Concussions in Ice Hockey. How is the injuries' assessment affected by the culture surrounding the sport and media coverage?

Term Paper 2016 10 Pages

Health - Sport - Theory and Practice


Table of Contents

Background ... 2

Concussions ... 2

Concussions in ice hockey ... 3

Ice hockey culture ... 4

How ice hockey culture affects concussions ... 5

The role of the media ... 6

Conclusion ... 7

References ... 9


Concussions and the prolonged effects these brain injuries can result in are a cause for concern in ice hockey. Ice hockey is one of the sports with the highest amount of concussions (Kerasidis, 2015). It is estimated that the number of concussions occurring in men’s ice hockey has been on the rise since the middle of the 1990s (Mårtensson, 2013) and in recent years many prominent players have openly discussed the problems they have had to endure after sustaining a concussion (Shoalts, 2015), leading to growing discussion in the media and among hockey fans about concussions, hits to the head and safety of the players. The aim of this paper is to discuss concussions in men’s ice hockey, with the main focus on the National Hockey League, from the 1990s to this day. I will explore how the prevalence of concussions and their subsequent assessment and management is affected by the culture surrounding the sport and the media covering these brain injuries.


There is no simple answer to the question what is a concussion (Kerasidis, 2015). Over the years the definition of concussion has evolved and there still isn’t a clear consensus among brain specialists (Kerasidis, 2015). According to The 4th International Conference on Concussion in Sport, concussion is “a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces” (McCrory et al., 2013, p. 250.) Some other definitions are
a clinical syndrome of biomechanically-induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness” (American Academy of Neurology, 2013 cited in Kerasidis, 2015)
a clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma” (American Association of Neurological Surgeons, 2011, cited in Kerasidis, 2015)

All of these definitions imply that a concussion is a complicated syndrome with varying symptoms. A concussion can be caused either by a direct hit to the head or by a hit to another part of the body which results in an impulsive force that causes the head to move rapidly (Kerasidis, 2015). Concussion is a functional injury rather than a structural injury, which means that even though concussion results in clinical symptoms, it cannot be detected by general neuroimaging studies (Kerasidis, 2015). Concussion can result in somatic, cognitive and emotional symptoms (Kerasidis, 2015). Some of the most common symptoms include loss of consciousness, amnesia, headache, nausea, vertigo, confusion and sleep disturbance (Kerasidis, 2015). Sometimes symptoms can have a late on-set and start minutes, hours or even days after the initial hit (Kerasidis, 2015).

Approximately 80-90% of concussions resolve in 7 to 10 days but occasionally concussion symptoms can last months or even years (McCrory et al., 2013, p. 251). When the symptoms last for longer than three months the condition is called post-concussion syndrome (Kerasidis, 2015). In rare cases multiple concussions can lead to a progressive, degenerative brain disease known as chronic traumatic encephalopathy (CTE) which has been linked to the deaths of some professional ice hockey and American football players (Kerasidis, 2015). Another catastrophic result from multiple concussions is the extremely rare condition known as second impact syndrome (Kerasidis, 2015). This syndrome can occur when another concussion occurs before the brain has completely healed from a previous concussion (Kerasidis, 2015). Second impact syndrome leads to fatality in about 50% of the cases and all of the survivors are left with permanent neurological damage (Kerasidis, 2015).

According to The 4th International Conference on Concussion in Sport “concussion is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage” (McCrory et al., 2013, p. 256). Because of the subjective nature of concussion symptoms, it is difficult to diagnose and physicians rely largely on the injured player’s own account to be able to diagnose a concussion (Kerasidis, 2015). However, in recent years there has been exciting progress in the research of bio-markers which would allow a concussion to be diagnosed based on a saliva or blood sample (Siman, Shahim, Tegner, Blennow, Zetterberg & Smith, 2015).

Concussions in ice hockey

Concussions can occur in every sport but their prevalence is especially high in contact sports (Kerasidis, 2015). Ice hockey is among the top sports when it comes to the number of concussions sustained by a player (Kerasidis, 2015). Between 2006 and 2013 the concussion rate in men’s ice hockey world championships was 1.9 per 1000 player-games (Tuominen, Stuart, Aubry, Kannus & Parkkari, 2014, p. 34). 7,7% of these concussions led to more than three weeks absence from the game (Tuominen et al., 2014, p. 34). Over 50% of the concussions were a result from a check to the head (Tuominen et al., 2014, p. 34).

In 1997 the National Hockey League (NHL) together with the players’ association (NHLPA) launched a concussion program to better examine and understand concussions in ice hockey (Benson, Meeuwisse, Rizos, Kang & Burke, 2011, p. 905). In the seasons 1997-1998, and 2003-2004 NHL team physicians reported on average 1.8 concussions per 1000 player-hours. Altogether that comes up to 559 concussions (Benson et al., 2011, p. 906). Absence from the game caused by a concussion ranged from 0 to 342 days (Benson et al., 2011, p. 907). The percentage of concussions that led to more than 10 days absence from the game ranged from 19 to 43 per season (Benson et al., 2011, p. 907).

It is noteworthy that experts estimate that up to 90% of concussions sustained in sports go unreported (Kerasidis, 2015), therefore the number of concussions sustained in professional ice hockey are likely larger than reported in these studies.

Ice hockey culture

In contact sports enduring pain and tolerating injuries is connected to desirable attributes such as toughness and commitment (McGannon, Cunningham & Schinke, 2013, p. 892). This can be described as a culture of risk, where pain and injury are seen as normal part of an athlete’s life and athletic performance is valued over the health and safety of the athlete (Nixon, 1992, p. 128). Culture of risk encourages and rewards pain and injury (Nixon, 1992, p. 128). Enduring pain and injury lets the athlete to gain respect of their teammates and coaches (Nixon, 1992, p. 129). If an athlete doesn’t play due to injury, their masculinity and athleticism may been questioned (McGannon, Cunningham & Schinke, 2013, p.891) .

Ice hockey is a contact sport where masculinity is appreciated and embraced (Allain, 2008, p. 462). Especially in hockey’s birth place Canada, rough and tough play is the desired style of playing and other types of players are often ridiculed and their masculinity is diminished (Allain, 2008, p. 462). The kind of masculinity promoted in hockey culture is hard and aggressive (Allain, 2008, p. 462). Hockey players express disdain towards any displays of vulnerability or sensitivity, which are seen as feminine qualities (Allain, 2008, p. 464).

Ice hockey has a long tradition of players following their own code when it comes to violence and aggression on the ice (Proteau, 2013). There are certain unwritten rules about aggressive actions on ice that all hockey players are supposed to adhere to (Proteau, 2013). Some of these rules include retaliating for aggressive behaviour perpetrated by the opposition earlier in the game or in a previous game, and challenging a player into a fight (Proteau, 2013).

How ice hockey culture affects concussions

The culture in ice hockey can exacerbate the concussion issue by two different mechanisms. The culture affects on-ice behaviour which leads to concussions, and off-ice attitudes which complicate concussion assessment and management.

Some players, coaches and sport journalists have suggested that there is a profound lack of respect for other players’ and their safety which leads to violent hits to the head (Forbes, 2015; Shoalts 2012). In a sport where physical acts with the purpose of causing physical or psychological harm to the opposite player are valued and seen as a successful game strategy (Cusimano et al., 2013), it is easy for the lines between acceptable and unacceptable aggression to become blurred. When players are taught to play aggressively and do everything for a win, the health and safety of other players might become an afterthought (Forbes, 2015). The code of the game which includes fighting and taking justice into own hands by retaliating earlier hits, leads easily to the type of hits that result in concussions.

Researchers who study concussions in ice hockey have reported instances of coaches and players avoiding examinations and ignoring medical advice, even after they have agreed to sign up for the study (Delgado, 2013). Neuropsychologists who work with concussed ice hockey players report players being uncooperative and even hostile, while trying to hide or downplay their symptoms (Echemendia, 2006, p. 39).

According to Paul Echlin, who has done three studies on concussions in ice hockey, he is often met with resistance from both coaches and players (Delgado, 2013). Echlin claims that coaches are often against having an independent physician at the games (Delgado, 2013). In one of Echlin’s studies of university-level ice hockey the researchers didn’t use independent physicians but instead the team physicians were expected to report all concussions occurring to the players (Delgado, 2013). The team physicians reported only one concussion in the entire regular season, a result that is significantly lower than reports made by independent physicians, suggesting that team physicians underreport concussions (Delgado, 2013).

There are multiple factors that can explain aforementioned behaviour. Players have a strong desire to play and help their team win, which can lead to them hiding or downplaying symptoms in the fear of being kept away from the game. Coaches and team physicians want their team to win, which can result in reluctance to keep concussed players off the ice (Delgado, 2013). A study on the NHL and NHLPA concussion program showed that players fail to report concussion symptoms for fear of not being allowed to play (Benson et al., 2011, p. 909). It is also possible that players and team staff simply lack knowledge about concussions which leads to uninformed decisions concerning return to play.

For those who have experience of the phenomenon, it is obvious that the culture in ice hockey encourages players to continue playing despite of sustaining a concussion (Delgado, 2013). A culture of risk which emphasizes toughness and aggression encourages players to keep playing in spite of pain and discomfort (Nixon, 1992, p. 128). Concussion symptoms are often subjective and can include emotional symptoms such as depression (Kerasidis, 2015), which may make it more difficult for players to admit they’re suffering from a concussion as they may view these symptoms as a sign of mental weakness. It is believed that the ideals of a tough, masculine athlete are so strong that it prevents concussed athletes to come forward about the emotional and psychosocial symptoms they’re experiencing (McGannon, Cunningham & Schinke, 2013, p. 892).

Team staff may be reluctant to participate in concussion research because they are afraid revealing the high prevalence of concussions in ice hockey will lead to changes being made to the game (Delgado, 2013). Aggression and occasionally even violence are entrenched and embraced elements of ice hockey (Cusimano et al., 2013). Some people are concerned that these elements will be removed if our knowledge about concussions improves (Delgado, 2013).

The role of the media

Many people follow sports through the media and the media have considerable power to direct public discussion. The media teach the general public how they should view and understand ice hockey, and give insight into what behaviour is valued in the game (Allain, 2008, p. 470). In Canada the media celebrate aggression, violence and playing with pain (Allain, 2008, p. 464). The media also construct athletes’ identities by influencing how society and the athletes themselves view athletes (McGannon, Cunningham & Schinke, 2013, p. 892).

Media reports also play a crucial role in shaping the culture around health-related behaviours (Cusimano et al., 2013). A 2013 study examined the style in which North American newspaper articles from 1985 to 2011 portrayed concussions and on-ice behaviour leading to concussions (Cusimano et al., 2013). The newspaper articles saw aggression as a valued and integral part of hockey but condemned violence (Cusinamo et al., 2013). The significance of concussions was recognized and concussions were regarded as serious injuries but simultaneously they were seen as an unavoidable part of the game (Cusimano et al., 2013).

NHL star player Sidney Crosby suffered a hit to the head in a game on January 1st 2011 (ESPN, 2012). Despite feeling minor symptoms he returned to the game (ESPN, 2012). On the game on January 5th he sustained another hit to the head and again continued to play (ESPN, 2012). The next day Crosby started to feel concussion symptoms that continued until November (ESPN, 2012). After playing only seven games Crosby’s concussion symptoms returned in December and he was side-lined until March 2012. Because of Crosby’s fame and the long period of his concussion symptoms the incident received wide media coverage (McGannon et al., 2013, 893).

McGannon, Cunningham and Schinke (2013) found that newspaper articles covering the issue used Crosby’s concussion as a cautionary tale and a political platform. The journalists and Crosby himself drew attention to the problematic culture of risk in ice hockey (McGannon, Cunningham & Schinke, 2013, p. 894). Crosby’s concussion was seen by the media as a warning about the dangers of ice hockey and it was used as a political platform to rally for changes to the rules of ice hockey and to question the culture of the game (McGannon, Cunningham & Schinke, 2013, p. 894). Because it was a high profile case, Crosby’s concussion was used to raise awareness about the severity of concussions (McGannon, Cunningham & Schinke, 2013, p. 894). The media reports focused on the physical symptoms of Crosby’s concussion, ignoring the possible psychosocial health issues (McGannon, Cunningham & Schinke, 2013, p. 895). This may be because the hockey culture views vulnerability and openness about emotions as feminine and unwanted.

Despite Crosby pulling himself out of the game due to ambiguous concussion symptoms, the media reports covering the event did not question Crosby’s masculinity or athleticism (McGannon, Cunningham & Schinke, 2013, p. 894). Instead the media questioned the rules of the game and pressured the NHL to change policy (McGannon, Cunningham & Schinke, 2013, p. 894). This may be an indicator that concussions are taken more seriously and the media’s view on ice hockey is changing.


Concussions are a growing issue in ice hockey. The current medical consensus is that concussions are significant brain injuries which may lead to long-term complications. The masculine, aggressive, culture of risk in ice hockey affects both the prevalence of concussions and the assessment and management of concussions. Violent on-ice behaviour leads to more concussions and the downplaying of symptoms compromises concussion management. The way the media portrays ice hockey and concussions affects the general opinion on the issue.

Sidney Crosby’s concussion brought a lot of awareness to the concussion issue in the NHL. It led to the media directing criticism towards the league and the game, while possibly changing attitudes towards head injuries and how they should be handled. In recent years some journalists have brought up a more critical view of on-ice violence and aggression, especially in relation to hits that can lead to concussions.

When interpreting these results it should be noted that the sources used in this paper cover North-American men’s hockey. As it is widely believed that European hockey puts less emphasis on tough play and aggression, and women’s game is played with different rules in regards to physical play, the hockey culture and the way the media portrays the game might be different if these variations of the game were studied.


Allain, Kristi (2008). “Real Fast and Tough.” The Construction of Canadian Hockey Masculinity. Sociology of Sport Journal, (2008:25), p. 462-481.

Benson, Brian W., Meeuwisse, Willem H., Rizos, John, Kang, Jian & Burke, Charles J. (2011). A prospective study of concussions among National Hockey League players during regular season games: the NHL – NHLPA Concussion Program. Canadian Medical Association Journal (2011:183), p. 905-911.

Cusimano, Michael D., Sharma, Bhanu, Lawrence, David W., Ilie, Gabriela, Silverberg, Sarah & Jones, Rochelle. Christie, Brian (ed.) (2013). Trends in North American Newspaper Reporting of Brain Injury in Ice Hockey. PLos One, (2013:4).

Delgado, Fernando J. (2013). A culture problem: new study shows that concussions are being underreported in ice hockey: TEAM Business spoke with Dr. Paul Echlin, lead investigator of a new study of hockey concussions, to better understand the ramifications behind the underreporting of concussions in the game of ice hockey and what can be done to change an unhealthy culture and reduce head injuries. Team Business. Business insights: Essentials. January 1st

Echemendia, Ruben J. (2006) Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury.

ESPN (2012). Timeline: Sidney Crosby’s Concussion. http://espn.go.com/nhl/story/_/id/7459581/sidney-crosby-concussion [2016-01-04]

Forbes, Andrew (2015). Respect, hockey’s biggest issue. http://thehockeywriters.com/respect-hockeys-biggest-issue/ [2016-01-24]

Kerasidis, Harry (2015). Concussion-ology: Redefining Sports Concussion Management For All Levels.

McCrory, Paul, Meeuwisse, Willem H., Aubry, Mark, Cantu, Bob, Dvorak, Jiri, Echemendia, Ruben J., Engebretsen, Lars, Johnston, Karen, Kutcher, Jeffrey S., Raftery, Martin, Sills, Allen, Benson, Brian W., Davis, Gavin A., Ellenbogen, Richard G., Guskiewicz, Kevin, Herring, Stanley A., Iverson, Grant L., Jordan, Barry D., Kissick, James, McCrea, Michael, McIntosh, Andrew S., Maddocks, David, Makdissi, Michael, Purcell, Laura, Putukian, Margot, Schneider, Kathryn, Tator, Charles H. & Turner, Michael (2013). Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine, (2013:4), p. 250-258.

McGannon, Kerry R., Cunningham, Sarah M. & Schinke, Robert J (2013). Understanding concussion in socio-cultural context: A media analysis of a National Hockey League star’s concussion. Psychology of sport and exercise (2013:14), p. 891-899.

Mårtensson, Fredrik (2013). Läkaren med minskat antal hjärnskakningar på hjärnan. Läkartidningen, January 15th.

Nixon, Howard L. (1992). A social network analysis of influences on athletes to play with pain and injuries. Journal of Sport and Social Issues, (1992:09), p. 127-135.

Proteau, Adam (2013). Fighting the Good Fight: Why On-Ice Violence Is Killing Hockey.

Shoalts, David (2012). Hockey desperately needs a concussion cure. https://web.archive.org/web/20120111015851/http://www.theglobeandmail.com/sports/hockey/david-shoalts/hockey-desperately-needs-a-concussion-cure/article2295520/ [2016-01-24]

Siman, Robert, Shahim, Pashthun, Tegner, Yleverton, Blennow, Kaj, Zetterberg, Henrik & Smith, Douglas H. Serum SNTF Increases in Concussed Professional Ice Hockey Players and Relates to the Severity of Post-Concussion Symptoms. Journal of Neurotrauma, (2015:32), p. 1294-1300

Tuominen, Markku, Stuart, Michael J., Aubry, Mark, Kannus, Pekka & Parkkari, Jari (2014). Injuries in men’s international ice hockey: a 7-year study of the International Ice Hockey Federation Adult World Championship Tournaments and Olympic Winter Games. British Journal of Sports Medicine, (2014:49), p. 30-36.


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Title: Concussions in Ice Hockey. How is the injuries' assessment affected by the culture surrounding the sport and media coverage?