Is it safe for a patient with potential pre-existing medical conditions to play hockey?

Should This Patient Be Playing Hockey?

The answer depends entirely on whether the patient has hypertrophic cardiomyopathy (HCM) or another high-risk cardiac condition—if they do, ice hockey is absolutely contraindicated; if they have no cardiac disease, hockey participation is generally safe with appropriate protective equipment.

For Patients WITH Hypertrophic Cardiomyopathy or High-Risk Cardiac Conditions

Competitive Ice Hockey: Strongly Contraindicated

Ice hockey is explicitly listed as a prohibited high-intensity sport for patients with HCM and receives a "0" rating (generally not advised or strongly discouraged) on the eligibility scale. 1

• Ice hockey is classified as a high-intensity sport requiring approximately 6 metabolic equivalents, involving both explosive dynamic exertion and significant static components 1
• The 2011 ACC/AHA guidelines state that patients with HCM should not participate in most competitive sports, with exception only for low-intensity activities like golf and bowling 1
• Ice hockey specifically appears in Table 2 of the ACC/AHA guidelines with an eligibility score of "0" for recreational participation in HCM patients 1

Recreational Ice Hockey: Also Contraindicated

Even for non-competitive recreational play, ice hockey remains inadvisable for HCM patients:

• The European Association of Preventive Cardiology (2019) notes that hockey carries a smaller collision risk compared to rugby or American football, but still poses significant bodily contact concerns 1
• Hockey involves potential for traumatic injury, which is particularly concerning for individuals at risk for impaired consciousness from arrhythmias 1
• The high-intensity bursts required in hockey can trigger sympathetic-vagal imbalance, microvascular ischemia, and metabolic acidosis in HCM patients 1

Physiologic Rationale for Restriction

The prohibition is based on multiple mechanisms of harm:

• High-intensity exercise may increase dynamic left ventricular outflow tract obstruction, elevating LV pressure and wall strain, potentially triggering arrhythmias 1
• Intermittent increases in LV pressure could worsen myocardial fibrosis over time in HCM patients 1
• The risk of sudden cardiac death during intense exertion remains the primary concern, though recent data suggest this risk may be lower than historically believed 1

Special Consideration: ICD Patients

For HCM patients with implantable cardioverter-defibrillators (ICDs):

• Hockey is specifically contraindicated due to bodily collision risk that could damage the generator box and cardiac leads 1
• Even with padding of the ICD site (which has unproven effectiveness), the collision risk in hockey remains prohibitive 1
• The ICD does not prevent arrhythmia occurrence during intensive exercise—it only treats it after onset 1

For Patients WITHOUT Cardiac Disease

General Safety Profile

For healthy individuals without pre-existing cardiac conditions, ice hockey is a reasonable sport with appropriate precautions:

• Ice hockey has an injury incidence rate of 78.4 per 1,000 player-game hours, which is high compared to other sports 2
• However, practice-related injuries are much lower at 1.4 per 1,000 player-practice hours 2
• 80% of hockey injuries result from direct trauma (body contact, puck/stick contact) rather than cardiovascular events 3, 2

Common Injury Patterns to Anticipate

The most frequent injuries in hockey include:

• Contusions, strains, and sprains comprise the majority of injuries (73% are minor) 2
• Upper extremity: acromioclavicular joint separations, clavicle fractures, scaphoid fractures, gamekeeper's thumb 3, 4
• Lower extremity: hip adductor strains, medial collateral ligament tears, thigh contusions 3, 4
• Concussions remain a significant concern, with rates of 2.79 per 1,000 game-hours in body-checking leagues 5

Risk Mitigation Strategies

To minimize injury risk in healthy players:

• Mandatory use of helmets with full face protection significantly reduces facial injuries 3, 2
• Strict enforcement of rules against stick violations and illegal checking reduces trauma-related injuries 2
• For youth players aged 11-12, leagues without body checking show 50% reduction in overall injury rate and 64% reduction in concussion rate 5
• Proper conditioning and training programs reduce overuse injuries (which account for 20% of hockey injuries) 3

Specific Contraindications in Otherwise Healthy Athletes

Even without HCM, certain conditions preclude hockey participation:

• Marfan syndrome, Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, or any aortic aneurysm disorder due to catastrophic aortic event risk 6
• Markedly dilated aorta (>45 mm or z-score >3.5-4) 6
• Uncontrolled systemic hypertension 6
• Athletes on dual antiplatelet or full anticoagulation therapy (due to bleeding risk from trauma) 1

Clinical Decision Algorithm

1. First: Obtain cardiac screening including history, physical exam, ECG, and echocardiogram if any concerning features
2. If HCM or high-risk cardiomyopathy diagnosed: Ice hockey is contraindicated for both competitive and recreational play 1
3. If aortic disease present: Assess severity; any significant dilation or aneurysm precludes hockey 6
4. If structurally normal heart: Hockey participation is reasonable with appropriate protective equipment 3, 2
5. For youth players: Consider non-checking leagues to reduce injury risk by 50% 5

Common Pitfall to Avoid

Do not assume that recreational or "just for fun" hockey is safe for HCM patients—the guidelines make no distinction between competitive and recreational play for high-intensity sports like hockey. 1 The physiologic demands and collision risks are present regardless of competitive intent.