Fortney, Thomas A.

ImportanceNational Hockey League (NHL) players are exposed to frequent head trauma. The long-term consequences of repetitive brain injury, especially for players who frequently engage in fighting, remains unknown.ObjectiveTo investigate the mortality rates and causes of death among NHL enforcers with more career fights and penalty minutes as compared with matched controls.Design, Setting, and ParticipantsThis matched cohort study examined 6039 NHL players who participated in at least 1 game in the seasons between October 11, 1967, and April 29, 2022, using official NHL data. Cohorts designated as enforcer-fighter (E-F) and enforcer-penalties (E-P) were selected. The E-F cohort consisted of players who participated in 50 or more career fights (n = 331). The E-P cohort included players with 3 or more penalty minutes per game (n = 183). Control-matched NHL players were identified for each E-F player (control-fighter [C-F]) (n = 331) and each E-P player (control-penalties [C-P]) (n = 183).ExposuresFighting and penalty minutes were both used as proxies for head trauma exposure. Players with significantly increased exposure to fighting and penalties (E-F and E-P cohorts) were compared with NHL players with less frequent exposure to head trauma (C-F and C-P cohorts).Main Outcomes and MeasuresMortality rates and age at death of the enforcer and control cohorts, and their causes of death using data obtained from publicly available sources such as online and national news sources, including NHL.com.ResultsAmong the 6039 NHL players identified (mean [SD] age, 47.1 [15.2] years), the mean (SD) number of fights was 9.7 (24.5). The mortality rates of E-F and C-F players (13 [3.9%] vs 14 [4.2%], respectively; P = .84) or E-P and C-P players (13 [7.1.%] vs 10 [5.5%]; P = .34) were not significantly different. The mean (SD) age at death was 10 years younger for E-F players (47.5 [13.8] years) and E-P players (45.2 [10.5] years) compared with C-F players (57.5 [7.1] years) and C-P players (55.2 [8.4] years). There was a difference in causes of death between the control and enforcer players (2 neurodegenerative disorders, 2 drug overdoses, 3 suicides, and 4 vehicular crashes among enforcers vs 1 motor vehicle crash among controls; P = .03), with enforcers dying at higher rates of overdose (2 of 21 [9.5%] vs 0 of 24) and suicide (3 of 21 [14.3%] vs 0 of 24) (P = .02).Conclusions and RelevanceThe findings of this matched cohort study indicate that there is no difference in overall mortality rates between NHL enforcers and controls. However, being an enforcer was associated with dying approximately 10 years earlier and more frequently of suicide and drug overdose.

Background: Ice hockey referees and linesmen are at risk for musculoskeletal injuries because of the lack of protective equipment and contact with players, sticks, pucks, the ice surface and boards. Purpose: To quantify and analyze injuries reported by officials of the International Ice Hockey Federation (IIHF). Study Design: Descriptive epidemiology study. Methods: A 61-question survey tool was designed by an interdisciplinary team to evaluate musculoskeletal injuries experienced by ice hockey officials. This survey was administered to 600 active IIHF referees and linesmen. Only completed survey responses were included in the statistical analysis. Continuous variables were analyzed using unpaired t-tests, while categorical data were assessed utilizing chi-square tests. Results: Of the 600 surveys administered, 264 surveys were completed by officials from 45 countries (44% response rate). Of the respondents, 72% were male, and 28% were female, with a mean age of 31.1 ± 5.8 years. Officiating experience averaged 11.4 ± 6.0 years (6.3 ± 4.5 years with the IIHF). A total of 295 injuries were reported by 55% of the officials. Injuries occurred more frequently during games compared with training, and officials who worked year-round had more total injuries than those who took time off ( P = .03). The most common injuries involved the wrist and hand (n = 64 [22%]), head and face (n = 58 [20%]), and the knee (n = 47 [16%]). Wrist and hand trauma included 23 fractures. Knee and shoulder injuries were most likely to require surgery compared with other body areas ( P < .001); 30 officials underwent surgery because of an acute knee injury (10%). Injury prevention activities were effective at reducing injuries ( P = .04). Conclusion: Most ice hockey officials experienced musculoskeletal injuries during their career. The risk of trauma to the wrist and hand can possibly be reduced via equipment modifications including protective gloves. A greater emphasis should be placed on injury prevention programs and time away from officiating competitions.