Translate this page into:
High rates of return-to-play and No deterioration in performance following ankle fractures in National Hockey League players
, Katherine L. Essera, Jared Rubina, Bradley A. Lezaka, Nathaniel P. Mercera, James J. Butlera, Hayden Hartmana, Andrew J. Rosenbaumb, John G. Kennedya
⁎Corresponding author: Alexander Tham. alexander.tham@nyulangone.org
-
Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Ankle fractures are common injuries in high-impact sports but have not been extensively studied in professional hockey. Given the high-speed, collision-heavy nature of the National Hockey League (NHL), ankle fractures may significantly affect player performance and team resources.
To investigate the incidence, management, and impact of ankle fractures on return-to-play (RTP) and performance metrics among NHL players.
A retrospective review of NHL players from 2013 to 2023 identified 30 athletes who sustained ankle fractures. Injury data, treatment intervention (surgical vs. non-surgical), and mechanism of injury were recorded from an online databse. Performance metrics were compared between pre- and post-injury seasons using non-parametric statistical methods.
The calculated rate of occurrence was 0.52 ankle fractures per 10,000 athlete exposures. All players returned to NHL play, with a mean time to return of 1.8 ± 1.0 months. There were no significant differences in performance metrics, including goals, assists, points, time on ice, or shooting efficiency, between pre- and post-injury seasons. Surgically treated players had a longer recovery time (2.7 vs. 1.4 months; p = 0.007) but missed a similar number of games compared to non-surgically treated players (16.6 ± 14.5 vs 16.2 ± 12.1 games missed, p = 0.756). Puck impact injuries were more likely to require surgery than contact-related injuries (p = 0.038). No player sustained a refracture.
This study found that ankle fractures are a rare injury sustained by NHL players but do not lead to statistically significant deterioration in player performance metrics. All NHL players successfully returned to play at the NHL level at a mean time to RTP of 1.8 months. Taken together, these findings indicate that ankle fractures in NHL players have minimal effect on their ability to return to and maintain pre-injury performance levels.
1 Introduction
Ice hockey is an intense, high-speed sport characterized by frequent collisions and high-impact interactions with other players, equipment, and rink boards. This environment creates a high risk of lower extremity injuries, which comprises 27–50 % of all reported injuries in the National Hockey League (NHL).1 Foot and ankle injuries experienced by athletes participating in the NHL can be complex and can have substantial implications on the athlete's ability to return to play (RTP).2 These injuries can significantly disrupt performance and impose a high financial cost on teams, resulting in players missing up to 10 games per season, and contributing to a mean loss of $283,100 in player salary per injury.3
Ankle fractures are common in high-impact sports and the prevalence of ankle sprains in ice hockey has been widely documented.2,4–7 However, there are no studies on the occurrence or implications of ankle fractures in NHL players. Ankle fractures are common in high-impact sports like the National Football League (NFL), where an average of 16 distal fibula fractures occur every season, with more than half requiring operative intervention in order to allow for timely RTP(8). NFL players demonstrate a RTP rate of approximately 71 %–90 % following surgical intervention.8–10 Interestingly, Robbins et al. found that NFL players that are able to return to sport after operative ankle fractures do not see a difference in game time or performance metrics from pre-injury baseline.9 This gap in the literature is noteworthy given the high-impact forces involved in ice hockey, ranging from collisions with other players and from puck impacts travelling at over 100 miles per hour.11 These forces combined with recent trends to reduce skate padding for speed gains12 create a high risk for osseous injury, with studies showing that the most common sites for fractures from direct impacts are the medial malleolus, distal fibula, and navicular bone.13
This study sought to address this gap by examining the incidence, management, and pre-versus post-injury performance outcomes of ankle fractures in NHL athletes. The purpose of this study was to provide insight into these injuries in professional hockey players that may guide players, coaches and front office personnel alike regarding the effect of ankle fracture on return to sport and performance metrics.
2 Methods
2.1 Patient identification
A retrospective review of NHL players was completed to identify players who sustained an ankle fracture from 2013 to 2023. The occurrence of injuries was identified using data from injury transactions, injury reports, and injury reserve placements. Data on player statistics was sourced from NHL injury databases, media reports, and other news sources (Hockey-Reference.com, ProSportsTransactions.com, CBSSports.com and ESPN.com). This methodology has been used several times in the literature to report on NHL injuries [18–23].
2.2 Data extraction
Player demographics included age, body mass index, player position, and laterality of injury (Table 1). Injury data included timing of injury, mechanism of injury, surgical intervention vs. non-operative management, as well as re-fracture incidence (Table 1). Mechanism of injury was organized into five categories: hit by puck, contact with a player, contact with boards or net, non-contact, unknown/other. Performance metrics were gathered in the season pre- and post-injury, including a return to play, games missed, games played, total career starts, total starts per season, goals, assists, plus/minus, penalty minutes, power play goals, power play points, short-handed goals, short-handed points, time on ice per game, game-winning goals, overtime goals, shots, and shooting percentage (Table 2). Mean performance metrics per season played was obtained pre- and post-injury. Additionally, performance metrics at one season pre-injury and post-injury were obtained as well as cumulative statistics for all years pre-injury and post-injury (Table 3).
| n | 30 | p |
| Age at injury (years) | 26.6 ± 5.1 | |
| Body Mass Index (kg/m2) | 26.6 ± 1.4 | |
| Career Games Played | 687 ± 349 | |
| Total Games Played Pre-Injury | 408 ± 320 | |
| Total Games Played Post-Injury | 285 ± 186 | |
| Player Position | ||
| Defenseman | 14 (47 %) | |
| Center | 9 (30 %) | |
| Right Wing | 4 (13 %) | |
| Left Wing | 3 (10 %) | |
| Goaltender | 0 (0 %) | |
| Laterality (L:R) | 20 (67 %): 10 (33 %) | |
| Mechanism of Injury | ||
| Hit by Puck | 11 (36.7 %) | |
| Contact with player | 7 (23.3 %) | |
| Contact with boards or net | 8 (26.7 %) | |
| Non-contact | 1 (3.3 %) | |
| Unknown (%) | 3 (10.0 %) | |
| Timing of Injury | ||
| Off-Season | 1 (3.3 %) | |
| In-Season | 29 (96.7 %) | |
| Treatment | ||
| Surgical | 9 (30.0 %) | |
| Non-Surgical | 21 (70.0 %) | |
| Return to play at NHL level | 30 (100 %) | |
| Time to return (months) | 1.8 ± 1.0 | 0.007 |
| Surgically treated | 2.7 ± 0.9 | |
| Non-surgically treated | 1.4 ± 0.9 | |
| Number of NHL games missed (n) | 16.3 ± 12.6 | 0.756 |
| Surgically treated | 16.6 ± 14.5 | |
| Non-surgically treated | 16.2 ± 12.1 | |
| Refracture rate | 0 % | |
| Pre-Injury Season | Post-Injury Season | p | |
| Games Played (n) | 59.3 ± 23.5 | 61.9 ± 20.9 | 0.943 |
| Goals (n) | 10.5 ± 10.0 | 10.2 ± 9.7 | 0.512 |
| Assists (n) | 19.2 ± 15.1 | 19.4 ± 13.0 | 0.929 |
| Points (n) | 29.7 ± 23.6 | 29.6 ± 20.6 | 0.773 |
| Plus/Minus Rating (n) | 1.0 ± 10.2 | −1.5 ± 11.9 | 0.589 |
| Penalty Minutes (n) | 28.0 ± 20.6 | 30.9 ± 20.3 | 0.692 |
| Power Play Goals (n) | 2.1 ± 2.7 | 2.2 ± 3.1 | 0.808 |
| Power Play Points (n) | 6.6 ± 7.7 | 7.2 ± 8.6 | 0.986 |
| Short-Handed Goals (n) | 0.3 ± 0.6 | 0.2 ± 0.5 | 0.608 |
| Short-Handed Points (n) | 0.8 ± 1.1 | 0.5 ± 0.9 | 0.478 |
| Time on Ice/Game, (min) | 17.9 ± 4.2 | 18.3 ± 3.9 | 0.624 |
| Game Winning Goal (n) | 1.5 ± 1.7 | 1.7 ± 1.9 | 0.824 |
| Overtime Goal (n) | 0.4 ± 0.7 | 0.3 ± 0.5 | 0.783 |
| Shots on Goal (n) | 114.8 ± 77.8 | 123.3 ± 76.9 | 0.719 |
| Shooting Percentage (%) | 7.5 ± 4.8 | 7.1 ± 4.2 | 0.820 |
| Pre-Injury Seasons | Post-Injury Seasons | p | |
| Games Played (n) | 55.8 ± 20.5 | 55.2 ± 16.0 | 0.362 |
| Goals (n) | 9.6 ± 8.1 | 9.1 ± 7.8 | 0.090 |
| Assists (n) | 16.9 ± 11.0 | 16.4 ± 10.4 | 0.339 |
| Points (n) | 26.7 ± 18.0 | 25.5 ± 17.0 | 0.168 |
| Plus/Minus Rating (n) | 0.25 ± 5.9 | −0.17 ± 9.8 | 0.90 |
| Penalty Minutes (n) | 29.7 ± 7.1 | 25.6 ± 17.0 | 0.027 |
| Power Play Goals (n) | 2.7 ± 2.6 | 2.0 ± 2.2 | 0.016 |
| Power Play Points (n) | 7.5 ± 6.7 | 6.4 ± 6.4 | 0.043 |
| Short-Handed Goals (n) | 0.3 ± 0.4 | 0.3 ± 0.5 | 0.747 |
| Short-Handed Points (n) | 0.5 ± 0.6 | 0.6 ± 0.7 | 0.808 |
| Time on Ice/Game, (min) | 17.9 ± 3.6 | 17.6 ± 3.5 | 0.412 |
| Game Winning Goal (n) | 1.5 ± 1.4 | 1.4 ± 1.2 | 0.178 |
| Overtime Goal (n) | 0.3 ± 0.4 | 0.2 ± 0.3 | 0.327 |
| Shots on Goal (n) | 106.2 ± 64.9 | 101.7 ± 54.6 | 0.425 |
| Shooting Percentage (%) | 8.0 ± 4.2 | 7.6 ± 4.1 | 0.165 |
2.3 Statistical analysis
Statistical analyses were conducted using SPSS Statistics 28.0.1.1 (IBM, Armonk, NY, USA). Descriptive statistics were calculated, with categorical data reported as frequencies with percentages and continuous data as mean ± standard deviation. As the data could not be assumed to follow a normal distribution, the Wilcoxon signed-rank test was used to compare pre-injury and post-injury performance metrics. Missing data was handled by listwise exclusion. Mann-Whitney U test was used to compare continuous unpaired performance metrics, and point-biserial correlation was used to evaluate correlation between variables. Fisher's exact test was used for comparisons of proportions.
3 Results
3.1 Patient characteristics
Thirty NHL players who sustained ankle fractures during practice or play were included in the study (Table 1). Over a 10 year period, the mean age at the time of injury was 26.6 ± 5.1 years, and the mean body mass index (BMI) was 26.6 ± 1.4 kg/m2. The distribution of ankle fractures across player positions was as follows: 14 defensemen (46.7 %), 9 centers (30 %), and 7 wingmen (23.3 %); no goaltenders were present in the cohort. The calculated rate of occurrence was 0.52 ankle fractures per 10,000 athlete exposures.
3.1.1 Injury data
Table 1 represents the ankle fracture injury details for the cohort, with 10 players (33.3 %) having sustained right-sided ankle fractures, while 20 players (66.6 %) had left-sided fractures. Most injuries (96.7 %) occurred during the in-season period, while only 1 player (3.3 %) sustained an ankle fracture in the off-season. The mechanism of injury was reported as follows: 11 players (36.7 %) were hit by a puck, 7 players (23.3 %) were injured due to contact with another player, 8 players (26.7 %) sustained injuries from contact with the boards or the net, 1 player (3.3 %) sustained a noncontact injury, and 3 players (10 %) were injured due to an unknown mechanism. Of the 30 players, 9 (30 %) underwent surgical treatment, while 21 players (70 %) were treated nonoperatively. No players experienced re-fractures following initial recovery.
All players returned to play at NHL level, with a mean time to return of 1.8 ± 1.0 months. Patients who underwent surgical treatment had a statistically significantly longer mean return time to play at NHL level (2.7 ± 0.9 months vs 1.4 ± 0.9 months, p = 0.007) compared to those treated conservatively. The mean number of missed NHL games was 16.3 ± 12.6, but there were no statistically significant differences between patients treated surgically and non-surgically (16.6 ± 14.5 vs 16.2 ± 12.1 games missed, p = 0.756). Surgical treatment correlated with a longer time to return to play at NHL level (r = 0.564, p = 0.003), but did not correlate with more missed NHL matches (r = 0.013, p = 0.944). When dividing the mechanism of injury into puck impact (n = 11) and any contact injury (n = 15), a statistically significantly higher proportion of puck impact injuries were treated surgically compared to contact injuries (54.5 % compared to 13.3 %, p = 0.038).
3.1.2 Performance metrics
Table 2 shows the key performance metrics of the NHL players in the season directly prior to injury and the season directly after injury. There were no statistically significant differences in games played, scores (goals, game winning goals, overtime goals, assists, points), power play metrics (goals and points), short-handed metrics (goals and points), penalty metrics, plus/minus rating, time on ice, and shot metrics (shots on goal and shooting percentages) for players in the season directly prior to injury and the season directly after injury.
Table 3 highlights the mean performance metrics from all seasons played pre-injury and the mean performance metrics from all seasons played post-injury. There were statistically significant differences in mean penalty minutes (29.7 ± 17.1 min vs 25.6 ± 17.0 min, p = 0.027), in power play goals (2.7 ± 2.6 vs 2.0 ± 2.2, p = 0.016), and in power play points (7.5 ± 6.7 vs 6.4 ± 6.4, p = 0.043) in the seasons post-injury compared to the seasons pre-injury. All other mean performance metrics per season demonstrated no statistically significant differences between pre- and post-injury. Table 1 in the supplemental media compares performance metrics of NHL players who underwent surgical treatment and those that did not in the season directly prior to injury and the season directly after injury, whereas Table 2 in the supplemental media compares the mean performance metrics from all the seasons played pre-injury and the mean performance metrics post-injury. For subgroup analysis, there were no statistically significant differences in performance metrics directly one season pre-injury and one season post-injury in athletes who underwent surgical and non-surgical treatments (Supplemental media, Table 1). Additionally, there were no differences in any of the mean post-injury performance metrics per season between surgically and non-surgically treated players (Supplemental media, Table 2). In patients treated non-surgically for ankle fractures, there were statistically significantly fewer mean power play goals per season post-injury compared to pre-injury (3.1 ± 3.0 vs 2.1 ± 2.3, p = 0.022).
4 Discussion
The most important finding of this study is that ankle fractures are a rare injury sustained by NHL players does not lead to statistically significant deterioration in player performance metrics. All NHL players successfully returned to play at the NHL level at a mean time to RTP of 1.8 months. Of note, NHL players who underwent surgical treatment had statistically significantly longer RTP times compared to those who underwent non-surgical treatment (2.7 ± 0.9 months vs 1.4 ± 0.9 months, p = 0.007), however, there were no statistically significant differences in the post-injury performance metrics between players treated surgically or conservatively. Taken together, these findings suggest that ankle fractures sustained by NHL players do not have a significant impact on their ability to perform at pre-injury levels.
The mechanism of injury of ankle fractures in ice hockey comes from the high energy impacts intrinsic to the sport, including direct puck strikes to the ankle and collisions between athletes and their environment including other players and dasher boards. This study found that the most common mechanism of injury for ankle fractures was due to direct contact with an opposing player or a collision with the dasher boards (50 %). During collisions with other players, the injured player often has one foot fixed on the ice that is either absorbing a hit or being drive into the dasher boards. The fixed-foot position prevents the ankle from accommodating rotational or translational forces.7 As a result, the torsional stress is directly transmitted to the tibia and fibula and when these forces exceed the failure threshold of bone or ligaments, a fracture can occur. This can manifest as a distal fibular fracture due to inversion or eversion mechanisms, or medial malleolar fractures from valgus impacts during high energy collisions.13 Interestingly, 37 % of NHL players sustained an ankle fracture following a collision with the hockey puck. Hockey pucks, weighing 170g, can reach speeds of over 100 miles per hour following a slapshot, which can potentially generate forces of over 2000 N.11 The contact forces necessary to fracture the distal tibia and distal fibula range from 1595 N to 2612 N, indicating that, under the right circumstances, direct impact with a hockey puck travelling at high velocity to produce a fracture.14 Of note, modern hockey skates have been modified to become stiffer and lighter, usually incorporating carbon fiber shells to achieve this.15 To further reduce the weight of the skates, the protective tongue and side wall materials have been thinned for further speed and agility gains. However, this leaves the foot and ankle more vulnerable to high velocity puck impacts,4 which may increase the fracture risk from these external forces.
This current study investigated the distribution of injuries across different player positions. The defensemen were most susceptible to sustaining ankle fractures (47 %), followed by center (30 %), right wing (13 %) and left wing (10 %), with no goaltenders sustaining ankle fractures in this cohort. Goaltenders are equipped with extensive padding designed to protect against high velocity puck impacts and repeated contact with the ice surface. The lower leg is shielded by thick, multi-layered leg pads that protect the tibia, fibula, and malleoli. The pads are integrated with the stiff skate boot and provide full protection in the region of the anterior tibia and malleoli. Conversely, defensemen who also commonly block such high velocity shots have much less protection padding in the lower limb. Standard shin guards offer some anterior tibial protection but do not adequately protect the malleoli, especially during dynamic movements such as plantar flexion and abduction. Compared to the thick and well protected skates of goaltenders, defensemen have thin, rigid carbon fiber shells that immobilize the ankle joint and provide little cushioning against high energy impacts. The lack of circumferential malleolar padding combined with the role of the defenseman creates a predisposition for ankle injury.
This study demonstrates an encouraging 100 % RTP rate following sustaining an ankle fracture with no refractures reported. The players missed a mean number of 16.3 ± 12.6 games, but there were no significant differences between patients treated surgically and non-surgically (16.6 ± 14.5 games missed vs 16.2 ± 12.1 games missed, p = 0.756), despite the longer time to recovery for players who underwent surgical treatment compared to non-surgical (2.7 ± 0.9 months vs 1.4 ± 0.9 months, p = 0.007). There were no statistically significant differences in post-injury game participation, or offensive score metrics, and no significant differences in offensive metrics (goals, assists, points) and in shooting statistics (shots on goal, and shooting percentages) in the seasons pre- and post-injury were observed. This highlights that players continued to generate opportunities for scoring without their efficiency to convert into points being compromised. The plus/minus rating in ice hockey reflects a player's impact on even-strength or shorthanded goals. A player receives a point if their team scores while they are on the ice and loses a point if the opposing team scores, thereby acting as a marker for on-ice effectiveness. There were no significant differences in mean plus/minus ratings in the seasons post injury compared to preinjury, demonstrating that once players are game ready their effectiveness remains unchanged.
The lack of deterioration in player performance is likely due to a combination of the stabilizing effects of the skate boot during play and the relatively low functional demands placed on dynamic ankle mobility in skating compared to other sports, allowing NHL players to return to their pre-injury levels of performance. Although the data on severity of fractures is not available, it is likely that most of these fractures were non-displaced, given the relatively rapid recovery times and that only 30 % of ankle fractures required surgery. This means that there was less disruption of soft tissue and thereby less inflammation to interfere with bone healing, which facilitated a faster recovery. A significantly greater proportion of players injured by puck impacts underwent surgery compared to those injured via direct contact with other players or the field, indicating that puck impacts may potentially cause more serious injuries. Collectively, these findings suggest that once NHL players are ready to return to play, ankle fractures do not have a significant impact on their ability to perform at pre-injury levels.
5 Limitations
There are numerous limitations and potential biases associated with this study. Firstly, this study is limited by its retrospective nature. Additionally, the reliance on publicly available data may introduce inconsistencies in the accuracy of injury reporting and performance data. While the high-profile nature of the NHL means that player injuries and team injury reports are closely followed by the media and publicly reported, it is possible that some injuries or details were missed in these reports. Furthermore, the severity of each ankle fracture as well as the specific treatment protocols, be it surgical or non-surgical rehabilitation, were not reported. This limits the study's ability to comment on the association between ankle fracture severity with any of the other metrics.
6 Conclusion
This study found that ankle fractures are a rare injury sustained by NHL players but do not lead to statistically significant deterioration in player performance metrics. All NHL players successfully returned to play at the NHL level at a mean time to RTP of 1.8 months. Taken together, these findings indicate that ankle fractures in NHL players have minimal effect on their ability to return to and maintain pre-injury performance levels.
Informed consent statement
Not applicable.
Author contributions
Conceptualization: A Tham, KL Esser, J Rubin, JJ Butler; Methodology A Tham, KL Esser, J Rubin, JJ Butler; Formal analysis: A Tham, KL Esser, J Rubin, BA Lezak, NP Mercer, JJ Butler, H Hartman; Data curation: KL Esser, J Rubin, BA Lezak, NP Mercer, JJ Butler, H Hartman; writing – original draft preparation A Tham, KL Esser, J Rubin, BA Lezak, NP Mercer, JJ Butler; writing – review and editing: A Tham, J Rubin, BA Lezak, JJ Butler, AJ Rosenbaum, JG Kennedy; project administration, AJ Rosenbaum, JG Kennedy. All authors have read and agreed to the published version of the manuscript.
Institutional review board statement
Not applicable.
Funding
There was no funding for this study.
References
- What is the injury incidence and profile in professional Male ice hockey? A systematic review. Int J Sports Phys Ther. 2024;19(1):1398-1409.
- [Google Scholar]
- Return to sports following operatively treated ankle fractures. Foot Ankle Int. 2009;30(4):292-296.
- [Google Scholar]
- Economic burden of time lost due to injury in NHL hockey players. Inj Prev. 2014;20(5):347-349.
- [Google Scholar]
- Epidemiology of foot and ankle injuries in national collegiate athletic association men's and women's ice hockey. Orthop J Sports Med. 2019;7(8)
- [Google Scholar]
- Doctor, I fractured my ankle. When can I return to play? An updated systematic review. Br Med Bull. 2022;143(1):35-45.
- [Google Scholar]
- Epidemiology, management, and outcome of sport-related ankle fractures in a standard UK population. Foot Ankle Int. 2014;35(11):1143-1152.
- [Google Scholar]
- High ankle sprains in professional ice hockey players: prognosis and correlation between magnetic resonance imaging patterns of injury and return to play. Orthop J Sports Med. 2019;7(9)
- [Google Scholar]
- Distal fibula fractures in national football league athletes. Orthop J Sports Med. 2017;5(9)
- [Google Scholar]
- Return to play and performance measures for national football league athletes following operative ankle fractures. Foot Ankle Orthop. 2022;7(4)
- [Google Scholar]
- The NFL orthopaedic surgery outcomes database (NO-SOD): the effect of common orthopaedic procedures on football careers. Am J Sports Med. 2016;44(9):2255-2262.
- [Google Scholar]
- Theoretical implications of the biomechanical fracture threshold. J Bone Miner Res. 2008;23(10):1541-1547.
- [Google Scholar]
- A 7-year review of men's and women's ice hockey injuries in the NCAA. Can J Surg. 2010;53(5):319-323.
- [Google Scholar]
- Subradiographic foot and ankle fractures and bone contusions detected by MRI in elite ice hockey players. Am J Sports Med. 2016;44(5):1317-1323.
- [Google Scholar]
- Investigation of tibia and fibula fracture risk during football impacts using finite element human body models. Proc Inst Mech Eng P J Sports Eng Technol 2025
- [Google Scholar]