure the matting was free of debris, directed teams to locker rooms, hot coffee pots were always full, and helped the arena crew with anything that was asked.? Similar to visiting locker room attendants, they did all that was asked without batting an eye; the most positive, and cheerful people I saw over the weekend.

As I said earlier, it was the coolest thing I have been a part of in my entire career. The most memorable part would have to be the camaraderie of everyone involved: players, volunteers, fans, coaches, trainers, ice crew, media personnel, and so many more.? No matter what team you played for or who you were cheering for; you could feel the energy from the outdoor rink to the warming tents and across the entire community.

By Jon Geller, Asst. Athletic Trainer, Toronto Maple Leafs

As Athletic Therapists/Trainers, Physiotherapists, and Strength Coaches, our goal is to keep our players on the ice, performing at optimum levels. I believe that movement assessments are valuable in order to offer insight into how each athlete moves in a specific context, and to mitigate potential injuries. I agree that it is extremely difficult to replicate the unique movement patterns on the ice, but we can help the athletes build movement competency for pathways that they will require on the ice.

split squad stretch floor
split squad stretch floor

In my experience, one movement that we assess regularly in each of our athletes, which has provided relevant insight into the movement requirements of forwards and defensemen alike, has been the split squat.

The model I use is the In-Line Lunge from the Functional Movement Screen (FMS ? see pictured). The athlete stands on the platform with their front heel the length of their tibia away from their toes of the rear foot, in a straight line.

The dowel is held vertically along the spine. The arm that is opposite the front leg holds the dowel at the cervical spine, and the arm opposite the back leg holds the dowel at the lumbar spine. The natural lordosis of these segments allows room for the hands. The athlete is instructed to maintain the points of contact at the head, thoracic spine, and sacrum. They are then directed to squat down, in control, until their back knee touches the platform, and then return to the starting position, three successive times.

The athlete then performs the same movement on the opposite side. I allow for a small forward lean of the trunk (parallel to front tibia) seeing as though they will uptake this posture while skating. Having them perform the split squat on the elevated platform increases the stability requirement in the frontal plane, which is a requirement for efficient edge management.

A critical question we must consider, is what can we extract from this assessment? Essentially, what it represents for me is how does the athlete perform a squatting movement, with one leg in front and the other in back, on a narrow base of support, and how do they manage this with their spine and pelvis. It?s not imperative to have the athlete perform the movement with the dowel, however, I feel that it offers you invaluable insight into the behavior of the spine and pelvis during the movement. It also allows you to examine the relationship of the upper quarter to the split squat. I frequently have the athlete perform the same movement with their hands on their hips to see if there is an improvement. If there is, I know there is dysfunction in upper half that?s complicating the movement.

Why is it important for hockey? Given the nature of the sport, and the repetitive movements/postures involved, lower and upper crossed syndromes are common.

split squad stretch with ball
split squad stretch with ball

Sometimes there is nothing we can do to completely reverse these, given that our athletes make a living in these postures, however, we can work to have them show the capability of moving out of them, and stay out of them off the ice. In order to be proficient in the narrow base split squat, one must possess the ability to maintain a neutral, centrated spine and pelvis, while eccentrically controlling lower anterior chain (in the back leg), and lower posterior chain (in the front leg). As a whole, the movement should look clean and fluid. Doing it elevated on a board creates an added balance component to which we can evaluate the relationship of stabilizers (local and global) versus prime movers. Often, prime movers are forced to act as stabilizers as well, which will slow the movement down or make it look mechanical. The athlete?s strategy to perform the split squat, will give you a glimpse into how they may be moving on the ice. Unfortunately, sometimes what I see is an athlete who uptakes an anteriorly rotated pelvis, in this posture, and then, as they descend downwards, their pelvis will turn into their front leg. If we imagine the pelvis as a bowl of soup, in this case, the soup would be spilling forward, and towards their front hip. The anterior pelvis decreases the amount of room the hip has to flex, while the ipsilateral rotation of the pelvis brings the hip into further adduction and internal rotation. This will often result in a pinch felt in the anteromedial hip as the femur is coming into excessive contact with the acetabulum. Seeing as the athlete regularly flexes their hip in an athletic stance (quarter squat) while they are skating, this dysfunctional posture can result in coxofemoral pathology. Conversely, if we can address the reason behind these compensations, and then imprint a good movement pattern, we may be able to avoid further ramifications.

Once you?ve identified a dysfunctional split squat, the next, and hardest step is to determine why. A simple scan of each segment will help you determine if there are hardware and/ or software issues that are playing into the dysfunctional movement pattern. A hardware restriction would be a joint mobility restriction, or a soft-tissue restriction, while a software issue would be a stability restriction. Any hardware or software restrictions that you can address will help open up pathways that the athlete can utilize while they are performing a particular movement. If we take the anteriorly rotated pelvis, for example, this may be occurring because the hip is lacking range of motion, and is moving excessively as a result. If the hip is lacking in stability, the pelvis might be rotating towards the hip during the split squat, so that there is more congruency between the femur and the acetabulum as a false stability mechanism. I have noticed, though, that the split squat can look clean, but when you break it out, you may find that the hips are lacking range of motion in a certain plane, for example.  Every athlete?s hips will be morphologically different. During your evaluation, if you find symmetry in one plane, and as long as the hip is asymptomatic, assess your ability to affect change in another plane, as the range that they do possess, may be functional for them. Continuous work to improve range of motion in a certain plane on a joint that is already close to it?s maximum, sometimes has the opposite of the desired effect. This is a good opportunity to use your sports medicine staff, and delegate to a colleague who may have more expertise than you in a certain area.

When the hardware and/or software restrictions have been addressed, and the proper movement pattern needs to be re-imprinted, I usually start on the ground. The ground provides a point of reference for the body, while the spine and pelvis is supported.

Swiss ball roll-in?s (pictured) may seem remedial, however, they will provide a neurological challenge that your athlete might struggle with at first. From the ground, I then have my athletes move to the quadruped position. This is the first position where the hips and shoulder girdles are loaded, but the spine is still supported. Quadruped diagonal slides (pictured) performed with a foam roller placed vertically along the spine will force the athlete to create a fixed axis through their stationary hand, knee, and toe while working on dynamic stability of the moving shoulder and hip. This exercise is self-limiting in the sense that, done properly, the foam roller will stay on their back, however, if it is not, the foam roller will fall. I especially like this one for those whose pelvis rotates into their hips during split squat, as it forces them to keep their pelvis

square to the ground. In between quadruped and half kneeling, I have the athlete work to demonstrate competency in the plank position. These positions (front, side, or supine) challenge the trunk in different planes by having the athlete create a stiff axis of rotation, while allowing the opposite hip to move about that axis. Half kneeling is the first position where the spine is fully loaded.

Sometimes the bulk of my work here is on ensuring the athlete can get their pelvis into a neutral position before we start anything else. I have found that will exhibit a certain posture (usually an ipsilateral pelvis hike to the side of the flexed hip) in order to work around any soft-tissue or joint restriction they may have in their extended hip. Once we have created more awareness, I then ask them to lift their front leg (see pictured) into more flexion, and hold it. This position allows the athlete to take advantage of active insufficiency in the extended hip, and passive insufficiency of the flexed hip, while forcing the psoas to work as a prime mover. This, of course, is only possible with the help of the lumbo-pelvic stabilizers. If they?re having trouble with this exercise, I usually stack up more airex pads so that their front hip starts in less flexion. I usually have found isometric split squat holds (in a low position) to be helpful, as they are working on the movement from the bottom, up. Once they?ve mastered this position, and before they?re handed off to the strength coaches to begin re-loading the pattern, I make sure they are proficient in standing first. I?m not looking for perfection, but I?m looking to have made an improvement of what I initially saw.

In conclusion, I have found that assessing the split squat is an easy and effective way of gathering information, and gaining insight into movement strategies that the athletes may be utilizing on the ice. The split squat has numerous applications for hockey, and making sure the athletes are proficient with it may be a good way to mitigate potential injuries.