Derek Boogaard poised for a hockey fight

Evolving the Sport: A History of Head Injuries in Hockey

Written by: Katie Lakusta

December 31, 2024

Time to read 17 min

Across most contact sports, particular interest in head contact safety has become one of the primary focuses of general safety. But it hasn’t always been like that.

In this article, we will be taking a look at the history of head injuries and how they have affected the world of hockey—with a particular focus on concussions, as well as long-term conditions such as PCS and CTE. We will also be looking into how sports have responded to the growing awareness, whether that be through more advanced helmet technology or rule changes.

Note: This article discusses the history and impact of head injuries in hockey, including their potential severity. While the content itself is not graphic, the events referenced may include graphic injuries or more tragic outcomes.

hockey player holding a Jetspeed FT6 Pro stick

Head Injuries

The subject of head injuries is extensive—they can refer to a multitude of issues, from skull fractures to concussions, to something more chronic. A traumatic brain injury (TBI) occurs when a sudden jolt or blow disrupts normal brain function. As implied, collisions and falls can all lead to TBIs if they result in a hit to the head. While some injuries may lead to immediate symptoms like confusion or unconsciousness, others may go unnoticed at first, with more complications emerging over time.

One early albeit rather famous case that demonstrated both the impact and complexity of head injuries is that of Phineas Gage in the 1848. Gage was injured in an accident involving an iron rod driven through his skull and frontal lobe. Although he was able to recover with no loss to motor skills, language, and memory, witnesses noted dramatic changes to his personality. Gage’s once-polite demeanor shifted drastically; he became coarse, foul-mouthed, and impulsive. He also developed an unusually intense attachment to trivial objects, such as pebbles found along a stream. This case was among the first to link brain injuries with mood and behavioural changes, helping pave the way for modern neuroscience.

Phineas Gage holding the iron rod involved in his accident. Source Link.

Compared to hockey injuries, Gage’s case is rather extreme—however, it still puts a similar emphasis on the broader impact that head injuries can have on people. In hockey, TBIs are typically concussions, which can lead to a range of physical, behavioural, and cognitive complications.

Concussions

Your brain is not stationary in your head, but floating in your skull. A concussion is when your brain moves or twists within this space; although the skull does a pretty good job of protecting the brain from most trauma, there is no foolproof way to protect oneself from concussions. The cause has to do with your brain hitting the skull and does not necessarily require a skull or impact-based injury; so head collisions, as well as whiplash, can both result in a concussion.

Photo by Robina Weermeijer on Unsplash

Concussions are classified as mild brain injuries and are a common form of TBIs, but if mistreated or not treated at all, they can develop into worse injuries. Although there is no guaranteed way to prevent concussions, taking the appropriate precautions is still crucial. Failing to take concussions—and that said, all head injuries—seriously enough can lead to worsening and potentially even chronic symptoms.

Unlike other head injuries, concussions cannot be diagnosed through scans or normal, physical means. Symptoms may not even appear right away, but instead after a few days. For all these reasons, recognizing the signs of a concussion and monitoring players after head contact is vital. Some common symptoms include headaches, dizziness, ringing in the ears, nausea, and confusion, depending on the severity. Concussed players may struggle with speech, concentration, coordination, and overall playing ability and decision-making. If a player displays symptoms or signs of a concussion following head contact—no matter the time between the symptoms and incident—they must consult a physician for re-evaluation and to determine a proper treatment plan.

Treatment

Most minor hockey associations will have a concussion protocol in place for players, requiring a doctor’s visit, plan, and doctor’s clearance before they can return to the ice.

Dubbed the Zurich Graduated Return-to-Play Protocol, a guideline for returning to play was outlined in the Zurich Consensus statement following the first and second International Symposiums on Concussion in Sport, in Vienna and Prague respectively. Most associations will require players to follow this protocol after they have been symptom-free for one week. Hockey Canada follows and recommends this protocol, referencing it in their Concussion Awareness Card .

Photo by Alexander Grey on Unsplash

Zurich Graduated Return-to-Play Protocol

(from the National Athletic Trainers’ Association)

No activity: Complete physical and cognitive rest (Goal: recovery).
Light aerobic exercise: Walking, swimming, or stationary cycling, keeping intensity (Goal: Increase heart rate).
Sport-specific exercise: Skating drills in ice hockey, running drills in soccer; no head impact activities (Goal: Add movement).
Non-contact training drills: Progression to more complex training drills, etc, passing drills in football and ice hockey; may start progressive resistance training (Goal: Exercise, coordination, and cognitive load).
Full-contact practice: Following medical clearance, participate in normal training activities (Goal: Restore athlete’s confidence; coaching staff assesses functional skills).
Return to play: Normal game play.

Each step must be taken by the player for 24hrs, and if they are symptom-free, they can then move on to the next.

Bill Masterton and the Helmet Debate

On January 13, 1968, after a series of on-ice maneuvers gone wrong, Bill Masterton of the Minnesota North Stars was knocked backward and slammed his head against the ice. This incident would be the first and only fatal accident to occur in the NHL. Anyone who watched the accident live describes it similarly: the sound of his head impacting the ice was distressing and his head almost appeared to bounce. To onlookers, it was clear something was very wrong.

At the hospital, surgery was not an option due to the severity and speed of the brain swelling. He was taken off life support not long after. However, despite much of the outward evidence seeming to point to a lack of helmet and a failed play, the issues were much deeper.

Bill Masterton being taken off the ice on a stretcher. Source Link.

It goes without saying that concussions did not follow a proper protocol at the time—in fact, there was little to no protocol or check at all. Before the game, Masterton had been complaining about headaches, and although there was some concern about whether he should get checked or not, none of that happened. And even if it had, he likely would have still been in the lineup. Masterton’s autopsy revealed that his skull didn’t fracture; however, the speed at which his brain swelled coupled with his other symptoms right after the accident led doctors to believe that another head injury—most likely a concussion—was involved. Further evidence indicated that the brain’s rotation before impact with the ice may have worsened the injury.

The accident brought back the topic of helmets in the league, with the 1979-80 season making helmets mandatory for new players (although players who had signed contracts before June 1, 1979 were exempt from this rule). It took 18 years for all NHL players to comply with the rule fully.

Post-Concussion Syndrome

When symptoms of a concussion linger for longer than three months, then it has developed into a more serious issue: post-concussion syndrome (PCS) . Individuals with PCS may experience these lingering effects for months or even years, which may significantly impact their quality of life. The symptoms can vary widely, similar to normal concussions, often manifesting as physical (headaches, dizziness, fatigue, sensitivity to light and sound), cognitive (poor concentration, memory, and decision-making), behavioural, or emotional (anxiety, depression, irritability).

The exact causes for why a concussion or head injury may develop further into PCS are unknown. It should be noted that although some people may have symptoms that persist beyond three months, that percentage of people is small, with about 90% being able to start concussion protocol within a few weeks.

Infographic on post-concussion syndrome symptoms; Medical News Today. Source Link.

Chronic Traumatic Encephalopathy (CTE)

One of the arguably worst outcomes of head impacts and injuries is the development of chronic traumatic encephalopathy. CTE is a degenerative brain condition related to and similar to Alzheimer’s disease, which also involves the build-up of an abnormal protein known as tau. It develops as a result of repeated head trauma and can cause symptoms such as memory loss, shifts in behaviour, and struggles with decision-making. This disease is most common among athletes who take part in contact sports, although anyone who experiences repeated contact to the head may develop CTE.

Current Research - What We Know and Theories

Unfortunately, CTE is not only difficult to diagnose, but it is also just as difficult to research. It can only be diagnosed—and thus, researched—postmortem. Much of what we know about the disease is very recent, especially in relation to hockey. For years, research focused primarily on football until 2011, when the sudden and tragic losses of several hockey enforcers brought the issue up in the NHL. Additionally, while the disease is linked to repeated head trauma, there is no scientific evidence so far that has linked concussions to CTE directly; the lack of evidence has led some, like NHL commissioner Gary Bettman to raise some skepticism around the subject. Nevertheless, the link between CTE and repeated hits to the head is still a significant link.

Comparison between a normal brain and one with advanced CTE. By Boston University Center for the Study of Traumatic Encephalopathy - http://www-tc.pbs.org/wgbh/pages/frontline/art/progs/concussions-cte/h.png, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=37222621

Boston University is currently widely known as the leading researcher behind CTE research, and one of the studies presented by them in 2022 involved analyses of 74 donated brains of hockey players ranging from youth level up to professional. Of those studied, 40 (54%) were diagnosed with CTE with varying degrees of severity, with some dependence on the number of years played. It is important to note that this was a singular study, and not all 74 donors can be generalized to represent all players; more research would be needed to make these findings more than just theory. We can still acknowledge that this is still a good start, especially for a condition that is so difficult to study.

CTE in Women?

Heather Anderson, a professional Australian rules football player and Australian Army soldier, tragically took her own life in 2022 at the age of 28. After an autopsy and analysis done on her brain, which was donated by her family to the Australian Sports Brain Bank, she was diagnosed with having had CTE. She was the first woman with the diagnosis.

Up to this point, nearly all CTE research has been conducted using male groups. Boston University began a study in 2019 that focuses exclusively on CTE and women, called the Soccer, Head Impacts and Neurological Effects Study (SHINE). The hope is that researchers can learn about and document the differences between the disease in men and women. This longitudinal study will take time, but the hope is that we can learn more about the disease and its effects on women as well.

Heather Anderson playing Australian rules football in 2017. By Flickerd - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=57109766

A Call to Action

CTE is an ongoing concern in various contact sports; in the 1920s, it was referred to as “punch-drunk syndrome” when studied in boxers. In 2005, former NFL football player, Mike Webster, was the first officially diagnosed person with CTE after an autopsy performed by Dr. Bennet Omalu; this event was just one catalyst for further research into the disease and its link to football, and subsequently other contact sports.

In the hockey world, the issue was not subtle. Over the course of just a few months in 2011, multiple NHL hockey players were lost to similar circumstances—victims of substance abuse or other similar situations. What was most alarming was that they were all enforcers, showed symptoms similar to what football players with CTE had, and all died before they turned 50. Among them were Bob Probert, Derek Boogaard, Rick Rypien, Wade Belak, and some others.

Mike Webster with Jay Hilgenburg in1986 at the NFL Pro Bowl Game. NFL official photography, Source Link.

In simple terms, enforcers in hockey were players whose primary job was to intimidate the opposing team and protect their teammates. If a particularly violent play occurs on the ice, or one of their teammates is being harassed, it was their job to respond to it. Depending on the era of hockey, some players may have been “assigned” to protect a certain player; one notable example was Dave Semenko, colloquially known as Wayne Gretzky’s “on-ice bodyguard.”

The occurance of these tragedies being around the same time brought about a call to action for hockey and its relation to CTE.

Derek Boogaard

Derek Boogaard was regarded as one of the NHL’s most fearsome enforcers, earning him the nicknames “Boogeyman” and “the Mountie.” The fans loved him, but little did anyone know what was going on behind the scenes—behind the fan-favourite fighter, Boogaard was struggling with major substance abuse, would miss or sleep through team events, and, as some of his teammates described, he was like he was slowly losing his personality.

Derek Boogaard. USA Today, Matt Slocum photography. Source Link.

Boogaard passed away in May 2011 at the age of 28 from an accidental overdose of alcohol and painkillers, but his story didn’t end there. An autopsy revealed that Boogaard was suffering from advanced CTE—doctors would, in fact, say that they were shocked to see a brain so damaged at such a young age. Following the death of Boogaard, hockey also lost Wade Belak and Rick Rypien, both to suicide. Both also displayed many symptoms of depression and personality changes, similar to Boogaard. Though Belak was diagnosed with CTE, Rypien was not officially diagnosed.

With the loss of these players, further changes across multiple hockey leagues have been made to lessen the frequency of head contact incidents.

Prevention Measures

It’s important to keep in mind that any head injury can eventually lead to major damage to the brain; in particular, there has been little to no evidence that CTE is directly linked to concussions, but repeated head trauma—which includes concussions and other head impacts—is related to CTE.

Helmets/Head Gear

Although helmets cannot guarantee full protection from concussions and other potential serious injuries, they still lessen their impact and greatly increase protection against other forms of head and skull injury. Manufacturers are always working on redesigning their helmets and headgear to reduce the force from head contact. In football, for example, Guardian Caps have started to become more popular not just at the collegiate level, but in the professional scene as well. These caps have resulted in a lowered concussion rate among professional NFL players.

Hockey has taken up many initiatives to alleviate head injuries in the game. Manufacturers are constantly refining their helmet designs, working around balancing protection with the aerodynamic shape needed for speed and agility on the ice. Although designs across different manufacturers and price points change, one of the best ways to protect yourself and your head is still to use a helmet that fits your head shape best. A properly fitting helmet won’t move and cause extra impact, and it will also just be more comfortable. Some manufacturers have started offering custom-fit helmets that, although a bit more expensive, are designed to be the perfect shape for your head.

You can read more about head protection in our Injury Prevention article.

Rule Changes and Rule 48

The era of pure "enforcer" roles in hockey has passed. While fights and big hits may have added excitement to the game, the long-term harm they caused isn’t worth it. Across many sports, including hockey, organizations have been working on rewriting their rules and policies regarding head contact. Leagues like the NFL have been making rule changes over the years to help reduce head contact and the chances for concussions and development of CTE. Many youth-level soccer leagues are barring intentional headers for the same purpose.

Graphic depicting Hockey Canada's head contact rule; when the rule was first implemented, this and similar graphics appeared often in rule books and on signage. Source Link.

The 2011-12 season of hockey was defined with historical rule changes across the board, now including head contact penalties—in the NHL, formally known as Rule 48—that would vary based on the severity of the infraction. New rules addressing head injuries emerged in response to growing awareness and concern, triggered by high-profile incidents like Mike Richards' hit on David Booth in 2009 and Matt Cooke’s devastating hit on Marc Savard in 2010. At the time, since there were no rules surrounding head contact, players could commit to dangerous hits with few to no repercussions; Ray Shero, Pittsburgh Penguins GM at the time, described the circumstances as “like ‘The Untouchables’ and Al Capone. [...] There was nothing in the rulebook. There was nothing to have a hearing on.”

2011 marked the debut of the NHL’s first Department of Player Safety, whose purpose was to watch every game and review potentially dangerous hits and incidents, then respond accordingly. The rule changes coupled with greater reinforcement of the rule has helped pave the way to a safer era of hockey.