Wednesday, December 31, 2014

Best Canadian Forwards (points-wise) in 2014

After yesterday's post on the top American forwards, I decided to just to extend it to our brothers up north. While Canada didn't announce the team New Year's Day like Team USA, it has still been almost a full year and it's interesting to look at their plethora of forward talent.

Unlike Team USA, you can't argue with results because Team Canada did win gold, but the team did struggle to score at times. Team Canada's leading scorers were two defensemen, Drew Doughty and Shea Weber with 6 points each in the 6 games played. Canada won thanks to it's strong defensively play and stellar goaltending. Canada wasn't a slouch offensively, registering the most SOG of any country in the tournament (241), but were only tied for 3rd in goals (17).

Sochi Team Statistics can be found here.

Again, if I had more time, I'd do P/60, some #fancystats, etc. Just hoping for some discussion!

Statistics from 1/1/2014 through 12/29/2014

Top Sorted by Points: 

Players in orange were not named to Team Canada.

The top two Canadian scorers of 2014 were Claude Giroux (also the top point-getter of the last 4 NHL seasons) and Tyler Seguin, both who were not named to the Olympic roster. Of those two names, SEguin is interesting to me mostly because his teammate Jamie Benn was named and they have fantastic scoring chemistry which is something Canada really considered when naming the roster (Kunitz/Crosby).

Tyler Bozak is sort of a standout name. As Points/Game will show below, injuries definitely have an effect on this list (Tavares being so low, only played 55 games) . Canada of course has a bright future with Seguin, Johansen, MacKinnon (and McDavid on the way) at the Center position.

Top Sorted by Points/Game:

The Kunitz decision was still a head-scratcher and Giroux must really not be happy (you could argue Seguin's youth was a factor in the decision). Comparing this to the USA list, I just get unhappy.

If you go by P60, Seguin would be first, Giroux 2nd, and Crosby 3rd.

So, how does the forward roster constructed by Doug Armstrong, Kevin Lowe, Ken Holland, and Peter Chiarelli Poile, Ray Shero and Brian Burke (among others) seem now looking back?

Happy New Year all!

Tuesday, December 30, 2014

Best American Forwards (points-wise) in 2014

It has nearly been a full year since USA Hockey picked the 2014 US Olympic Men's Ice Hockey Team for the Sochi Olympics during the last Winter Classic. As 2014 is coming to an end, I'd like to do a quick review of how American forwards have done in the year 2014 (since the roster was announced).

If I had more time, I'd do P/60, some #fancystats, etc. Just hoping for some discussion!

Statistics from 1/1/2014 through 12/29/2014

Top 21 Sorted by Points: 

Players in orange were not named to team USA. One name that you may notice is omitted is Dustin Brown, the only team USA forward who is not on this list of 21 forwards. Brown came in way off the list with 26 points in his 76 GP in 2014. American players like Saad, Legwand, Wingels, Bobby Ryan, Atkinson, Galchenyuk, Kreider and Dubinsky all had higher point totals, even old guys like Chris Higgins, Cullen, and Brian Gionta (!) as well as rookie Johnny Gaudreau with just his 31 points from this season.

Standout names on this list have to be second-year players Tyler Johnson (not just benefiting from playing with Stamkos!), Brock Nelson and Nick Bjustad. Nick Bonino is also an interesting name, the centerpiece going from Anaheim to Vancouver in exchange for another American F, Ryan Kesler. Foligno has benefited from an insane (contract-year) season thus far, with 31 of his 47 points in 2014 coming this season with the Blue Jackets. Craig Smith whom a lot of people seem to forget has quietly done alright with Nashville.

Top 22 Sorted by Points/Game:

Since injuries can affect total points, I submit this list of points per game, rather than total points, giving a clearer picture. While this list is a bit better for Team USA's decisions, I just thought it was fun because not only does it show how impressive Gaudreau has been to start off his rookie season, but also how terrible a decision it was to omit Okposo from the roster.

This list shows 22 players because of the addition of Gaudreau (and me wanting to keep everyone on the previous list here). Dustin Brown is again omitted with his paltry 0.342 P/G.

So, how does the forward roster constructed by David Poile, Ray Shero and Brian Burke (among others) seem now looking back on how the US team performed in 2014?

Friday, December 19, 2014

NHL Transaction Trees

I have always been fascinated by trade and transaction trees. It probably stems from my New York Islanders fandom, as Mike Milbury has one of the most infamous transaction trees of all time as illustrated here by Mark D. Maybe it's my biology/genetics background and liking for pedigree charts.

A couple weeks ago, one of my favorite baseball writers and Grantland contributor Ben Lindbergh wrote an excellent piece on MLB Transaction Trees. His goal was to find the roster spot with the longest lineage on all 30 franchises in major league baseball. Ben's post gave me the inspiration to do the same for the National Hockey League's 30 franchises. As delineated in Ben's MLB post, there are two ways a player can be considered a direct roster descendant of previous player from the same time: He can be a product of the same linked sequence of trades, or he can come from a combination of trades and draft picks.

My research was done relying on the depth charts at RosterResource and the transaction records at ProSportsTransactions. Along the way I'll throw in some fun facts, as some of these trade lineages are absolutely absurd. This took a long time and hope you all have fun with it too and enjoy!

Let's start at the top with the 2003 NHL Draft, held June 21st at Bridgestone Arena in Nashville:

30. Anaheim Ducks 6/21/2003
(Ryan Getzlaf and Corey Perry)

In the 2003 draft, considered by scouts and analysts to be one of the most talented in the history of the NHL, Anaheim selected two franchise players still with the club today.

As one of the most recent lineages, it's fairly uninteresting. Ducks don't care about that though after winning the 2007 Cup and having these two draft picks continue to dominate in the NHL.

We'll continue with the 2002 NHL Draft, held June 22-23 at the Air Canada Centre in Toronto which accounts for a ton of team's lineages:

T23. Carolina Hurricanes - 6/22/2002
(Cam Ward)

Despite their best efforts to trade him this offseason, the Hurricanes still have goaltender Cam Ward who they drafted late in the 1st round in 2002. Cam Ward became the first starting goaltender to win the Stanley Cup as a rookie since Patrick Roy in 1986.

Chicago Blackhawks - 6/22/2002
(Duncan Keith and Matt Ellison -> Patrick Sharp)

The Blackhawks can actually trace two of their top players to the 2002 Draft. Two-time Norris trophy winner Duncan Keith was drafted 54th overall and in December of 2005, Patrick Sharp was acquired for Matt Ellison (selected 128th in the 2002 draft and a 3rd round pick in the 2006 NHL Draft.

Columbus Blue Jackets - 6/22/2002
(Rick Nash -> Artem Anisimov, Brandom Dubinsky)

On the morning of the 2002 draft, Columbus traded the 3rd overall pick (and the option to flip draft sports the following season) to the Florida Panthers for the 1st overall pick, which they used to select Rick Nash. Nash has since been traded to the Rangers for 4 pieces as outlined below.

Edmonton Oilers - 6/22/2002
(Jesse Niinimaki -> Jeff Petry)

One of the more unique lineages lies with the Edmonton Oilers. The Oilers traded the 14th overall pick in the 2002 draft to the Canadiens (Chris Higgins) in exchange for the 15th overall pick and the 245th overall pick. The Oilers selected Jesse Niinimaki who failed to sign with the team. As compensation, the NHL awarded the Oilers with the 45th overall pick in the 2006 NHL draft, with whom they selected Jeff Petry.

New York Islanders - 6/22/2002
(Frans Nielsen)

The last remnants of Mike Milbury, the Danish Prince/Deity Frans Nielsen.

Toronto Maple Leafs - 6/22/2002
(Matt Stajan 

Elisha Cuthbert's husband...I mean current captain of the Leafs and former 9th overall pick in the 2003 Draft Dion Phaneuf is the longest lineage on the current Leafs roster.

Winnipeg Jets - 6/22/2002
(Kari Lehtonen -> Ivan Vishnevskiy -> Andrew Ladd)

Formerly the Atlanta Thrashers (since the lineage begins when the ATL still had an NHL franchise), the Jets' longest lineage traces back to current Stars starting goaltender Kari Lehtonen and leads us to their current captain, Andrew Ladd.

22. Minnesota Wild - 6/23/2001
(Mikko Koivu)

Current captain Mikko Koivu holds the longest lineage on the self-proclaimed "State of Hockey's" franchise

21. New York Rangers - 6/25/2000
(Henrik Lundqvist)

Sometimes life isn't fair.

20. Pittsburgh Penguins - 11/14/2000
(Jeff Norton -> Johan Hedburg -> Alex Goligoski -> James Neal -> Patric Hornqvist and Nick Spaling)

Woo now we're getting to some fun stuff!

19. Tampa Bay Lightning - 7/31/2000
(Martin St. Louis -> Ryan Callahan)

In one of the bigger blockbuster trades of 2014, Yzerman and the Lightning sent the Hart and Stanley Cup winner to the Rangers in exchange for their captain Ryan Callahan, a 2014 conditional 1st rounder, a 2015 1st rounder and a 2015 7th rounder (also conditional).

T15. Boston Bruins - 6/27/1998
(Andrew Raycroft -> Tuukka Rask)

One that still makes Maple Leaf fans tear up. Raycroft, a Calder winner with the Bruins was traded to the Leafs in exchange for Rask, a 21st overall pick in the 2005 Draft. When the Leafs determined that Justin Pogge was their 'goaltender of the future,' Rask became expendable and was traded in exchange for Raycroft. It was later revealed that the Bruins intended to release Raycroft and the Leafs could have gotten him for free instead of trading a future Vezina winner for him. 

T15. Detroit Red Wings - 6/27/1998
(Pavel Datsyuk)

Sometimes life REALLY isn't fair. Or the Red Wings front office is just really smart, yeah let's go with that one.
T15. Montreal Canadiens - 6/27/1998
(Andrei Markov)

T15. Nashville Predators - 6/27/1998
(Tomas Vokoun -> Nick Spaling -> James Neal)

The Predators actually have two lineages that could qualify, but the one below is a bit more unique. Tomas Vokoun was drafted by the Canadiens in the ninth round of the 1994 NHL Draft (226th overall) and only played one game in the NHL for Montreal. He was chosen by the Predators in the 1998 NHL Expansion draft and eventually traded to the Panthers for a 2007 2nd rounder which the Predators used to draft Nick Spaling, a piece used to acquire James Neal along with Patric Hornqvist. In the trade with the Panthers, the Predators also acquired the Panthers 2008 1st round pick (eventually becoming Colin Wilson). 

The other lineage involves rookie Calle Jarnkrok. Jarnkrok was acquired along with Patrick Eaves and a 2014 2nd rounder (#46 Julius Bergman) for David Legwand. Legwand was a 2nd overall pick in the 1998 by the Predators (who traded the 3rd overall and 29th overall picks - Brad Stuart and Jonathan Cheechoo - to the Sharks in exchange for the 2nd overall and 85th overall - Geoff Koch). 

14. Philadelphia Flyers - 8/20/1997
(Chris Gratton -> Daymond Langkow -> Jeff Carter -> Jakub Voracek and Sean Couturier)

This is why you don't see RFAs signed by other teams anymore. After signing RFA Chris Gratton to a five-year, $16.5 million deal, the Flyers traded Mikael Renberg and Karl Dykhuis to the Lightning in order to retrieve the four first-round draft picks lost as compensation. Just a season later, the Flyers traded him back to Tampa Bay with Mike Sillinger for Mikael Renberg (again) and Daymond Langkow. Langkow was traded to the Coyotes and in exchange for the Flyers choice of a 2002 1st rounder and 2003 2nd rounder or a 2002 2nd rounder and a 2003 1st rounder. The Flyers chose the latter and drafted Jeff Carter 11th overall in 2003. Carter was then traded to Columbus in the summer of 2011 and acquired Voracek, a 2011 1st rounder used to draft Sean Couturier and 2011 3rd rounder (drafted Nick Cousins). 

13. Dallas Stars - 6/21/1997
(Brenden Morrow -> Joe Morrow -> Tyler Seguin and Rich Peverly)

Brenden Morrow took over the Captaincy in Dallas after franchise legend Mike Modano. Morrow was eventually traded to the Penguins for Joe Morrow (no relation) who was a piece used to acquire budding superstar Tyler Seguin. 

12. Ottawa Senators - 6/22/1996
(Chris Phillips)

11. Arizona Coyotes - 7/8/1995 
(Shane Doan)

Before the relocation to Arizona, the Jets drafted future captain Shane Doan with the 7th overall pick in the 1995 draft. 

10. New Jersey Devils - 6/28/1994
(Patrik Elias)

9. Florida Panthers - 6/24/1993
(Tom Fitzgerald and Jesse Belanger -> Mark Parrish and Oleg Kvasha -> Roberto Luongo -> Todd Bertuzzi -> Shawn Matthias -> Roberto Luongo)

This only begins to emulate how much of a mess Roberto Luongo's career has been.

8. San Jose Sharks - 10/04/1992
(Igor Larionov -> Ray Sheppard -> Matt Bradley -> Wayne Primeau + Brad Stuart + Marco Sturm -> Joe Thornton)

How is the Joe Thornton trade not talked about more often? What an absolute steal for the Sharks. 

7. Colorado Avalanche - 6/22/1991

Before relocating, The Quebec Nordiques drafted Eric Lindros despite Lindros letting the entire world know he wouldn't sign or play with them. In what became one of the largest trades in NHL history, the Nordiques acquired pieces that would transform them to a legitimate Cup contender. 

After moving to Denver, the lineage of this trade has led to Ryan Wilson. 

6. Washington Capitals - 6/16/1990
(Peter Bondra -> Brooks Laich)

The Capitals traded franchise legend Peter Bondra to the Senators for Brooks Laich who remains with the team today. 

5. Vancouver Canucks - 6/11/1988
(Trevor Linden -> Todd Bertuzzi + Bryan Allen + Alex Auld -> Roberto Luongo -> Shawn Matthias and Jacob Markstrom) 

Like the Panthers lineage, this tree features Milbury mistakes and Luongo getting shuffled around. 

4. Calgary - 6/13/1987
(Theo Fleury + Dingman -> Robyn Regehr + Ales Kotalik -> Paul Byron)

Theo Fleury, who was the Flames' all-time scoring leader for ten years until passed by Jarome Iginla in 2009, was traded to the Avalanche along with Chris Dingman. The Flames chose to select Robyn Regehr with the Avalanche's pick. Regehr was eventually traded to the Sabres along with Ales Kotalik for Paul Byron. 

(Note: Calgary got Prust and the 98th overall pick in the 2004 draft from the Blue Jackets for a 2nd rounder, #46 overall used to draft Adam Pineault. 

3. St. Louis Blues - 6/9/1982
(I honestly got lost but it ends up with Craig Conroy -> Cory Stillman -> David Backes)

Seriously, this is my masterpiece and I'm impressed that I fit it all on one page.

2. Buffalo Sabres - 6/3/1975
(Don Edwards + Richie Dunn -> Paul Cyr -> Alex Mogilny -> Mike Wilson -> Ryan Miller -> Chris Stewart + Michal Neuvirth - from Halak)

Note: In this lineage I failed to include a part of the Miller trade. Miller was traded along with Steve Ott to the Blues. Ott was acquired from the Stars for Derek Roy in July 2012. Roy was drafted by the Sabres 32nd overall in 2001, a pick they acquired along with Chris Gratton in a trade with the Tampa Bay Lightning. 

1. Los Angeles Kings - 6/01/1975

This one is pretty convoluted. Essentially it begins with HOFer and Kings Legend Marcel Dionne, includes other HOFers along the way (Paul Coffey), includes another Milbury trade and ends up with the robbery trade for Jeff Carter. 

Part 1: Showing how Paul Coffey, Steve Seguin and Jim Hiller were acquired. 

Part 2: Showing impact since Paul Coffey, Steve Seguin and Jim Hiller were traded to the Red Wings

Hope you all enjoyed! This was fun to do and took a lot of work and time. Comments are welcome, especially if I'm missing anything. 

Wednesday, October 22, 2014

Discussing Michael Grabner's Injury and Surgery: What is a Sports Hernia?

A couple weeks ago, the New York Islanders announced that Austrian winger Michael Grabner would start the season on IR with an undisclosed lower-body injury. Grabner, known around the NHL for his speed, has battled some groin soreness over his career. It was revealed that Grabner had a "sports hernia" that required surgery and that he would be out indefinitely (*ignore the 4-6 weeks in the tweet below).

Sports hernia surgery successful for Michael Grabner. Just picked him up from hospital. Back in 4-6 weeks #Isles #NHL
— Andy Strickland (@andystrickland) October 9, 2014


One of the more frequent sports injuries that poses a difficult clinical problem is chronic groin pain in male athletes. Chronic exercise-related groin pain can present as a difficult diagnostic and therapeutic challenge. The condition 'sports hernia' was only recently described but is becoming an increasingly recognized source and cause of chronic groin pain. Sports hernia, sometimes known as athletic pubalgia, is a diagnosis which is poorly understood as there is little consensus in medical literature regarding pathophysiology, criteria for diagnosis, and treatment methods. 

Sports hernia as a diagnosis often goes unrecognized for several months or even years [1]. Athletes will often present with groin pain and be diagnoses with a 'groin strain,' receive light treatment and be recommended rest. In sports hernia, there actually is no classical herniation of soft tissue, and the diagnosis and treatment decision requires a team/multiprofessional approach consisting of general physicians, surgeons, radiologists and physiotherapists. 

The team approach is required due to the criteria required for a diagnosis of sports hernia. While still a poorly understood phenomenon, sports hernia is essentially a set of injuries to the abdominal and pelvic musculature that cause a weakness of the posterior wall of the inguinal canal [2]. The groin pain is "associated with an incipient direct bulge of the inguinal wall whenever the abdominal muscles contract forcefully" [3]. The minimum required criteria required for a diagnosis of a sports hernia include [4]:

  • Chronic groin pain which develops during exercise 
    • Pain is located over the lower lateral edge of the rectus abdominis muscle
      • Radiation of pain to the testis or adductor longus origin (but not required)
      • Pain is often aggravated by sudden acceleration, twisting and turning, cutting and kicking, sit-ups and coughing or sneezing
  • Subtle but consistent physical examination findings 
    • May or may not include; subtle bulges, pain due to resistance, tenderness, etc.
  • Appropriate imaging characteristics. 
So, to obtain a diagnosis, all of these criteria must be simultaneously present due to the numerous other potential causes for groin pain, and the fact that these hernias have also been found to be asymptomatic in the general population [4]. 


Chronic groin pain and sports hernia are often restricted or more common in sports that involve rapid acceleration along with a sudden change in direction (american football, ice hockey, soccer - in which kicking can also cause the injury).  Athletes with this injury often present with pain that is exacerbated with exercise in the regions shown in the image below:

Solid arrows indicates that the pain can sometimes radiate to the testis.
Dotted arrows show pain radiating into the medial thigh along the path of the adductor longus. [3]
Athletes will not only complain about pain occurring on exertion or certain movements, but also the pain persisting after activity with accompanying stiffness or tenderness. Some athletes believe the pain to be disabling to the pain of cessation from activity and the pain returning even after an extended period of rest. 

A physical examination will reveal tenderness over the affected region, and sometimes a skilled examiner will be able to feel a dilation or weakness in the inguinal canal area [5].  Physicians should test the athlete for pain with resisted sit-ups and resisted hip adduction and should also look for a restricted range of motion of the hip. One of the more important parts of the physical examination is ruling out other possibilities for groin pain and other injuries as shown below:


Imaging is one of the most useful diagnostic tools available for physicians when an athlete presents with chronic groin pain. However, a majority of the time, imaging techniques are  largely used as a method of ruling out other causes of groin pain (due to the overlapping symptoms between sports hernia and other sources of chronic groin pain) [5]. Two of the main imaging sources are ultrasound and magnetic resonance imaging (MRI). While these diagnostic tests are largely helpful and imaging protocols have improved over the years, physicians still rely heavily on the history and physical examination of a patient to make a diagnosis. Investigating chronic groin pain routinely involves several imaging examinations (radiographs & CT scans in addition to those shown below). just to rule out other potential causes such as pelvic instability, hip joint problems (which could be co-existing) including labral tears, bone stress, soft tissue calcifications, and finally supporting ligament damage.

There are two key imaging features that must be simultaneously present to support a clinical diagnosis. The first feature is an incipient direct bulge of the posterior inguinal wall when the patient forcefully contracts the abdominal muscles (for example when doing a sit-up). This feature is best seen during a real-time ultrasound as shown in the videos below.

The video above shows a normal pattern of inguinal wall motion. When the conjoint tendon becomes taught as internal oblique and transversus abdominis muscles contract, the superior wall of the inguinal canal normally moves inferiorly to protect agains herniation of abdominal contents [3]. 

This can be compared with the video below, showing an incipient direct bulge of the posterior inguinal wall on contraction of the same muscles (usually done by a half sit-up).

Sports hernia: Dynamics of the inguinal wall from John Read on Vimeo.

Here, the red line indicates the posterior inguinal wall which is initially concave at rest, but when strained, it displaces anteriorly as a convex bulge shown by the yellow arrow [3]. Although this bulge can have a variety of causes, when found together with a second imaging feature, it helps confirm the diagnosis of sports hernia.

That second key imaging feature is a demonstrably abnormal conjoint tendon, normally very subtle on imaging exams. Shown below is an MRI of a left conjoint tendon demonstrating this 'tendonitis.' 

MRI of left conjoint tendon [3]

Non-operative management of sports hernias and chronic athletic groin pain consists of a combination of; rest, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and physiotherapy. Usually, non-operative treatment is the first plan for patients presenting with the symptoms consistent with a diagnosis of sports hernia and can last a period of between 6-12 weeks [6]. One of the most important parts of physiotherapy is core strengthening exercises that target the abdomen, lumbar spine, and hips. These strengthening exercises combined with focused stretching exercises on the hip rotators, adductors, and hamstrings work together to try and correct the imbalance of the hip and pelvic muscle stabilizers; a common source of groin pain. 

While a small subset of patients will improve with rehabilitation and non-operative treatment, the large majority of patients that have been accurately diagnosed with sports hernias will eventually require surgical repair. In fact, some experts argue that if the pain from a groin injury does not improve within 4 to 6 weeks after diagnosis, the athlete is at increased risk of developing chronic inguinal pain [7].

The primary goal of operative management is reinforcing the posterior abdominal. Two main techniques include:

  • Open surgical techniques (Bassini, Shouldice, Lichtenstein) aim to reinforce the abdominal muscles or fascia near the inguinal ligament.
  • Laparoscopic repair (preferred to open) which involves reinforcement of the posterior abdominal wall with mesh. 
Both techniques have produced successful results and success rates (return to full athletic activity) have been reported as 92.8% for open techniques and 96% for laparoscopic techniques [6]. 

In a clinical trial of 60 patients with sports hernia, it was indicated that surgical treatment was more efficient and effective than conservative, non-operative therapy. The study randomized 30 athletes with similar characteristics and pain scores into two treatment groups (one received non-operative treatment, the other received surgery) and followed them for 12 months. 27/30 who received the operation returned to sports activities after 3 months, compared with 8/30 in the non-operative treatment group. Of the 30 athletes in the conservative treatment group, 7 (23%) eventually elected to undergo surgery due to persistent groin pain. [8]

In 2003, Dr. Muschaweck and Dr. Berger developed an innovated open suture repair (Minimal Repair technique) to fit the needs of professional athletes [7]. The surgical intervention aims to eliminate groin pain by decompression of the genital branch of the genitofemoral nerve. The surgery stabilizes the posterior wall via a tension-free suture through a minimally-invasive procedure (minimal dissection). After a small inguinal incision and dissection of subcutaneous tissue, the repair beings and is demonstrated via the figures below.

In comparison with the aforementioned commonly-used surgical procedures (open repairs and laparoscopic repairs), the Minimal Repair technique presented here has several advantages including: no insertion of prosthetic mesh, no general anesthesia use, less traumatization, lower risk of complication, equivalent and sometimes quicker recovery [7]. Avoiding mesh is key especially for athletes who require full elasticity and movement. Mesh can result in localized stiffening, leading to restricted movement of the abdominal muscles. Additionally, mesh can sometimes be prone to complications such as infections and fistula formation (which requires removal of the mesh) along with mesh migration.


Much like the non-operative management, post-operative treatment involves conventional non-steroidal anti-inflammatory drug (NSAID) use along with physiotherapy. Safe progression through the various stages of a rehabilitation program are key towards a full recovery. The main goals of rehab include [4]:

  • Minimizing pre-existing risk factors
  • Implementing core stabilization exercises 
  • Maintaining good motor control and strength around the pelvis. 
Recovery after laparoscopic repair generally takes 6-8 weeks before full return to play is permitted. This can range from 4-12 weeks in the extreme. Post-surgical recovery times for open surgeries was found to be an average of 17.7 weeks compared to the average of 6.1 weeks for laparoscopic repairs [6]. 

On the other hand, the minimal repair technique described above reported that 124/129 patients resumed training in 4 weeks time while 75.8% of those 129 reported a full return to pre-injury sports activity levels at the 4 week mark.

In a study of 43 NHL players who were reported to have a sports hernia and who underwent surgery from 2001-2008, 80% ultimately returned to play 2 or more full seasons [9]. Players were split into two groups, one group with players with 6 or fewer seasons of play, and another consisting of players with 7 or more years of play [in the NHL]. Players with over 7 full seasons returned but with significant  decreases in their overall performance levels while players with 6 or fewer seasons were able to return to play without any statistical decrease in performance. While the decrease in play could be based on a natural decline seen across the board with NHL players, the surgery was definitely a factor. Results can be seen below: 

[9] Study shows that players who undergo the surgery RTP and depending on veteran experience, may perform less than their pre-surgery level.

These results should be taken with a grain of salt. Many of these injuries, and subsequently their repairs, occurred years ago and in the time that has passed (close to 6 years) methods and rehab techniques have improved. Unfortunately, this study did not obtain the average time to recovery for NHL players.


Sports hernia is a difficult injury to both diagnosis and manage. The process is long:

Diagnosis requires a high index of suspicion, a multidisciplinary approach and a plan for recovery. Surgery has proven to be the best method and recent innovations have made returning from the injury much quicker and easier. Recent advances in imaging, techniques and understanding the underlying causes and pathophysiology of sports hernia has led to improved clinical outcomes and a shorter recovery time.


  1. Brown A, Abrahams S, Remedios D, Chadwick S. Sports Hernia: a clinical update. Br J Gen Pract 2013; DOI: 10.3399/bjgp13X664432
  2. Meyers WC, McKechnie A, Philippon MJ, et al. Experience with 'sports hernia' spanning two decades. Ann Surg 2008; 248(4): 656-665. 
  3. Dr. John Read, Sports Medicine Imagine: Sports Hernia.
  4. Garvey JFW, Read JW, Turner A. Sportsman hernia: what can we do? Hernia 2010; 14: 17-25. 
  5. Minnich J, Hanks J, Muschaweck U, Brunt LM, Diduch DR. Sports Hernia: Diagnosis and Treatment Highlighting a Minimal Repair Surgical Technique. Am J Sports Med 2011; 39(6): 1341-1349. 
  6. Caudill P, Nyland J, Smith C, et al. Sports hernias: a systematic literature review. Br J Sports Med 2008; 42(12): 954-964.
  7. Muschaweck U, Berger L. Sportsmen's groin - diagnostic approach and treatment with the minimal repair technique: a single center uncontrolled clinical review. Sports Health 2010; 2: 216-221. 
  8. Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: A randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia). Surgery 2011; 150(1): 99-107. 
  9. Jakoi A, O'Neill C, Damsgaard C, Fehring K, Tom J. Sports Hernia in National Hockey League Players: Does Surgery Affect Performance? Am J Sports Med 2013; 41(1): 107-110. 

Updated for grammatical errors and to include more information about recovery times. 

Friday, August 15, 2014

Discussing Helmets and Concussions

Over the past few months, I've written several articles on concussions including their impact in the NHLin soccer, along with specific case studiesdiscussing current research and new methods, and how head injuries should be managed

A topic I'd like to discuss has come up in the media a lot over the past few weeks; new helmets that are meant to stop or limit concussions and claiming to do so. 

There is general agreement among the medical community that concussion incidence can be reduced through rule changes in play, changes in concussion protocol and procedures, and teaching proper hitting and tackling techniques. However, there remains debate as to whether the design of helmets can also help reduce the incidence of concussions. 

This is an issue that Deadspin covered very well when the NFL announced a $60 million partnership with GE and Under Armour to "tackle concussion-safety science," of which $10 million would be dedicated to developing "improved helmet technology." When you consider the NFL only spent $60 million (or 0.6% of the NFL's annual revenue) over a 5-year partnership, it's extremely disappointing, especially when 1/6 of the money will go to something [helmets] that may not help reduce concussions at all. It comes into question how much the NFL really cares about the long-term safety and health of it's current players. 

The issue regarding helmets arose again (and was once again covered by Deadspin well) when researchers at Virginia Tech released that they would be looking to rate and design new hockey helmets to reduce concussion risk

To understand why improving helmets wouldn't help reduce concussion risk, it's important to understand the mechanism behind the injury:


Also know as a mild traumatic brain injury (mTBI), the concussion is the most common type of traumatic brain injury. Concussion experts have been working together to develop consensus-based principles to establish a consensus definition of what occurs during a mTBI, what a diagnosis entails, and encourage correct return to play (RTP) decisions. The Concussion in Sport Group defined a concussion as:

Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include:  
  1. Concussion may be caused either by a direct blow to the head, face, beck or elsewhere on the body with an "impulsive" force transmitted to the head.
  2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.
  3. Concussion may result in neuropathological changes but the acute clinical symptoms  largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.  
In essence, the panel wanted to define concussion as an injury to the brain which creates a temporary loss in normal functioning. This injury is created by a force and may result in a variety of physical, cognitive and emotional symptoms which differ on a case-by-case basis.  

Something I'd like to highlight in this definition (which was put together at the 4th International Conference on Concussion in Sport and included 39 concussion experts) is that concussion isn't just a basic injury, it's a process. This is extremely important especially when recognizing that the onset of symptoms may occurs up to 24 hours after the original hit or injury and they may progress over time. Additionally, the panel agrees that contact with other parts of the body may result in a concussion, you do not need to be hit directly on the head. 

This is something that was highlighted by neurologists and concussion experts at Weill Cornell Medical College as well. In an article following the World Cup, Dr. Barry Kosofsky, a pediatric neurologist and concussion expert described the injury process with a nice metaphor: 

"The brain can be thought of as resembling a piece of broccoli, with the stalk (brain stem) at the base and the flower (cortex) on top. When someone experiences rotational torque resulting from a concussion, it is similar to stretching the part of the broccoli where the stalk meets the flower. The stalk is held in place but the brain is free to move, due to acceleration or de-acceleration. Concussions are not just due to direct hits, but also the stretching of these fibers due to torque."
The article continues with:
While impact and torque cause the initial injury, the physical symptoms of a concussion occur from the resulting neurometabolic cascade in the brain. This cascade causes cellular damage that inhibits neurons' ability to communicate with each other. The result is often impaired cognitive function and the mental fog experienced by athletes after a head injury. 

Helmets are designed to prevent and reduce skull fractures. Their basic design is one that is meant to lessen the blow by spreading the force of impact over a greater surface area. Helmets are designed to attenuate high-impact linear acceleration forces (front-to-back) but do not consider rotational acceleration, despite the strong evidence linking it to injury. 

Is it possible to design a helmet that could limit this? No, probably not. Your brain floats in the skull and is cushioned by a thin layer of cerebrospinal fluid. When the brain accelerations or deaccelerates due to a force (be it a hit to the head or neck) the brain can come crashing into the skull or suffer rotational damage. How could an outer shell limit this? The key in preventing concussions is not how hard the head is struck, but how the brain moves inside the skull due to impact. 

As the present moment, a concussion is a clinical diagnosis based largely on the observed injury mechanism and symptoms. While this is mostly due to the debated nature of the onset of injury, most of the public believe a concussion will only occur after a huge hit. In reality, it's important that team trainers, coaches and physicians be vigilant of players receiving a large amount of smaller hits or getting into contact and receiving multiple hits in a short period of time. A recent study evaluated the relationship between the force of impact and clinical outcome, finding that magnitude of impact did not correlate with clinical injury (Guskiewicz et al.). The study showed that despite the fact that the impact magnitude of the hits sustained by concussed athletes ranged from 60.5 to 168.7 g, no significant relationships between those impacts and symptom severity/neurocognitive functioning were found. Also, several players sustained hits at that impact threshold and were not diagnosed with concussions. 

Bringing it back to helmets, once again, I'll refer to the Conference panel:
There is no good clinical evidence that currently available protective equipment will prevent concussion, although mouth-guards have a definite role in preventing dental and orofacial injury. Biomechanical studies have shown a reduction in impact forces to the brain with the use of head gear and helmets, but these findings have not been translated to show a reduction in concussion incidence. 
This is echoed in a 2013 report on youth sports-related concussion by the Institute of Medicine and National Research Council which stated "There is limited evidence that current helmet designs reduce the risk of sports-related concussion."

A study done by the Cleveland Clinic compared newer NFL "concussion reduction technology" helmets along with other NFL-approved helmets with vintage "leatherhead" helmets used in the 1940s. Researchers wanted to know how the newer helmets compared in impact testing (which they of course excelled) but also in rotational acceleration. The study found that "in many instances the head impact doses and head-injury risks while wearing vintage leatherheads were comparable to or better than htose while wearing widely used 21st-century helmets." None of the helmets were protecting what causes a concussion, the brain moving inside the skull. 

Micky Collins, director of the UPMC Sports Medicine Concussion Program, went on to comment that "there's no helmet out there that will ever prevent a concussion from happening. The main focus should be treating athletes as soon as the symptoms appear."

Even Dr. Henry Feur, member of the NFL's Head, Neck and Spine Committee echoed these statements saying “It’s always some new material. We’ve heard it for years. Reducing the G-forces in a collision may help with concussions, but it has yet to be proven. The problem is that the brain is encased in fluid, and in cases of rotational force, there is little you can do to stop the brain from crashing against the skull.” 


There's a multitude of studies published about concussions, helmets, mechanism of injury and rates of sports-related concussion. I won't list them all here as most of them all agree that incidence of concussion is similar regardless of the helmet brand or what the helmet is selling. 

Some studies may state that use of sport-specific helmets have been found to reduce head injuries such as concussions. However, these case studies have a hard time eliminating confounding factors such as: 

  • Risk-avoidant behavior leading to less injury rather than the helmet itself
  • Concussions that aren't diagnosed 
  • The use of protective equipment adversely affecting player behavior, encouraging risky hits.

The problem is, parents and players are eating up the marketing for these "Five-Star" and "Concussion-reducing technology" helmets. Sales for five-star football helmets which run upwards of $250 have soared in the last year, while older helmets have plunged. This is about money right now. 

The research being done at Virginia Tech and other institutions is not a bad thing. If they can somehow find a way to decrease rotational acceleration inside the skull via an outer-shell, it would be ground-breaking. It is, however, extremely unlikely. 


Bartsch A, Benzel E, Miele V and Prakash V. Impact test comparisons of 20th and 21st century American Football Helmets. J Neurosurg 116:222-233, 2012. Published online November 4, 2011; DOI:10.3171/2011.9.JNS111059.

McCrory P, et al. Br J Sports Med 2013;47:250-258.

McCrory P, et al. Br J Sports Med 2013;47:268-271.

Guskiewicz KM, Mihalik JP, Shankar V, et al. Measurement of head impacts in collegiate football players: relationship between head impact biomechanics and acute clinical outcome after concussion. Neurosurgery 2007;61:1244–52. 

Institute of Medicine and National Research Council. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press, 2014.

Monday, July 28, 2014

A Primer on Concussions in Soccer : The Negligence of FIFA Regarding Head Injuries

In this article I'll examine briefly what a concussion is, the prevalence of concussion in the sport of soccer, and also discuss three incidents of head injury that occurred during this past FIFA World Cup.


Mild traumatic brain injury (mTBI), or concussion, is the most common type of traumatic brain injury/ While typically not too serious in most cases, concussion has a serious risk of short and long-term sequelae. At the 4th International Conference on Concussion in Sport (Zurich, November 2012), a panel discussion took place to obtain a consensus-based definition of a concussion. The Concussion in Sport Group (CISG) defined a concussion as follows:
Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include:
In essence, a concussion is a head injury with a temporary loss of brain function that may result in a variety of physical, cognitive, and emotional symptoms. Presently, concussion is a clinical diagnosis based largely on the observed injury mechanism (point of contact, force on head area, etc.), signs, and symptoms. The first step towards a diagnosis of a concussion is actual recognition of the injury.

The hallmark signs and symptoms of acute sports concussion include (but are not limited to):
  • Loss of consciousness (LOC) 
    • However, the majority of concussions in sports occur without a LOC
  • Problems with attentional mechanisms 
    • Manifested as (but not limited to): slowness to answer questions and follow directions, easily distracted, poor concentration, vacant stare/glassy eyed.
  • Memory disturbance
  • Balance disturbance 
These symptoms may be apparent immediately after the head injury or other signs and symptoms of a concussion may evolve and appear gradually over several minutes. Additionally, over the course of the first 24 hours following a concussion injury, other signs and symptoms may manifest. However, it's important to note that there is a large range of these symptoms and they often vary, not all of these symptoms are seen in every case of sports concussion. The most common symptoms reported in concussion literature include:
  • Somatic symptoms such as headache
  • Cognitive symptoms such as feeling like in a fog
  • Emotional symptoms such as lability
  • Physical symptoms such as LOC and amnesia
  • Behavior changes such as irritability
  • Cognitive impairment
  • Sleep disturbance (insomnia)
  • Dizziness and balance problems
  • Blurred vision
  • Fatigue
If any one or more of these symptoms is recognized, a concussion should be suspected and a management plan should be implemented.

I'd like to focus on amnesia because it will come into play later. Amnesia is a common physical symptom associated with mTBI. Amnesia almost always involves loss of memory for the traumatic event but frequently includes loss of recall for events immediately before (retrograde amnesia) and after (anterograde amnesia) the traumatic event.

Since concussions are often hard to recognize and to diagnose, the Zurich Consensus on Concussion in Sport proposed diagnostic criteria for sideline evaluation. An athlete shows any of the following, they need to be removed from play and assessed.
  • Initial obvious physical signs consistent with concussion (LOC, balance problems)
  • Teammates, trainers, coaches observe cognitive or behavior changes in functioning consistent with concussion symptoms reported
  • Any concussion symptoms reported by the athlete injured
  • Abnormal neurocognitive or balance examination
Following a removal from play:
  • Physician evaluated the player using standard emergency management principles, most notably to exclude  severe head trauma or cervical spine injury
  • Once first aid issues are addressed, assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools (NHL uses ImPACT concussion testing, read here:
  • The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury
  • A player with diagnosed concussion should not be allowed to return to play on the same day. 
    • It has been unanimously agreed that an athlete should not return to play on the same day of the injury. Studies have shown that athletes allowed back into play following a concussion may demonstrate neuropsychological deficits post injury. 

The graduated return to play protocol following a concussion is a stepwise process and is outline below: 

In this stepwise progression, an athlete only proceeds to the next level if they are asymptomatic at the current level. Each step should take at least 24 hours, making the minimum amount of time to proceed through the full rehabilitation protocol one full week. Athletes should never return to play on the same day as an injury.


Most people associate concussions with violent/physical sports, specifically American football, hockey and boxing. Of all sports played in the United States, football is the sport associated with the greatest number of traumatic brain injuries, but it also has the largest number of participants.

In the US, soccer is a sport growing in popularity. Between 1982 ad 2008, approximately 7.2 million men and 5.2 million women played soccer at the high school level and an additional 430,000 men and 322,000 women at the college level (Cantu and Mueller).

Recently, a study (Rosenthal et al) was published which analyzed data from High School Reporting Information Online (HS RIO), a national high school sports injury surveillance system. In this system, high schools across the nation with at least 1 certified athletic trainer were invited to participate. The trainers would log into the system and report injuries and athlete-exposures (AE) which was defined as 1 athlete participating in 1 competition or practice. The study used a sample of 100 schools for participation in the concussion rate study and focused on 9 sports: baseball, boys and girls basketball, football, boys and girls soccer, wrestling, softball and girls volleyball. These sports were chosen because data was available from 2005-2006 through 2011-2012.

The study reported the following rates:

"The HS RIO data showed a significant increase in overall concussion rate in the 7-year period of the study. The rates significantly increased in 5 of the 9 sports studied and showed increasing trends in the others. As can be seen from our results, the majority of the rate increase for all sports was observed after the 2008-2009 academic year."
The graphs from the study shown below show total concussion rates for girls and boys sports from 2005-2006 through 2001-2012:

As you can see, the rate of concussions has increased in both boys and girls soccer. However, girls sustain a higher rate of concussions.

Another study (Gessel et al) also used the HSRIO data to survey the injury and drive targeted injury-prevention projects.  The researchers determined that the risk factors for concussion in soccer differed significantly by sex. Concussions in soccer players most frequently occur as a result of head to head collisions in the act of heading the ball; 40.5% of the time in males and 36.7% in females. Girls soccer players sustain a greater proportion of concussions related to contact to the ground (22% compared to 6%) and contact with the ball (18.3% compared to 8.2%). Another risk factor for concussions in soccer is playing the position of keeper, with 21.7% of injuries to goalkeepers being concussions, compared with 11.1% of injuries to other positions.

Up to 50% of players admit to bending the truth about their symptoms to get back into action more quickly. It's imperative to teach them that a brain injury is not like any others, it could be irreversible. You can cause serious damage by not being honest about your symptoms and condition and by returning to play with a brain injury.

There are three incidents that occurred to three separate players and national teams during the FIFA World Cup that I'd like to discuss.