Bodychecking in hockey
======================

* Michael D. Cusimano
* Anthony Marchie

*   © 2004 Canadian Medical Association or its licensors

As R. van Reekum notes, legal bodychecks are often the cause of trauma and concussions; only 8% of injuries are caused by illegal checks.1 However, stricter enforcement of existing rules would not solve the problem, as Angus Juckes and Ian Ross suggest. 

It is difficult to see how anyone can perceive entertainment value in bodychecking, especially if its victims are children and youth. The American Psychiatric Association has concluded that, in addition to desensitizing viewers, violence in entertainment promotes more such violence.2 Neal Shaw's suggestion that violence and aggression are often manifested in legal bodychecking raises the important question of whether these are values we wish to foster in the next generation of citizens.

Yet remaking the game is unnecessary. For example, most high school and women's hockey games are already played without bodychecking, and the injury rates in these settings are much lower than in the National Hockey League (NHL).3 What needs remaking is attitude: we need to refocus the game on fun, skill and sportsmanship, rather than violence and aggression. 

Although his review of our references is admirable, Ross's comments are limited in applicability, given that many athletes underreport injuries such as concussions. Because concussions are often missed or misdiagnosed,4 the incidence is probably much higher than that reported.3,5 Ross also fails to mention that Honey's review6 indicated that 2 studies reporting no concussions did not have large enough sample sizes to allow definitive conclusions. Nonetheless, a conservative estimate of 1 or 2 concussions per 1000 player hours,6 for 560 000 registered minor hockey players who average 15 hours on ice per season, would yield at least 8000 to 16 000 concussions alone for the upcoming season in Canada. On the basis of an injury rate of 15 per 100 players (9 to 15 years of age) per season,7 we would expect bodychecking to account for the majority of the 84 000 injuries in the 2003/04 minor hockey season. 

Some people, including various media pundits, coaches, parents and health care professionals, have suggested — erroneously — that the benefits of checking outweigh the risks, even for young children and adolescents. They argue that this technique must be learned to minimize the risk of injury at older ages, but the data do not support this contention. The incidence of concussion and other injuries consistently increases with increase in bodychecking experience, reaching its zenith at the elite levels in collegiate leagues and the NHL,3,6,8 and is associated with significant risk of fracture,9,10,11 concussion8,12 and spinal injury.13 One concussion is a risk factor for a second one, and those who have sustained 3 or more concussions are 9 times more likely to have altered mental status than those without prior concussion.14 A frequently overlooked cost is that of attrition from the sport, which is greatest in those 13 and 14 years of age, when differences in the size and weight of players are also at their greatest.11 

When these reasons against bodychecking are considered along with the concept of patient autonomy, we are compelled to recommend banning bodychecking until players are at least 17 or 18 years of age. It should be permitted thereafter only if players have given proper informed consent. Parents and young players need to know the risks before starting play in a contact league, and physicians should take into account not just when but if a player should return to play in a contact league after injury.15 Indeed, as Stephen Anderson reminds us, these principles should apply not only to ice hockey but to all sports.

Ultimately, a multifaceted approach that incorporates the elimination of bodychecking, enforcement of rules, engineering advances in materials and education holds the greatest promise for making hockey a safer game.

**Michael D. Cusimano** **Anthony Marchie** Injury Prevention Research Centre and Division of Neurosurgery St. Michael's Hospital University of Toronto Toronto, Ont.

## References

1.  1. McFaull S. Contact injuries in minor hockey: a review of the CHIRPP database for the 1998/1999 hockey season. *CHIRPP News* 2001;(19):1-9. Available: [www.hc-sc.gc.ca/pphb-dgspsp/publicat/chirpp-schirpt/19jan01/index.html](http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/chirpp-schirpt/19jan01/index.html) (accessed 2003 Oct 27).
    
    

2.  2. American Psychiatric Association. *Psychiatric effects of media violence*. Arlington (VA): The Association; [no date]. Available: [www.psych.org/public\_info/media_violence.cfm](http://www.psych.org/public_info/media_violence.cfm) (accessed 2003 Oct 13).
    
    

3.  3. Wennberg RA, Tator CH. National Hockey League reported concussions, 1986-87 to 2001-02. Can J Neurol Sci 2003;30(3):206-9.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=12945942&link_type=MED&atom=%2Fcmaj%2F170%2F1%2F16.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000184716400006&link_type=ISI) 

4.  4. Kaut KP, DePompei R, Kerr J, Congeni J. Reports of head injury and symptom knowledge among college athletes: implications for assessment and educational intervention. Clin J Sport Med 2003;13(4):213-21.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00042752-200307000-00004&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=12855923&link_type=MED&atom=%2Fcmaj%2F170%2F1%2F16.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000184374400004&link_type=ISI) 

5.  5. NIH Consensus Development Panel on Rehabilitation of Persons with Traumatic Brain Injury. Consensus conference. Rehabilitation of persons with traumatic brain injury. JAMA 1999; 282(10):974-83.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/jama.282.10.974&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10485684&link_type=MED&atom=%2Fcmaj%2F170%2F1%2F16.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000082335900037&link_type=ISI) 

6.  6. Honey CR. Brain injury in ice hockey. Clin J Sport Med 1998;8(1):43-6.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00042752-199801000-00010&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=9448957&link_type=MED&atom=%2Fcmaj%2F170%2F1%2F16.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000073038900010&link_type=ISI) 

7.  7. Brust JD, Leonard BJ, Pheley A, Roberts WO. Children's ice hockey injuries. Am J Dis Child 1992; 146:741-7.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/archpedi.1992.02160180101026&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=1595632&link_type=MED&atom=%2Fcmaj%2F170%2F1%2F16.2.atom) 

8.  8. Goodman D, Gaetz M, Meichenbaum D. Concussions in hockey: There is cause for concern. Med Sci Sports Exerc 2001;33:2004-9. 
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00005768-200112000-00005&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=11740291&link_type=MED&atom=%2Fcmaj%2F170%2F1%2F16.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000172607300005&link_type=ISI) 

9.  9. Roberts W, Brust JD, Leonard B, Hebert BJ. Fair-play rules and injury education in ice hockey. Arch Pediatr Adolesc Med 1996;150:140-5. 
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/archpedi.1996.02170270022003&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=8556117&link_type=MED&atom=%2Fcmaj%2F170%2F1%2F16.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1996TT87800003&link_type=ISI) 

10. 10. Pinto M, Kuhn JE, Greenfield ML, Hawkins RJ. Prospective analysis of ice hockey injuries at the Junior A level over the course of one season. Clin J Sport Med 1999;9(2):70-4.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00042752-199904000-00005&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10442620&link_type=MED&atom=%2Fcmaj%2F170%2F1%2F16.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000081451800005&link_type=ISI) 

11. 11. Regnier G, Boileau R, Marcotte G, Desharnais R, Larouche R, Bernard D, et al. Effects of body-checking in the Pee Wee (12 and 13-years-old) division in the Province of Quebec. In: Castaldi CR, Hoerner EF, editors. *Safety in ice hockey*. Philadelphia: American Society for Testing Materials; 1989. p. 84-103.
    
    

12. 12. Biasca N, Wirth S, Tegner Y. The avoidability of head and neck injuries in ice hockey: an historical review. Br J Sports Med 2002;36:410-27.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYmpzcG9ydHMiO3M6NToicmVzaWQiO3M6ODoiMzYvNi80MTAiO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTcwLzEvMTYuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

13. 13. Tator CH, Carson JD, Cushman R. Hockey injuries of the spine in Canada, 1966–1996. CMAJ 2000; 162(6):787-8.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjIvNi83ODciO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTcwLzEvMTYuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

14. 14. Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. Cumulative effects of concussion in high school athletes. Neurosurgery 2002; 51:1175-9.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1097/00006123-200211000-00011&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=12383362&link_type=MED&atom=%2Fcmaj%2F170%2F1%2F16.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000178984700017&link_type=ISI) 

15. 15. Marchie A, Cusimano MD. Bodychecking and concussions in ice hockey: Should our youth pay the price? [editorial]. CMAJ 2003;169(2):124-8.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjkvMi8xMjQiO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTcwLzEvMTYuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)