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Handle with Care

By Jamie MacDonald , 09/16/21, 1:45PM EDT


Injury Prevention

As luck would have it, the same kinds of things that can make you a little less injury-prone on the ice might also make you a better player.

When it comes to injury prevention, Sara Carpenito, an athletic trainer at Northeastern who has been working with hockey players since her graduate school days and for the better part of a decade since, knows firsthand the kinds of injuries hockey players most often encounter.

As a focus of Carpenito’s work, which has included populations ranging from under 10 to over 70, from kids to Olympians such as Hilary Knight and Breanna Decker when they were with the Boston Pride, she is quick to point out that the young and the not-so-young shouldn’t be considered the same kind of athlete.

“I think one of the biggest messages I have to get across – to parents and to coaches and obviously to the athletes – is the fact that [youth hockey players] are still growing,” says Carpenito. “Their development is still in a process. Their bones are growing so fast and their muscles can’t keep up – and if we’re not training those muscles well to handle the demand that they’re going through, then that’s going to increase our risk for injuries.”

In other words, youth hockey’s players should be handled with care. And it can start with something as simple as body positioning on the ice.

“The best way I can explain it is finding your athletic position,” Carpenito says. “Like a shortstop, or when you’re playing defense in basketball. You’re kind of in that half-squat, hip-hinge position.”

Still, because hockey is a tiring sport, that ready position is something that can eventually get away from a player. Tired players, just as they lose the ability to make the plays they want, also might get a little loose on their posture.

“When you’re tired, you stand right up,” says Carpenito. “And then you hyperextend your back, you hyperextend your knees. Our muscles are so tired they’re not conditioned to sustain that position. So, once we are tired, that stress starts to creep into that low back and hip complex, and sometimes even into the knees for some players for sure.”

For Carpenito, the most frequent injuries she sees in hockey players are in the low back.

“The ones I spend the most time taking care of are mainly low back injuries like sacroiliac joint dysfunction, or even something as serious as a stress fracture in the lumbar spine,” she says. “One thing I found is that hockey players have extremely, extremely tight hip flexors – strong, strong, but extremely tight hip flexors. What that does is kind of rotate the pelvic bone forward, placing so much increased stress on the lower backs. So it actually puts stress on their lumbar spine and can sometimes create the stress injury to their bones.”

There are also hip flexor strains, groin strains and femoroacetabular impingement or “FAI.”

“[Femoroacetabular impingement] essentially means there’s some bone growth on the femoral bone, the thigh bone that connects to the hip joint,” says Carpenito. “But I have actually found that it can be prevented to an extent. Some of it has to do with genetics and your general build and makeup – but, also, if you are in the correct positioning and using the correct muscles, the stress in those areas can be decreased. We can actually help prevent those things from happening or at least the severity of those things.”

In Carpenito’s line of work, for someone who grew up an athlete and whose husband is associate head coach of the Huskies’ women’s hockey team, the goal is always to keep athletes on the ice. 

Training can certainly help.

“It actually kind of starts with posture,” says Carpenito. “In hockey, we are so forward, we’re in this hyper-flexed position all the time. There’s all this stress on our lower back and hips. Our shoulders are rounded and our head goes forward. So, it’s starting with upper-back or mid-back exercises, dedicated strength and conditioning programs for the upper-back and mid-back muscles to help support your shoulders and your neck. We also talk about how that affects concussion prevention, the control of your neck.”

From there, Carpenito wants hockey athletes to think about their core strength.

“I think one of the biggest messages I have to get across – to parents and to coaches and obviously to the athletes – is the fact that [youth hockey players] are still growing,” says Carpenito. “Their development is still in a process. Their bones are growing so fast and their muscles can’t keep up – and if we’re not training those muscles well to handle the demand that they’re going through, then that’s going to increase our risk for injuries.”

“I’m not talking about situps or holding a plank for 10 hours,” she says. “I’m talking about rotary stability. OK, you can do planks, but you have to pick one arm up and hold it or you have to switch arms. There are different exercises in the antirotation area that can actually help with rotary stability that would be extremely helpful for youth athletes. Something that probably every single one of my athletes, doesn’t matter what age, all of them need to work on rotary core stability – especially in hockey because every stride they take is rotational. You need to be able to control that. They have all this power, but they have no sense of control, especially in the developmental stage. So my goal as an injury pension specialist and athletic trainer is to make it so that they can control their movements.”

The same goes for those upper- and mid-back exercises such as lat pull-downs, where the goal should be managing the weight and not simply yanking as much as possible with form that might be more likely to injure a player than make them better.

“The best feedback I get from my clients is when they know why they have to do certain things,” Carpenito says. “They start feeling better and realizing how their body is supposed to work, and the reasons why they have to train that way. They start to pay attention to how they’re feeling. And that translates to how they are on the ice, and they start paying attention to how they feel. ‘Wow, I feel more powerful today. I feel faster today. My cuts were sharper. I am battling harder on the boards.’ That’s the rewarding part to me, getting that kind of feedback.”

Pliability also comes in to play.

“Absolutely,” says Carpenito. “Especially in the hip flexors. I’m finding that the hip flexors, they are giving other areas of the body a bad rap. Because they are so tight and they are super strong, and that’s a great thing, but they’re actually, one, messing with the positioning of your pelvis, putting pressure on your lumbar spine and on your hips in general and, two, they are inhibiting the use of our glutes and hamstrings.”

Glutes and hamstrings are also another point of emphasis for Carpenito.

Q&A with Nicole Siglin ATC, CSCS, USA Hockey Player Safety Coordinator - Massachusetts District

Q: What is the role of the Safety Committee for Mass Hockey?

Siglin: Our role is to ensure that players and officials enjoy hockey in a safe environment. The Committee is comprised of Tom Smith, Dr. Alan Ashare, Mark Boldrighini, Ron Cincotta, Dana DeMatteo, Dan Esdale, Steve Fitzgerald, Howie Hunter, Tim McMahon, John Murray, Joan Nardone, Ryan Scott, Maura Sheehan, Jeremiah Tabor, Chris Valeri and myself. As the player safety coordinator for Mass Hockey, I act as a liaison between USA Hockey and Mass Hockey to coordinate safety information and help to implement initiatives set forth by USA Hockey.

Q: How passionate are the members about making hockey a safer place for youth hockey in the state of Massachusetts?

Siglin: Our Safety Committee is very passionate about creating a safe environment for all of our members. For Tom Smith, having had three paralyzing accidents, two from hockey, it’s extremely personal. He is the biggest proponent of player safety in Mass Hockey and it is his passion that drives our Safety Committee. For me as an athletic trainer, safety has always been paramount to any athletic experience. Collectively, our committee wants to create a safe playing environment in hockey, and we are always striving to fulfill that obligation.

Q: Which initiatives of the past few years would you point to as successes in regards to player safety in the state?

Siglin: Most recently, I would highlight Covid-19 over the past year. The fact that we were able to have some 50,000 youth hockey players play hockey during the pandemic is remarkable. Tom Smith was in constant contact with the Governor’s office, collaborating and devising ways to keep our teams playing. 

Q: Are there any particular initiatives to look ahead to Mass Hockey implementing in the future?

Siglin: Unfortunately, with the recent on-ice injuries of A.J. Quetta and Jake Thibeault, we will be focusing on Heads Up Hockey and the Look Up Line. We will be asking our coaches to make sure proper checking and body contact drills are being taught. Also, we want to make sure athletes are aware of where they are spatially on the ice. The use of the Look Up Line and teaching safer body contact techniques can reduce the occurrence of these types of injuries if they are being reinforced at every level of play. We will also be focusing on the concussion protocol and making sure teams are following it consistently.

“[Hockey players,] they think that they have the strongest glutes and hamstrings on the planet, and I don’t think they’ve accessed their glutes and hamstrings in hockey in years,” she says. “That’s the first thing I have to do once I hit home that core stability, that postural stability, and stretch out those hip flexors a bit. We have to keep everything there and we have to get those glutes and hamstrings on board. I found that a lot of hamstring strains and groin strains, a lot of those things come from lack of strength and control in the glutes and hamstrings.”

Carpenito might suggest an athlete try a single-leg glute bridge.

“So, you’re laying on your back, but I want your foot up on a foam roller,” she says. “And when you perform the bridge, I want you to make sure that the foam roller doesn’t move.”

More often than not, hockey players find themselves cramping, shaking, or generally feeling uncomfortable.

“Essentially that’s your body’s response saying, ‘Oh, no, we don’t do that. We need the hip flexors to help us do those things,” says Carpenito. “It’s, like, ‘No, it shouldn’t be that way.’ Your hamstrings and glutes should be nice and strong to perform their duties. They shouldn’t rely on the hip flexors and quads – because eventually that’s going to lead to increased risk of injury. Working on that glute and hamstring complex is extremely important.”

This is a win-win, too.

“Not only will you be helping prevent these types of injuries to your hips and back,” Carpenito says, “but you’re also going to be a lot faster.”

Players’ hamstrings may also be getting a bad rap.

“It’s a common misconception that the hamstrings are tight,” says Carpenito. “In the youth population, I have found that they’re not actually tight. They’re out of position. If you could picture of your pelvic bone, and your hip flexors are attached to the front, and your hamstrings are attached to the bottom, but it’s the same bone. So, if the hip flexors are tight and pulling that bone forward then they’re going to tighten your hamstrings as well. It’s sort of pseudo-tightness, to be honest. In order to strengthen your hamstrings and loosen up those hamstrings, you need to stretch the hip flexors and get them in the correct position first. That cramping with the foam roller exercise, that cramping is a cry for help. That is your hamstring saying, ‘I am thirsty for strength and I need strength now.’”

In addition to keeping an eye out for hip flexor strains, Carpenito is also aware of a more worrisome hip issue for players who are still growing.

“One thing that can also happen, especially in growing bones, yes, they can get hip flexor strains, but in the growing population they can get what’s called hip flexor apophysitis,” she says. “That growth plate is now stretched out.”

In some cases, surgery may be needed.

And if you haven’t yet noticed, for an athletic trainer, whose long hours mean being on the job longer than just about anyone in sports, there are potential issues to try to mitigate around every corner. In addition to the head, shoulders, upper- and mid- and low back, hip flexors, glutes, hamstrings, there are also the knees, ankles and feet. Again, training can help.

“In order to prevent a lot of these hip, back and knee injuries like patellofemoral pain syndrome, patellar tendinitis, meniscus injuries or MCL injuries, a lot of that injury prevention starts with glute strength, to be honest,” says Carpenito. “Your glutes and hamstrings have such a direct impact on your knee, ankle and foot positioning. And if you are able to get that glute strength and loosen up those hip flexors a little bit, you’re probably going to have a lot more control over the positioning of your knees and ankles. It kind of comes back to the game-ready position. So, having a strong core, having strong glutes and loosening up those hip flexors in the front of our hips, those are great ways to prevent a lot of these injuries. But then you’re also in a better position to play. Again, it’s a win-win from the injury prevention standpoint – but then you’re also going to perform a lot better.”

In terms of just how much work young players should be doing in this regard, Carpenito understands that the lives of players and their parents are busy.

“If you can at least get three or four days a week of 30 minutes of exercise, meaningful exercise, that would be ideal,” she says. “So, even if it’s just a couple of exercises or a routine that takes you 30 minutes, with foam rolling, doing a couple of strength exercises for the muscle groups we talked about and then ending with some hip flexor stretching, I’m happy. I found that if we can at least get that in, it’s something that is absolutely attainable. This is something that they can use to motivate themselves, and they will be able to see progression.”