Case Study: In Season Hockey Player

The reason for sharing case studies is to start a collective conversation, not to suggest that there's anything particularly sound or exemplary about the methodology. Many people agree in the abstract and pay homage to things like progressive overload, periodization, graded exposure, and desensitization but rehabilitation and coaching ultimately require actionable decision making and the application of theoretical concepts. We share these examples to demonstrate what we do when we have real skin in the game- when we're professionally responsible for someone's preparation. Population based studies can be informative but individual cases promote greater clinical transparency. We welcome the scrutiny that accompanies this transparency even if it comes at the expense of our mistakes.

Background

Professional hockey player (in season) w/history of chronic bilateral groin pain (including labral repair on one hip), current grade 1 AC joint separation (occurred during a recent game), and chronic bilateral pain at junction between lat and tricep.  Athlete also attends national team camps throughout the year, including during the professional team’s season. Skating load during the season is substantial and the athlete doesn’t tolerate off-ice, eccentrically-oriented adductor well when the on ice volume is high.  I do think the athlete would ultimately benefit from more direct adductor work when the on-ice demand is lower. We manage the groin in season by maintaining sagittal plane lower body strength and proximal anti-rotation ability while adhering to a high technical standard on all exercises. With the AC joint separation, horizontal pressing is too painful to perform but everything listed below is well tolerated.  Lat/tricep pain occurs with no predictable pattern or mechanism of injury. Recent MRI of both triceps was unremarkable and clinical exam revealed no obvious pathology. The team orthopedist and I agreed the athlete isn’t at risk for additional injury by playing but we’re unable to come up with a definitive diagnosis. The program below is replete with direct lat and tricep work to give the athlete confidence that if there was a significant injury there, it would manifest in training.  In season, the athlete plays one game per week, usually on Saturday or Sunday, and practices 2-4 days/week at varying intensities. National team camps occur several times throughout the year and last 1-2 weeks at time. The volume of practice and game play at these camps is significantly higher than what the athlete encounters on the professional team.

Initial Findings

• Lacking (passively and actively): hip internal rotation/adduction/extension bilaterally, shoulder flexion bilaterally, thoracic rotation bilaterally
• Dynamically/at speed excels in the frontal plane (e.g. lateral plyo variations, COD drills) but less so in the sagittal plane (linear acceleration, upright running mechanics)
• Struggles isometrically in the frontal plane, compensates with rotation

Rationale For Program

• Everything included below was performed in a single session, 2x/week while supervised
• Might seem aggressive in season but player is undersized for position and loses strength/body mass easily if not training off the ice.  I also thought the athlete needed extra work to be sufficiently prepared for the national team camps.
• Eccentric Pull-Ups (with bands for assistance) are to challenge deceleration ability of lat through a full ROM.  Heavy emphasis on lat and tricep work to build load tolerance/capacity and decrease pain sensitivity. One can hide from problem areas or confront them head on. Athlete ultimately determined what we did and didn’t do based on comfort level. We always had a plan B or C if option A wasn't suitable on a particular day.
• Patient is tested at the start of each national team camp in various off-ice linear speed and change of direction drills hence the inclusion here.  Even if these areas were not tested, however, I’d probably still include many of the same exercises as they reflect a disconnect between the athlete’s specialized sporting skill and general ability.  Mach drills that reinforce vertical force production can be regarded as accessory hamstring work, as an example.
• We did modify programming variables around practices and games, traveling, etc.  I have a good enough relationship with the athlete that a brief conversation at the beginning of the session and watching the warm-up provided sufficient basis from which to deviate as required. 
• While athletes have unique movement signatures, the exercises were performed to a certain technical standard or the set was terminated

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