The dreaded re-injury: Why do they happen?

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With Mike McKenna

What does it mean to be “ready” to return from an injury? Sometimes, everything on paper suggests it’s time, but intuition does not.

A memory embedded in the brain of Matt Nichol, longtime pro athlete high-performance trainer and NHLPA player health and safety advisor, illustrates the point. Years ago, a client of his was nearing the end of a rehab period. They were meeting with the surgeon who had repaired the injury, reviewing all their information, which was splayed out on a medical table. The imaging showed significant improvement. The field testing was decent. So was the athlete ready to return?

“Just one more thing,” Nichol remembers the surgeron asking. “Do me a favor: can you hop up onto the medical table here? Great. Stand up. Now I want you to jump off and land on one leg.”

“Whoaaa,” the athlete said.

“You could see the look of fear in their eyes,” Nichol recalled. “And the doctor said, ‘OK, we don’t need any more diagnostics or tests.’ If you can’t make the two-foot jump as a professional athlete, that shouldn’t be a scary task.”

Sometimes, then, the right gut reaction at the right time can save an athlete from returning too early.

But it doesn’t always play out that way. Oftentimes, as far as anyone can tell, an athlete is ready and the return doesn’t go as planned. What a gut punch it was for Ottawa Senators fans Monday morning when center Josh Norris, just days after returning to the team’s lineup, was declared out for the season. He will require surgery on the same shoulder he injured earlier this season, the same shoulder that had cost him 38 games already. The news came just days after the Carolina Hurricanes’ Max Pacioretty suffered a season-ending Achilles tendon tear that was an aggravation of a previous injury from which he had just returned.

When Norris was first injured in October, his projected recovery timeline was the entire season. Yet he made it back by mid-January only to last three games. Pacioretty’s projected timeline in the summer was six months and he returned after five. Are these reinjuries a case of bad luck? Or is there concern that players are rushing or being rushed back from injuries too quickly in hopes of making an impact?

In Norris’ case, he had opted for 12 weeks of rehab rather than surgery before returning, having consulted with five doctors and two specialists, and had a clean bill of health when he rejoined the lineup Jan. 18. But it was telling that he wasn’t taking faceoffs. Despite what we assume were the best intentions between player and team, optics suggested he was hurrying back.

I’m no player. Nor am I a doctor. I’m not qualified to accurately speculate on why these things happen. Speaking to an NHL player representative, I was given the impression it isn’t a player’s decision to rush back.

“Players don’t have the ability to rush back too quickly,” the representative said. “All players want to play and return from injury and get back in the lineup. It’s not up to them. It’s 100 percent on the team surgeons and team doctors to clear the players for return to play. It’s the medical professionals and clubs’ responsibility to ensure the players have met all protocols from returning to action. A player can say, three months out from shoulder surgery, ‘I’m ready!’ No team should clear that guy and let him play.”

From Nichol’s perspective – not speaking to any specific injury cases but just to injuries in general – there often isn’t any blame to go around. There could be just as much internal pressure for a player to return or a sense of “the inmates running the asylum.” Sometimes, an injury slips past everyone, from team to player, because the imaging can be misleading.

“The problem is we’ve become sometimes a little bit too reliant on imaging,” Nichol said. “Things can look great on imaging and they can not be great in real life. And sometimes things can look bad on imaging and they can be great in real life.

“I use an analogy with my clients – phantom limb pain. You can have someone who has no leg, but they can have pain in their leg that no longer exists. That doesn’t mean the pain’s not real. They have very real pain in a leg that doesn’t exist. There are other people that have no pain and say they feel fine but they’re not fine. Like when you do diagnostics, whether that’s pictures and imaging and MRI or actual field testing, you can say it’s great that you feel fine, it’s great that you’re not in pain, but your right leg is 20 percent weaker than it was before the injury.”

What’s an actual player’s interpretation on returning from injuries? I can solicit that directly from my colleague, retired goaltender Mike McKenna, a 13-year pro between the NHL and AHL, who collaborated with me on this story.

Mike – you were an extremely durable player during your career. But how often did that require playing through injuries and/or rushing back from minor ones?

Well Matt, I was very lucky. I never missed a game in my career due to injury. But I played through some pretty serious ailments.

Not many people know this, but I pulled my groin during the 2017 AHL Calder Cup playoffs when I was a member of the Syracuse Crunch. And then again – really badly – the following year when I was a member of the Texas Stars and we were playing against the Toronto Marlies in the Calder Cup Final.

Every time I went down into the butterfly it felt like someone was stabbing my groin with a chef’s knife. Over-the-counter medicine could only do so much – the pain would only subside once my adrenaline kicked in during the first period. But those first few saves hurt like hell.

I fractured my index finger once and had a really deep cut on my knee cap another time. But I played through both of those. Neither injury could really get much worse, so I just gutted it out. My team needed me.

Almost every season I had some minor tweak or pull. But the training staff never shut me down, or even advised me to consider it. I’m grateful that I never had to make those choices.

If a player is ready to return but isn’t cleared, does he ever have the ability to overrule the team or doctor, or will he always have to adhere to what the team decides, as the player representative suggested?

The player representative is correct, Matt. Team medical staff does need to give a player clearance to return to the lineup. And that’s a good thing because players would absolutely force the issue if they could.

I saw it happen often during my career, especially with head injuries. Keep in mind that my pro career started in 2005, well in advance of concussion protocols that the NHL has adopted in recent years. But even now, I know there are players that want back in the lineup as soon as they feel alright. Not great. Not perfect. Just, in their eyes, good enough to play.

And that’s where medical staff is so important. Players simply cannot tell on their own if they are fit to resume activity involving physical contact after sustaining a head injury. I’ve seen players get shot down from rejoining the lineup because their head wasn’t back to 100 percent. And it was the right call.

Other injuries are tricky. Soft tissue damage is pretty easy. For the most part, it comes down to the player’s pain tolerance. But for structural issues – bones, joints, etc – doctors need to be involved.

But let’s not kid ourselves. If it’s the Stanley Cup playoffs, and the player wants to be in the lineup, it’s going to take something major to keep that person off the ice. Doctors know that. But doctors also will not put their credibility and professionalism on the line by allowing someone to play that shouldn’t. It’s a delicate balance that takes a lot of communication and honesty on both sides.

On the flip side, are there ever cases in which a player isn’t ready to return but, medically, he’s cleared to do so? Are the hurdles more mental in those cases? Does the player feel pressure to hurry back?

Oh absolutely, that happens as well. But it’s usually more about conditioning than it is the mental side. When players miss game action due to injury, it’s the lungs that really suffer. I heard it all the time from players when they were rehabbing. That the strength was there, but they didn’t feel like they were in game shape. And that’s not a good headspace for a player to be in, thinking that they can’t keep up with the pace of play.

I know of instances where players have been emphatically urged to draw back into the lineup. There is definitely pressure to rejoin the lineup once a player is cleared. And the stress level really depends on where a team sits in the standings.

If the club is in a heated battle to make the postseason, the player is going in the lineup whether he wants to or not. But if a team is comfortably in (or out) of the Stanley Cup playoff picture, things are different. The team has more latitude to give the player time to feel closer to 100 percent before suiting up for game action.

This is also where the term ‘day-to-day’ comes from. Players that are given the designation typically are capable of playing and cleared to do so. It just comes down to comfort level. Sometimes the pain is too much. Or the swelling won’t go down. There’s a lot of variables.

Is it sometimes a case of an injury showing up as healed in imaging, but you can’t truly know until it’s tested in a game situation?

I won’t pretend to be a doctor here, either. But I’m sure there’s been cases where everything looked fine on film, only to find out later that wasn’t the case.

But what you touched on about game situations is important. It’s really difficult to simulate that intensity in practice. And a player truly won’t know if their injury is rehabbed enough to handle the rigors of game action without actually taking part in it.

That’s why you’ll see players return for a few games, then end up in the stands just days later. Maybe the comeback was rushed a little. It happens. Pulls, tears, and tweaks – they can be aggravated quite easily. And that’s a really tough spot to be in for a player: the endless cycle of rehabbing just long enough to join the lineup, only to have the injury reappear. Or get worse.

Those are the ones you worry about. And eventually, team medical staff might have to step in and make a judgment call on if the player should be shut down the remainder of the season.

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When a player returns from an injury, it’s generally assumed they, their team, their doctors and trainers are rowing in the same direction. No one wants an athlete rushing back too soon and aggravating an injury. But sometimes, whether it’s caused by bad luck or the inability to truly test in a game situation, it just happens. It’s an unfortunate reality of sports.