In an ice rink measuring 200 feet by 85, 10 of the 12 players on a professional hockey team skate at speeds of up to 20 miles per hour, vying for a frozen, vulcanized rubber puck that, when forcefully shot, can reach 100 miles per hour. Players collide with each other, get rammed into the rink’s wood or fiberglass walls and steel goal posts, skate on razor-sharp blades and swiftly maneuver hockey sticks measuring up to 63 inches in length. What could possibly go wrong?

That was the question posed to the Washington University sports medicine orthopedic surgeons at Barnes-Jewish Hospital who manage the care of St. Louis Blues hockey players during home and playoff games. The orthopedic department’s affiliation with the Blues began when the hockey team was founded in 1967 and has continued for all but two of the ensuing 54 years. At each home game, two sports medicine orthopedic surgeons, a general surgeon, an internal medicine physician, a dentist, an oral surgeon, a chiropractor and an emergency medicine physician are present to evaluate and treat players’ injuries.

Washington University sports medicine orthopedic surgeon Matthew Matava, MD, the current medical director for the Blues, joined its medical team in 1996. Washington University sports medicine orthopedic surgeon Matthew Smith, MD, joined in 2009; and Washington University sports medicine orthopedic surgeon Robert Brophy, MD, became a permanent member of the medical team in 2019, after several years rotating in when needed. Each of these specialists knows exactly what can go wrong for a Blues player during the high-speed, high-risk game of professional hockey.

Before talking about your work with the Blues, could you first define sports medicine orthopedics and how it differs from other orthopedic subspecialties?

Matava: Our primary focus is on musculoskeletal injuries and conditions specific to athletes or those who are athletically active. We treat people who may not consider themselves athletes per se but develop problems that affect their ability to function.

Smith: In sports medicine, our primary goal is to return patients to the active lifestyles they enjoy. We generally treat ligament and cartilage injuries to preserve or restore function. We also treat certain fractures associated with sports activities. Whether function is compromised by athletic endeavors or by activities of daily living or work, our goal is to get people back to those activities as effectively and safely as possible.

Matava: Not all sports medicine physicians are surgeons. Those in primary care with training in specialties like internal medicine, pediatrics, family practice and emergency medicine also may choose to complete the one-year fellowship needed to be certified in sports medicine. The difference is that we can perform surgery and they cannot. The good news for our patients is that only 10% of injuries treated in sports medicine need surgery. The other 90% may be successfully treated without.

What was the appeal of sports medicine for you?

Smith: I grew up in the D.C. area, which supportedfive major professional sports teams: basketball,baseball, football, soccer and hockey. I’ve alwaysplayed sports, and I find it rewarding to help peoplemaintain an active lifestyle.

Matava: I’ve participated in and enjoyed sports allmy life. I played basketball while enrolled in medicalschool at the University of Missouri - Kansas City,with the ultimate goal of becoming a surgeon.When I tore my ACL while playing ball, I realized thatwhile some surgeons save lives, I couldspecialize insaving lifestyles.

Brophy: I played soccer in college and continued participating in sports after graduation. I’ve had my share of injuries over the years. Before I entered medical school, I completed an engineering degree. Given my interest in how structures are designed and function, I felt orthopedic surgery was a natural fit for me.

Even the most avid Blues fan probably doesn’t know what the medical team’s role is during games. What are the basics?

Matava: We take care of players at home games only; in most cases, that means taking care of the opposing team’s players as well. Just a few NHL teams have a physician who travels to away games during the regular season. The only time members of the medical team travel is when the Blues are in the playoffs. In those instances, the team most often consists of an orthopedic surgeon, internal medicine physician and chiropractor.

Brophy: League rules require that during a game, team physicians are within 50 feet of the ice at all times. But we aren’t on the bench with the players; we sit in designated seats behind the bench or watch the game from the locker room.

Matava: At most games, more than one orthopedic surgeon is on the medical team, which means we can discuss treatment options together. For the same reason, we have two orthopedic surgeons on hand in case surgery is required.

Smith: Other specialists on the team include a general surgeon, who can assess players for conditions like abdominal traumas and sports hernias; a dentist and oral surgeon to evaluate facial trauma, especially when a compromised airway is a concern; an internal medicine physician to treat and advise players who experience common illness, such as a cold, or who might have trouble sleeping. It’s a convenience to the players to have that kind of care available.

What happens when a player is injured?

Smith: When a player needs to come off the ice, the Blues’ athletic trainer, Ray Barile, usually is the first person to triage the injury. He notifies us when a full evaluation or treatment is needed, including suturing a laceration, taking an X-ray of an extremity or evaluating injury to the mouth and jaw. On occasion, a player will be transported to the hospital for a more significant work-up.

Matava: At every game, there’s a monitor in the arena who watches for players who receive blows

to the head or exhibit behaviors suggestive of a concussion or other head injury. In addition, the NHL and the NHL Players Association have a staff of spotters located in New York that watches all

the games. They have the authority to require a player be removed from the game if he exhibits

specific symptoms following a direct or indirect blow to the head. Additionally, each player takes a cognitive test at the beginning of the season, so we have a baseline to compare to an assessment we conduct during a game. A benefit of having cared for these players for many years is that it allows us to know their personalities. Occasionally, a change in demeanor may be the only sign the player has sustained a concussion.

What are the most common injuries you see?

Smith: Lacerations caused by a hockey puck or stick are common, as are contusions on lower extremities, particularly on the foot and ankle. Common orthopedic injuries are acromioclavicular joint injuries to the shoulder and medial collateral ligament sprains in the knee.

Matava: We also see fractures around the foot and ankle from the puck striking bone, as well as shoulder instability or shoulder separation, sprains of the MCL—medial collateral ligament—when a player is hit on the outside or lateral part of the knee, groin strains and “sports hernias” resulting from repetitive rotational forces to the pelvis encountered during skating, and tendonitis in the hands and forearms because of the force required to shoot the puck and pass it. Less common injuries are lumbar or lower-back disc herniations caused by the powerful torque needed to shoot a puck or by being checked while skating, and rib fractures that occur from being hit by an opposing player or checked into the glass.

Who decides whether an injured player can return to the ice?

Matava: As the team’s medical director, I have the final say. However, this decision is made in conjunction with input from my orthopedic partners and the other team physicians, depending on the injury or condition. We also are in constant communication with the Blues’ athletic training staff as to each injured player’s condition, response to treatment and ability to perform various hockey-specific activities.

Smith: When a player is hurt, our No. 1 priority is to protect his injury to ensure whatever part of the body is involved—shoulder, knee, hand, spine— will continue to work for the rest of the player’s life, well beyond his career as a professional athlete. Most hockey players retire in their late 20s to early 30s, which leaves a lot of life left to live. Our second priority is to give a player as long a sports career as he wants. Our third priority is to get a player back on the ice as quickly as possible. But we don’t compromise the first two for the third.

Brophy: Hockey players are savvy about and attuned to their bodies. They want to compete as effectively and safely as they can.

How do you watch a hockey game differently than an average fan would?

Brophy: We know when a player has an ongoing issue, so we watch him carefully to see how he is doing from a performance standpoint. We also watch players closely when there is a hard collision or fall—or when a fight breaks out—to assess how they recover. When incidents happen quickly, we rely on replays and different camera angles to understand exactly what occurred.

Smith: Sometimes we can tell in advance that something serious is about to happen. After a significant collision on the ice, a fan may watch the puck as play continues; we watch the person involved in the hit. We look for certain behaviors: a slow recovery if the player fell or unusual movements of a hand or leg that suggest an injury. We’re all fans and want the team to do well, but it’s our job to watch for players’ behaviors and abilities that others might not notice.

Dr. Matava, you have been involved with the Blues’ medical team the longest. Is there an incident that has left a lasting impression?

Matava: In 1998 during the playoffs against the Detroit Red Wings, Chris Pronger, a Hall of Fame player who was the Blues captain and stalwart defenseman, was hit in the chest with the puck during a Detroit power play. After the hit, he stood on the ice while the game continued, then took a few steps and fell flat on his face. When Ray Barile and I got out to him on the ice, he was blue, not breathing. He had sustained a condition called commotio cordis: The puck had struck his chest at the exact time in his heart’s electrical conduction sequence to cause it to stop pumping and just flutter. It’s a life-threatening condition. Fortunately, he lived—and to my knowledge is the first professional athlete to survive the condition.