Child and Adolescent Athletes at Greatest Risk of Concussions and Closed Head Injuries in Male Ice Hockey: A 20-Year Analysis of National Injury Data

Abstract

Context:

Ice hockey is a fast-paced and physically demanding collision sport that carries a high risk of injury, especially concussions and closed head injuries (CHIs). The purpose of this study was to evaluate the frequency, trends, and mechanisms of injury of concussions and CHIs sustained by male ice hockey players in the United States (US).

Evidence Acquisition:

Concussions and CHIs sustained playing male ice hockey presenting to US emergency departments from January 1, 2004 to December 31, 2023 were queried using the National Electronic Injury Surveillance System (NEISS). For each injury, patient demographics, disposition, and mechanism of injury were recorded. National estimates (NEs) were calculated using the NEISS statistical sample weight. Injury trends were evaluated by linear regression modeling.

Study Design:

Descriptive epidemiology study.

Level of Evidence:

Level 3.

Results:

A total of 62,070 concussions and CHIs occurred during the study period. From 2004 to 2023, overall injury incidence increased (P = 0.06). From 2004 to 2012, there was a significant increase in concussion and CHI incidence (P < 0.001) followed by a plateau after 2013. The age group affected most commonly was adolescents (ages 13-19 years) (52.3%, NE = 32,455). The top 3 mechanisms were head-to-ice contact (28.6%, NE = 17,741), head-to-boards contact (22.8%, NE = 14,123), and head-to-player contact (15.4%, NE = 9575). Head-to-ice contact was the most common mechanism in children (33.6%, NE = 5960). Head-to-player reached its highest rate in young adults (21.3%, NE = 1567). Falls initiated 33.9% of all concussions and CHIs. The hospitalization rate across the study was 3.4%.

Conclusion:

Concussions and CHIs sustained from male ice hockey demonstrated a 290% increase from 2004 to 2023, with the child and adolescent populations at greatest risk and head-to-ice contact representing the most common injury mechanism. Focused injury awareness, educational prevention programs, and potential rule changes are essential to decrease the rising incidence of concussions and CHIs in this at-risk patient population.

Strength-of-Recommendation Taxonomy (SORT):

C-level recommendation.

Keywords

head injuries/concussion male ice hockey sports trauma NEISS

The speed and aggressiveness of ice hockey lead to increased risk of injury for all players; inherently, ice hockey has one of the highest incidence rates of concussion.¹⁰ Concussions and closed head injuries (CHIs) are of concern for players of all ages and skill levels in ice hockey, accounting for 2% to 14% of all injuries and 15% to 30% of all head injuries in the sport.¹⁰ The long-term health effects of concussions on professional and recreational players is of extreme importance, as they can result in developmental delays and physiological harm - a trend seen in many sports.^7,16 It has been demonstrated that prevention efforts and rule changes can reduce the number and severity of injuries in sports, such as the implementation of red cards in soccer.^2,9

Concussions in ice hockey are usually caused by direct contact to the head by shoulders, elbows, etc, of other players, especially to the lateral aspect of the head.⁸ Preventative rules, such as Rule 48-Illegal Check to the Head, were introduced in the National Hockey League (NHL) in 2011 to decrease head injuries.⁸ With such rules being implemented for professional play, there is speculation around whether concussion rates warrant enforcing safety guidelines in recreational ice hockey as well.

Understanding trends of head injuries, patient demographics, and how the severity of injury has changed over time can further inform how to prevent further concussions and CHIs in the game. This study aims to assess the epidemiology of concussions and CHIs among male ice hockey players, as they have been found to endure significantly higher rates of head impact.⁴ We hypothesize that concussions were acquired commonly through falling and making contact with the ice, especially amongst younger-aged players.

Methods

Data Collection

Institutional review board approval was not required for this study given that only publicly available data were included. Data used for this study were extracted from the National Electronic Injury Surveillance System (NEISS) database. NEISS is a national publicly available, deidentified database operated by the US Consumer Product Safety Commission that acts as a representative sample of injuries presenting to US emergency departments (EDs). ED visits are collected from a stratified probability sample of approximately 100 US hospitals. National estimates (NEs) for the data were calculated using the NEISS statistical sample weight. This allows for an accurate estimation of the true amount of injuries throughout the country. NEISS was queried for all concussions (NEISS diagnosis code 52) and internal organ injuries to the head (NEISS diagnosis code 62, NEISS body part code 75) sustained from ice hockey (NEISS product code 1279) amongst US male ice hockey players between January 1, 2004 and December 31, 2023.

Exclusion Criteria

Each case narrative outputted by NEISS was examined and were excluded if at any of the following criteria were met: (1) the injury did not directly involve the act of playing ice hockey in a game or practice, (2) an internal organ injury did not occur to the head, (3) the injury was from coaching or viewing an ice hockey game, or (4) the injury involved a female ice hockey player. A case that would not be excluded was defined as a patient acquiring a concussion or CHI during ice hockey play. Cases that had a concussion or internal organ injury to the head as a secondary diagnosis were included.

Variables

For each case, patient demographics, treatment date, discharge disposition, and clinical narrative were extracted. The clinical narrative for each patient was reviewed by 1 author to ensure the case did not meet any of the above exclusion criteria.

Variable groupings were defined for age and disposition based on NEISS injury codes. Age groups included children (2-12 years old), adolescents (13-19 years old), young adults (20-29 years old), adults (30-49 years old), and older adults (≥50 years old). Disposition categories included hospitalized (admitted, transferred, held for observation) and nonhospitalized (treated and released, left without being treated).

To provide more detail on the concussion and/or CHI used in this analysis, the clinical narratives were reviewed by 1 author to determine the type of contact that directly caused injury. Contact types were defined for each case by 1 author and verified by a second author as head-to-board, head-to-ice, head-to-player, head-to-goalpost, head-to-puck, head-to-stick, and unknown and/or unspecified. In addition, the narratives were further used to identify which concussions and/or CHI were initiated by falls. Any disputes were discussed with 1 of the senior authors.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics Version 28.0 (IBM Corp LLC). Descriptive statistics were performed to measure the distribution of NEISS cases across extracted variables and reported as NEs. Linear regression analysis was used to assess NE over time, and the associated P value, regression coefficient (β), and 95% CI were reported. Various injury frequencies were the dependent variable, and year of injury was the independent variable for the simple linear regression analyses.

Results

An estimated total of 62,070 concussions and CHIs from male ice hockey players were recorded by NEISS between January 1, 2004 and December 31, 2023; 65 cases were removed based on the exclusion criteria. The average age at injury was 15 ± 7.9 years.

There was a nonsignificant increase in the annual number of concussions and CHIs across the study period (P = 0.06; β = 0.425; 95% CI, –4.641, 172.256) (Figure 1). There was a significant increase in concussions/CHIs from 2004 to 2012 (p < 0.001; β = 0.950; 95% CI, 344.377, 631.623). The frequency decreased and remained relatively consistent from 2013 to 2019. A 62.7% decrease in injuries occurred from 2019 to 2020 followed by an overall increase from 2020 to 2023. A 5-year moving average line was added to visualize changes in average injury incidence over time, confirming a clear rise until 2012 followed by a sustained plateau afterwards.

Figure 1.

Frequency of male ice hockey-related concussions and CHIs presenting to US EDs by year between 2004 and 2023, with a 5-year moving average trend line (red) to illustrate changes in average slope over time. CHI, closed head injury; ED, emergency department; NE, national estimate; US, United States.

Male adolescents were the most frequent age group to sustain concussions and CHIs, making up 52.3% of all injuries across the study period (NE = 32,455), followed by children at 28.6% (NE = 17,740) and young adults at 11.8% (NE = 7355). Older adults sustained the fewest concussions/CHIs (2.1%, NE = 1325). There was a continuous increase in the frequency of concussions and CHIs sustained amongst young adults (P = 0.01; β = 0.532; 95% CI, 3.67, 30.846), adults (P = 0.01; β = 0.545; 95% CI, 2.802, 20.751), and older adults (P = 0.01; β = 0.560; 95% CI, 2.553, 16.596) from 2004 to 2023 (Figure 2). Injury frequency in children and adolescents demonstrated a nonsignificant increase from 2004 to 2012 and reached a steady state from 2013 onwards.

Figure 2.

The frequency of concussions and CHIs sustained from men’s ice hockey amongst various age groups to US EDs by year between 2004 and 2023. CHI, closed head injury; ED, emergency department; NE, national estimate; US, United States.

The majority of concussions and CHIs were acquired from head-to-ice contact (28.6%, NE = 17,741) followed by head-to-boards (22.8%, NE = 14,123) and head-to-player (15.4%, 9575). (Figure 3). Patient narratives demonstrated that 33.9% of injuries were initiated from falls (NE = 21,072). Falls most frequently were the initiator for player head contact on the ice (67.8%) and the goalpost (52.4%), while concussions and CHIs caused by head contact with the puck were least likely to be initiated by a fall (0.51%) (Figure 4a).

Figure 3.

Distribution of injury mechanisms leading to concussions and CHIs in men’s ice hockey from 2004 to 2023. CHI, closed head injury.

Figure 4.

Percentage of injuries where contact was initiated by a fall stratified by various categories from 2004 to 2023 across different (a) head contact types and (b) age groups.

The hospitalization rate for concussions and CHIs across the study was 3.4% (NE = 2134). The most common contact type for hospitalizations due to concussions and CHIs was head-to-ice (24.1% of all hospitalizations) followed by head-to-boards (23.2% of all hospitalizations) and head-to-player (15.5% of all hospitalizations) (Table 1). Head-to-puck contact had the highest rate of hospitalization amongst head contact types (5.4% of all head-to-puck concussions and CHIs), followed by head-to-boards and head-to-player both at 3.5%.

Table 1.

Concussions and CHIs sustained from male ice hockey across 2004 to 2023, stratified by head contact type and age group

Characteristic	Specific group	NE	%	Hospitalized NE	Hospitalization rate
Mechanism of injury	Boards	14,123	22.8	495	3.5
	Ice	17,741	28.6	515	2.9
	Player	9575	15.4	332	3.5
	Goalpost	526	0.8	8	1.5
	Puck	2350	3.8	128	5.4
	Stick	2379	3.8	6	0.3
	Unspecified	15,376	24.8	653	4.2
Age group, years	Children (2-12)	17,740	12.8	274	1.5
	Adolescents (13-19)	32,455	61.4	1310	4.0
	Young adults (20-29)	7,355	9.5	203	2.8
	Adults (30-49)	3,192	11.1	238	7.5
	Older adults (50+)	1,325	5.2	110	8.3

CHI, closed head injury; NE, national estimate.

In an age-specific analysis, adolescents (29.4%) and young adults (35.5%) were least likely to sustain concussions or CHIs from falls, while adults had the highest likelihood of injury from falling at 52.7% (Figure 4b). The top mechanisms of injury in children were head-to-ice (33.6% of all children injuries, NE = 5960), boards (23.9%, NE = 4238), and player (11.0%, NE = 1953). The top mechanisms of injury among adolescents were head-to-boards (26.9% of all adolescent injuries, NE = 8721), ice (25.0%, NE = 8099), and player (16.7%, NE = 5434). The top mechanisms of injury among young adults were head-to-ice (24.5% of all young adult injuries, NE = 1801), player (21.3%, NE = 1567), and boards (11.8%, NE = 865). The top mechanisms of injury among adults were head-to-ice (47.5% of all adult injuries, NE = 1517), player (15.3%, NE = 487), and puck (10.5%, NE = 336). The top mechanisms of injury among older adults were head-to-ice (27.6% of all older adult injuries, NE = 366), stick (21.7%, NE = 288), and player (10.0%, NE = 133) (Table 2). The rate of injuries caused by contact with the boards decreased steadily with age. The rate for head contact with the ice was the highest amongst children (33.6%) and lowest among young adults (24.5%). Head-to-player contact had the opposite trend to that of head-to-ice contacts, where the rate of injuries for head-to-player was highest amongst young adults (21.3%) and lowest for children (11.0%) and older adults (10.0%).

Table 2.

NEs and percentages of concussions and CHIs treated in US EDs from 2004 to 2023 caused by each head contact type from male ice hockey in different age groups

Head contact type	Children(2-12 years)		Adolescent (13-19 years)		Young adult (20-29 years)		Adult(30-49 years)		Older adult (50+ years)
Head contact type	NE	%	NE	%	NE	%	NE	%	NE	%
Boards	4238	23.9	8721	26.9	865	11.8	235	7.4	66	5.0
Ice	5960	33.6	8099	25.0	1801	24.5	1517	47.5	366	27.6
Player	1953	11.0	5434	16.7	1567	21.3	487	15.3	133	10.0
Goalpost	291	1.6	216	0.7	17	0.2	0	0.0	0	0.0
Puck	479	2.7	1265	3.9	159	2.2	336	10.5	110	8.3
Stick	991	5.6	852	2.6	214	2.9	32	1.0	288	21.7
Unspecified	3830	21.6	7867	24.2	2735	37.2	584	18.3	363	27.4

CHI, closed head injury; ED, emergency department; NE, national estimate; US, United States.

Discussion

This study analyzed the epidemiology of concussions and CHIs from male ice hockey that presented to US EDs from 2004 to 2023. There was a nonsignificant increase in concussion and CHI incidence over the study period. Adolescents followed by children demonstrated the highest incidence of concussions and CHIs. In addition, injuries due to player contact peaked among young adults, while stick and puck-induced concussions were highest among adults and older adults. Falls were most common in children and older adults, with contact with the ice and goalposts being the most common injury source.

The most important finding was a marked increase in concussion injuries and CHIs from 2004 through 2012, which is consistent with findings from previous studies analyzing concussion rates in the NHL.^11,13,21 From 2013 onwards, the overall frequency of these injuries remained stable, which was also observed in previous studies analyzing pediatric concussions from ice hockey.^1,13 Although causation cannot be inferred from this analysis, this drop coincided with implementation of rules in several leagues from 2010 to 2011 that began to severely penalize any form of contact to the head.^12,13,15 Studies have observed a similar trend around the implementation of no head contact rules in youth and professional ice hockey leagues.^9,13 There is, however, a notable dip in concussion and CHI incidence stability from 2020 to 2023, likely due to the decreased participation in ice hockey during the COVID-19 pandemic.¹⁷

When stratifying by age groups, we observed the same trend in child, adolescent, and young adult players as described for the overall concussion/CHI frequency trend. The timeline of these trends aligns with mandated rule implementations. For instance, USA Hockey, which oversees child and adolescent players, implemented Rule 620 in 2010, stating that contacting or checking an opposing player’s head, face, or neck with any part of the player’s equipment, stick, and body is illegal and will be penalized with a major or minor penalty as well as a game misconduct.¹² The NHL—a professional hockey league made up primarily of young adult players—implemented a similar rule for the 2010-2011 regular season and modified it in 2011, making any form of contact to a player’s head illegal and resulting in a minimum of a major penalty.^14,15 These rule changes align with our observed timing of plateauing of concussions and CHIs in our study, suggesting that the implementation of these rules may have had an impact on halting the rising concussion and CHI rates in male ice hockey. However, the fact that these injuries remained constant suggests that existing measures may have reached a plateau in effectiveness. Further investigation into the impact of rule enforcement and player behavior is warranted to determine whether additional safety interventions could be beneficial in further mitigating concussion and CHI rates.

Adult players do not typically play in hockey games overseen by the NHL or USA Hockey, yet participation in recreational hockey leagues amongst these age groups is still quite popular. Many of these leagues across the US and Canada have different game rules, including no contact or checking and no slapshots.^5,19 The significantly lower frequency of concussions and CHIs amongst male adult and older adult ice hockey players may be explained by these recreational league rules to increase player safety. In addition, clinicians should encourage the use of full facial protective helmets for hockey players of all ages, especially adult and older adult players. This study’s findings show that puck and stick concussion and CHI rates rise with age. The required safety equipment for players’ heads varies with age and across leagues. For instance, 16-year-olds in the US Hockey League can wear half-visors that protect only the eyes instead of full cages, leaving more than half of the face exposed.¹⁸ In addition, full cages are not enforced in professional hockey leagues, including the NHL as well as in many adult recreational leagues. Some argue for keeping this as full face protection occludes players’ views on the ice.²⁰ However, this exposes more of the head, making it more prone to being hit with a player’s stick or a fast-moving puck from shots, likely contributing to the rise in injury rates from these types of head contacts as players age. This was observed in the analysis, where head-to-puck collisions had the highest rate of hospitalization amongst mechanisms of injury. In addition, laxity in helmet regulations in recreational leagues is possibly why puck and stick injuries, as well as the hospitalization rate, increased with age, especially among adults and older adults. Because of this, it is hypothesized that mandating full head and facial protective equipment for all hockey players in all types of leagues, especially older-aged athlete leagues, will decrease the incidence of concussions and CHIs through those means.

Approximately 1 in 3 concussions and CHIs were initiated from falls, with the rate being highest amongst children, adults, and older adults. As children are learning the game of hockey, they are simultaneously improving their skating abilities and balance, which increases fall rate. Our results are consistent with previous studies demonstrating that children are more susceptible to falling in ice hockey due to learning simultaneously how to play ice hockey as well as how to ice skate.^3,13 This is also supported by this study’s findings determining that children’s most common mechanism of injury was contact with the ice and that a major proportion of head-to-ice contact was due to falls. Therefore, to combat the high fall rate and prevent further concussions and CHIs, it is imperative to re-evaluate the protective safety of helmets and create a mandatory rule for all children to wear head protection as they learn the game.

We also saw a decrease in goalpost-mediated contact to the head as players aged, which is in agreement with similar studies that analyzed concussions in youth hockey programs.¹ This was a form of contact commonly initiated from falls, so therefore possible addition of padding to the metal posts is a possible prevention measure to decrease athlete concussion incidence especially in youth, who were more susceptible to falls in hockey.

While falls appear to be a major cause of concussions and CHIs amongst all ages of male ice hockey athletes, nonfall mechanisms, one of which is body checking, still pose a great risk. We observed head-to-player contact become a major cause of concussions and CHIs at the adolescent and young adult ages. This aligns with the ages at which body checking becomes legal in male ice hockey, where USA Hockey establishes legality at 13- to 14-year-old leagues.⁶ The rise in player-to-head contact rates as well as why adolescent incidences of concussions and CHIs are the highest could be attributed to this age marker and the introduction of legal player-to-player contact and checking. The majority of adult and older adult recreational leagues also prohibit body checking, which explains why we see a decreased rate of head-to-player contact and concussion/CHI injuries in those age groups. Interestingly, a study performed by Williamson et al²² found no significant reduction in player head contact from before to after implementing a zero tolerance for head contact policy in 2011. Further research evaluating the effectiveness of head contact rules and penalty enforcement on concussion and CHI incidence is warranted.

Limitations

This retrospective database study had important limitations to consider. First, NEs are extrapolated from a representative sample of 100 EDs, meaning that our estimates of national injuries may differ from the actual number of concussions and CHIs from male ice hockey. In addition, patients who were treated outside of ED settings are not captured, which likely results in an underestimation of the true number of concussions and CHIs resulting from ice hockey each year. Further, the injuries included are only the most severe concussions presenting to US EDs. Another aspect that was not captured were concussions sustained by female hockey players. Finally, details of patient history including imaging, treatment type, and other potential comorbidities were unavailable and could not be included in our analyses.

Conclusion

There were an estimated 62,070 cases of concussions and CHIs due to ice hockey among male players from 2004 to 2023. The majority of contact among young players was between head and ice, with children accounting for the highest fall rates. As the average age of players increased to middle-aged, player contact became the most prevalent cause of head injury. This emphasizes the importance of proper protective gear such as padded helmets among children who are still acclimating to the fast pace of the game. Stick and puck injuries rose as players aged as well, possibly attributed to laxity in helmets and facial coverings in older athlete leagues. The results found in this study highlight the importance of enforcing new and stricter guidelines and rules in equipment use and head contact specific to player age and skill level.

Footnotes

All authors are listed in the Authors section at the end of this article.The authors report no potential conflicts of interest in the development and publication of this article.

IRB approval

IRB approval was not required for this manuscript as only publicly available data was included in the investigation.

ORCID iD

Luca M. Valdivia

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