So let's let's stay on time because it's one o'clock on a beautiful Saturday afternoon and I love how everyone just cares about hockey especially about women's hockey. My biggest disclosure is not that I am a I have a lot of conflicts of interest or I'm a Ranger fan is I am a hockey fan of women's hockey because I have two daughters that play hockey so and because of that I really wanted to have this session here and I don't know Ali are you on can you hear me yes I can hear you yes so so as I don't know if he heard so you know this is the first time this meeting which has always been NHL very heavy you know a lot of things have changed over the last you know 10 years and in the development of women's hockey and obviously Allison talk a lot about dr. how is the head team physician of the USA women's hockey program she's from Portland Maine works at intermed and she shows you the commitment to women's hockey is that they're in their training camp and that she's you know probably in between you know take care of players to do this so I really want to thank her and we've really a commitment to this and during the last six months it was really last minute I call her and she's like sure it's the middle of our training camp but I'll figure it out so that's the kind of desire and I think it's a great session so Ali is going to moderate this and also be one of our speakers from afar and I gave it up to dr. how thank you Ali very much okay thanks any I appreciate you it's nice to finally see your face I've never met we've talked on the phone answered lots of texts and emails over the last few months and also want to give a shout out to Holly Johnson who was a team physician with USA hockey went to the 2014 Sochi games and that's where Holly and I met each other but she gave my name to a Neal we're gonna talk today as he mentioned about some current topics in women's hockey and as he mentioned I am I work with our women's national team this week has been very fun we're in Lake Placid it's amazing to be in Lake Placid at the Olympic Training Center while the Olympics are going on watching Olympics Summer Olympics with winter Olympians it's I feel really lucky to be me to be honest I'm sorry I can't be there in Chicago but obviously this is something that was is also important in what in my schedule and what we do I'm gonna share my screen and and also sorry I'm sure probably everybody says it but I'm not a perfect zoomer so if somebody could tell me if I'm not doing it right that'd be awesome I won't take it personally we're gonna talk about the growth in women's hockey in particular women's sports have classically been sorry I should tell you I have no financial financial disclosures or conflict of interest women's sports as I mentioned have been classically marginalized by broadcast partners and the general public in sort of the court of public opinion as we say in women specifically about women's athletics we've come a long way this is a quote from 1936 it's a lady's business to look beautiful and there are hardly any sports in which she seemed to be able to do it just in 2006 well the vast majority of WMB players lack crossover sex appeal the baggy uniforms don't help by an HBO sports personality and then with a Sports Illustrated contributor just as recent as 2015 women's sports in general just not worth watching but when girls and women including O'Neill's daughters and my daughter and you know women in the in the audience when we don't see our athletic role models on television or in the newspaper and our families don't either it's kind of no wonder that everyone doesn't dream or hadn't dreamed of a way to make a professional career possible even obviously most people don't go to professional careers but even just deciding that you want to play in a women's league or deciding that you want to play in high school it's hard when you don't see people who look like you or are of your same gender playing luckily in 2024 things are really changing the face of women's sports is very different compared to all of the years I played sports in college in the 90s I feel like that was probably a hundred years ago approximately if you look at the growth that's happened since that time this year NCAA women's basketball dominated the TV ratings thanks to the talents of people like Kaitlyn Clark and Angel Reese Cameron Brink Camila Cardoso Paige Bucher's it's so hard to not mention so many of them the WNBA is receiving some unprecedented increase in attention the NWSL National Women's Soccer League has broken attendance records this year and the PWHL which we'll talk about a bit about had its inaugural season where ticket sales and attendance records exceeded all expectations the Kaitlyn Clark effect specifically her if you you know she was playing people were watching it just interested even Ted Lasso Jason Sudeikis got involved as you can see here his becoming more ubiquitous shirt everyone watches women's sports has been seen in all the stands the Iowa versus South Carolina NCAA championship game was the most watched basketball game at any level since 2019 and it had almost 19 million viewers if the video people can queue up the first video I'd appreciate it it's not all you know little girls and their moms at the games this is this is everybody loving this game thank you there we go so viewership is has been increasing in the WNBA and I thought this slide was a good representation that even the draft increased five times it's kind of an incredible graph to show how much more interest there is this year the games are averaging like across all the networks the WNBA games are averaging 1.32 million viewers which is a huge increase compared to just last year which was 460,000 the National Women's Soccer League in Chicago where you are boasted a huge fan attendance of 35,000 which was a record played at Wrigley Field and you'll see the numbers in 2021 592,000 fans attended games and that was more than doubled by 2023 so things are on the rise in reading about it remember this league goes from March to November and they have nearly surpassed that number already this year and the league obviously the the season continues on so this is a hockey summit let's talk about hockey the Professional Women's Hockey League this is the first season there were six teams the quote original six three in Canada three in the US each team played 24 regular season games and if you look at total ticket sales for the season there were about 400,000 tickets sold that averaged per game to about almost 5,500 fans which doesn't sound incredibly high I understand unless you look at the seating capacity for the arenas so other than Minnesota which had a seating capacity at the Excel Center where the wild play of 18,000 fans the other arenas were all under 10,000 fans and specifically in Toronto they had a arena of 3,800 and Montreal of 4,000 Boston was the next closest was 6,500 and so each season or each team had to change venue just to try to accommodate the fans the fans paid attention they were there there were young girls and boys there were hockey teams parents passionate super fans I went to three games myself I live in Maine so I was able to make it to the Boston games and signs were everywhere the kids were really jazzed so excited that there were finally women's hockey in their area people they could look up to the jerseys sold quickly the gear the merchandise sold quickly everybody wanted a piece of it this guy give a special shout out to creatively supported his is Boston goalie Aaron Frankel by using his retro ruins jersey and you end up bit of duct tape as I mentioned the the ticket sales went quick kind of fast and furious is how I would describe it the Toronto sales they only had 3,800 seats as we said in the arena they realized quickly that's probably not going to be enough they sold out in just days all the games they didn't have to move to some larger venues ultimately they broke multiple attendance records and the merchandise sold out within a few days or a week at most of opening and that was exceeded the expectations it was more than expected for the league though they did expect that there would be a lot of interest just what they weren't able to characterize exactly just as a reminder this is not the first women's professional hockey league that's occurred in a subsequent lecture I'll give in a few minutes I'll tell you about some how this kind of came about but there have been other leagues that have been trying to accommodate or should say to create this environment that the PWHL has been able to create the previous record for games for the attendance record was held by a game in 2017 which was this the Canadian Women's Hockey League all-star game which had 8,000 fans the this league started in January of 2024 and Minnesota had their first home game against Montreal and they broke that record at the XL Center with 13,000 plus fans only a month later in Toronto they had to move the game from the original Toronto site through the Scotiabank Center and sold 19,000 plus tickets and not to be outdone at the Montreal Bell Center this game which was between Montreal and Toronto sold out in only 20 minutes and they had a full capacity 21,105 fans so hockey participation numbers are increasing in the US registration has nearly doubled in the last 20 years we look back to the 2003-2004 season there were 49,000 women playing excuse me females playing in the 2013 to 14 season 67,000 and then this last season on record 94,000 which was a 48% increase and you'll see the men's rise or male rise over the same time as a 15% increase looking at that comparing to Canada specifically women across the board Canada has more women that participate each year I couldn't find 2003 that sort of membership numbers but 2004 seemed you know similar close enough but they they always had a little bit more and they have afforded or appreciated a 37% increase over the last 20 years very interesting looking this worth mentioning at least as I mentioned the US men have increased their participation numbers by 15% whereas in Canada there's actually been a more recent decline 5% decline and it's not really clear why though they've had other thought to be pandemic related and economy related decline in sport and hockey still being an expensive sport that may be part of it but there are people looking into this to try to change the game the reality is that women's hockey is growing and that's what we've been hoping to talk about now in general sports participation for females across the board there it occurs at a lower rate than boys at all ages all backgrounds and all levels there are 1.3 million fewer spots on teams than there are for boys girls just one anecdote from my own growing up period when I was a kid I remember I only played on boys teams really until I got to high school and I remember in high school trying to convince some of my friends to keep playing and they just didn't have the desire of family support or sort of didn't see the future for what was going to be possible and I played in college and it stayed in my life for a while but when my daughter was born I thought she would play for a while too and I noted when she was at a U14 level she loved hockey she wasn't the best player on the team that's for sure but she got a lot of benefit from being on a team and she went to a hockey tryout where previous years they've had an A and B team was a U14 level 14 under level and they decided that year to not have a B team to just cut the 16 kids who tried out for a team and there were coaches that were willing but the league itself just wasn't willing to put teams together and that was so sad to me because that luckily Lucy did have some hockey time but there were multiple kids on that team who did not play hockey again just talking about you know that the rates the Women's Sports Foundation founded in 1974 Billie Jean by Billie Jean King has tried to address some of this need for women to be in sports and be involved and have that benefit in their lives by age 14 they have looked through their research and noted that girls drop out of sports at twice the rate of boys and some of the reasons they may drop out include lack of physical education classes in school so they get decreased exposure to athletes athletics and movement lack of safe and close sport venues there's still a stigma that if you are playing sports you're a tomboy or could be gay good coaches can be difficult to find and those available seem at times more focused on boys teams girls have a higher rate of being affected by barriers of having insufficient uniforms difficult practice times and difficult ways to find quality competition the advantages of sport pretty clear girls I think we all would likely say we would expect the girls should be afforded the same opportunity to thrive as boys are with athletics academic benefits for girls across the board girls tend to get better grades when they're involved in sports and that's not actually always the case in boys that's that's sometimes the athletics don't come along with with higher academic achievement but in girls it channels pretty closely and that there's a much higher graduation rate in high school for girls who are playing sport their medical benefits the decreased risk of breast cancer is huge even four hours of sports a week can reduce your breast cancer risk by 60 percent then recall that this is a disease that occurs in one in eight to one in nine women so this is not a small thing and if you play a sport in high school you're more likely to have an active adult life as far as osteoporosis 40% of women over 50 develop osteoporosis and you know we compare women with their osteoporotic scores on bone densities to their to be the bone peak bone mass at 30 years old so if we can get kids exercising before they turn you know into high school level or into their adult life we're gonna impact and give them a chance to to do some of that weight-bearing type exercise it will help their bones there's been less risk of unintended pregnancies less risk of drug use things like that for for girls playing sports clear mental health benefits girls who are on teams have far less incidents of depression and they have higher self-esteem and confidence overall there is a much better body image as well and then social benefits there's a higher achievement level in the workplace I mentioned a second ago the word Women's Sports Foundation which was founded more than about 50 years ago excuse me just now and it's one of the first organizations to acknowledge and recognize the role that sports play in helping girls and women achieve their full potential it was started in 1974 by Billie Jean King with the mantra equality in sports leads to equality in life they have at this point donated more than a hundred million dollars towards programs to grow the number of girls and women who are exposed to sports they came up with some rules of athletics that seem to correlate to this why there may be a disadvantage in the work setting for women who don't play sports recall that in well we all I guess we're living this we can see it regularly in that there are increasing number of families where both parents need to work and where the quality of our children's lives is really dependent on income here's some research the Women's Sports Foundation reports that 94% of c-suite leaders so CMOs CFOs and the like played sports let me go back one side sorry we're gonna talk a little bit about the rule so there are rules of sports written rules and unwritten rules and some of my favorite ones that the Women's Sports Foundation reports on teams tend to be chosen based on strengths and competencies not based on who is liked or disliked that is a great lesson to learn in athletics where girls are socially more likely to feel that they should find their friendships based on who they like or dislike but that shouldn't be translated into the workforce errors are expected when you're doing new things so athletes are used to making mistakes and then correcting those mistakes in the game and that is to not panic when that happens to expect that as a normal part of business and to expect that in your co-workers is a huge advantage successful athletes are skilled in practicing the illusion of confidence I'll call this the fake it till you make it I think in medicine we all come across this as well we call it imposter syndrome where they maybe don't feel quite as good at our job first at some parts of our life or quite as ready but that that faking if you will or practicing that illusion of confidence is super important and happens in sports all the time think about a penalty shot think about a free throw think about when you're up at bat and the and the bases are loaded you know these are times where if you show a lack of confidence it will really affect your team and so that perfection is really important another is perfection is sequential attention to detail so our work ethic is often built through our athletics and the repetitive belief that we need to do something over and over and over again to try to make it a more perfect thing and something that has definitely gone on in my life and I know those of you medical providers which I think is a majority of you in the room can say that in sports you learn that when you think you can't go another step you sure can and you sure better in your job and if you have that talent and develop that habit in your athleticism you'll develop it career as well so what will the impact be from the PWHL super difficult to tell at this point but certainly seeing role models on TV and in newspaper is going to be powerful really interesting the rates of participation in girls sports, female participation following Olympic games always goes up. And if you think about it, it's really the only time when coverage of males and females of sport is equal. You see male swimmers, you'll see female swimmers. You see male volleyball players, you'll see female volleyball players. If you see a male soccer game, you'll see a female soccer game. And shout out to the women of our national team who won against Brazil today. That was an exciting game we fought just at the end. So what can we do? Simple things. We're busy people. Let's keep it simple. Watch a game. Watch a PWHL, WNBA, and MWSL game and see what all the buzz is about. Ask your patients and encourage sports participation in girls and boys because we know that this is good for all humans and for our society in general. Encourage your local organizations to provide opportunities for boys and girls. If you have the talent, coach. If you have the money, donate. Offer medical coverage. Adults, be accepting of co-ed opportunities if you're playing a sport. Be aware of your words. When we see someone who has an injury who is a teenage girl, for example, it could be career-ending if we don't present it in the right way. It's often riskier to her and to her overall health to have that athlete retire early than to change her sport or have her continue to compete in some way. And then my favorite overall, just Women's Sports Foundation commented on this, but by presence, you know, young boys by the age they're two have already received multiple bats and balls and sticks and nets and their bedroom may have been decked out in sporting sort of motif. And so give young girls sports toys. Give tickets to a game. Bring boys and girls to see women's events so that they can understand the value of having women participating as well. Buy a jersey that person's favorite team. This is a picture Kendall. We'll see her in a little bit. She and her team were actually off watching the women's gold medal game today, the US Women's Soccer game today, and she'll be by in a little bit. This is her winning the Walter Cup, which is the analogous Stanley Cup or the PWHL. Thank you. So I'm going to stop sharing my screen for a second. And next up we're going to have Mark Aubrey who's going to talk about injury patterns in international competition. Mark is the current chief medical officer for the International Ice Hockey Federation and for Hockey Canada. He's a team physician with the Ottawa Senators and he's the past president of the NHL Team Physician Society. Mark, are you on and ready to go? Thank you. Thank you, Ali. I'd like to thank the American Orthopedic Society of Sports Medicine, Brad Duran, for putting together a great program and for the invitation. I think that this is a very historic day in terms of putting a women's ice hockey program on the agenda. And I would encourage and hope that in the future, when we do this again in three years, that we'll have it not only in NHL, but also a professional women's hockey league agenda during the conference. As you can see, I have no disclosures or no conflicts of interest. I just want to talk to you a little bit about Hockey Canada. Well, first of all, the presentation. We're going to look at the injury reporting system that we have in place, review of injury in the Women's World Championships, review of the Swedish body checking project, and challenges for the future. First of all, the International Ice Hockey Federation. It is amazing to think that 36 years ago, women participated in the Olympic Games for the first time in ice hockey. And I go back to 1992, when the IHF hosted the first Women's World Championship in ice hockey. And it actually took place in my city, in Ottawa, and I was involved with Hockey Canada. And they were trying to figure out how to market, how to do things, and they had already ordered the sweaters. And, of course, the standards Canada sweater was a red sweater with a maple leaf, but our vice president, Pat Reid, who was a little bit, with some sort of marketing ideas, had actually ordered a set of jerseys about a month before that, that were pink. And he had gone to our president, Murray Costello, at the time and said to him, those sweaters that came in yesterday, those aren't the ones we're using. And Murray said, well, what do you mean? Well, I've ordered the pink sweaters and they're already in. And, of course, Murray, like the rest of us, being a traditional hockey guy, played in the NHL, Hall of Fame, and thought, what are we, what are we trying to do here? But Pat managed to actually talk him into it. And sure enough, when those pink sweaters turned up on the ice, it made headlines all across Canada, and certainly in different parts of the States. And I think what it did highlight the fact that we always had this idea that women's hockey had to be like men's hockey, but I think from that point onwards, I think the women really wanted a place of their own, and they wanted their own rules, and their own way of doing things. And I think that this is what we're now seeing, and I think we're seeing the explosion, as Allie pointed out, of ice hockey. The International Federation is fully behind its development, and as you can see, they govern all these championships that take place, including the Olympics. We do have a medical committee that oversees medical care, doping control, and this injury reporting system. And to that end, we appoint medical supervisors, who are usually team physicians from the different teams, at some point in time to become a medical supervisor. And their role at these championships is to really, basically, oversee the medical care that goes on at all across the world, and at the same time, collect and review the injury reports that they get from the team physicians. That injury reporting system has been in place since 1999, 25 years. It's a process by which we ask team physicians to fill out, and it's confidential information with no name or number. These injury report forms, and there's really two of them, and give it to the medical supervisor. So the injury report form that they give highlights the number of injuries that they have, and if they do have an injury, based on a definition, which I will talk to you about, they have to fill out this other form, which has all the details. Again, very confidential, and it's stored in a database that is also very confidential. The definition of injury is really very specific. It's really a time frame injury, missing a game or practice. We've added over the years concussion, lacerations, dental injuries, and fractures, and we've sort of respected the standard definition of injury in ice hockey, which was developed back in the 70s by Ronnie Lawrenson. So we're pretty happy with the injury reporting system. We think it has a lot of validity because of its features, but I think on its own, I think, I mean, data is data, but unless we do something with it, it really leads to nothing. So what the idea is, is to take that data, we give a report every year based on the injuries that occur, and we communicate that with our executive body and our president, and from that point recommend, perhaps, changes to the rules and regulations, whether it's medical care, whether it's concussion protocol, and of course the injuries and the rules that take place in the IIHF. The IHF has revised the rules based on recommendations. There's now no head checking allowed. Rule emphasis goes on every year based on injuries that we have, and of course the Women's Committee has been formed in order to really put an emphasis on development, and we will this year publish another report on the last 10 years of injuries that have occurred, and I can say that these injury reports have certainly influenced what has gone on with respect to safety and the rules of the game and the women's game. In the IHF, the rules are very specific. In other words, there's really no body checking. They sort of put it in a frame that you can body check or have body contact if you're trying to get the puck, but not if you're trying to remove a player from possessing that puck. There are also specific rules or equipment rules, and really the main one is really the fact that women have to wear the full face mask, and that has come under some question, and we can sort of talk about that a little bit later. Mouth guards are recommended but not mandated, and we will be mandating the neck laceration protector as a result of what happened this year in 24-25, but it will be for all the different groups that are playing hockey in the IHF. So, going on to what we have done in the last 10 years or reporting what we've done in the last 10 years, we have this injury rate which we have used consistently in order to compare championships in different age groups. We collect data on about 300 games per year, and again, as I said, we then write up a report that then goes to the the executive board. We have published, and through the work of Dr. Marcu Tuminen, a publication that appeared in 2016 on injuries in women championships, and what we found was there was a very low rate of injury, but in that low rate of injury, we had a fairly high rate of concussion, which was caused mostly by unintended body checking. So, we're not even talking about actual voluntary body checking. There was a higher rate of injury in the lower pools because of less skill probably, and what came to mind or what was documented was the fact that the lower body, which really was the knee in most cases, accounted for most of the lower body injuries and was the commonest injury that we saw in our championships, and again, because of it, we continued on with the full face mask and no body checking. So, here we are now, 10 years later, and we will be publishing another document relating to the last 10 years. To make it simple, as you can see on the left-hand side is a sort of bluish-green bar, and on the right side is the orange. The left one signifying 2006 to 2014, and the last one in the last 10 years, and as you can see, the injury rate has decreased in all our women championships by about 20 to 30 percent, but what's even more striking is if we look at the under 18, the injury rate has decreased almost 40 to 50 percent in the women's under 18. Looking at anatomy and the different areas of the body that are being injured, again, looking at the comparison between the first 8 years and then now the last 10 years, the head injury, which is mostly in majority 90 to 95 percent, has decreased about 30 percent, and again, when we look at the lower body injuries, we've almost cut lower body injuries in half, so I think that progress is being made in that, and as you can see, the shoulder injuries have increased a little bit over that time. Under 18, I think the biggest drop, again, in the two areas that concern us the most, head injuries and lower body injuries, which decreased from 3.1 to 1.2, and I think that's a really proud of that fact. When we looked at the lower body and then we broke it down to the different areas of the body, certainly the knee was by far the commonest area, and it was the area that was most affected over the last 10 years, because if you look at most publications in the literature, the knee is sort of the commonest area of injury in women, but to this effect now, as we're seeing in hockey, it's becoming less frequent than in actually the shoulder, so, and as you can see as well, ankle injuries have decreased over the last 10 years, and I think that's positive for our group and also for ice hockey. When we look at diagnosis, again, as in the men, contusion and sprains are the commonest ways that you do get injured. However, concussion is affected or is caused in, or is a cause in about 15% of cases, which I think is fairly high, so that if you get a small number of injuries in a world championship, chances are you will always have one to two concussions. And again, going down, going down from the different diagnosis and causes, as you can see for the fractures have increased over the last 10 years. When we, when we look at concussion injury rate, as I just talked, we've had a decrease in the women's substantially and in the under 18s, and I think when we look at reasons or causes of concussion, you can see on the left-hand side you have unintended checking or body contact, the orange one being body checking, and the the one on the right hand side being checking to the head, and so that, by and large, we still have this this sort of unintended checking that is the major cause. So, and I think with that in mind, a recommendation has been so far to keep no body checking rule in place at all IHF competitions. Summary-wise, injury rate has decreased substantially. Lower body injuries now similar to upper body with a decrease. Concussions have also decreased, and an unintended body checking is certainly the commonest cause of concussion. Well, in the interest of time, I had a whole bunch of published studies here that I was going to present, but I think, needless to say, there really aren't very many studies on women ice hockey injuries, and I think, I think it is our goal and our duty medically to catch up with some of these studies. The NCAA has produced most of the studies on women's ice hockey injuries, and really the last systematic review that appeared was in 2016, and compared women injuries to men's injuries, saying that they were very similar in nature. So, the same injuries that we're getting in men, we're getting in women, except that the ACL, it seems to be perhaps a little bit more common in our women ice hockey injuries. I think our goal is to encourage and also to do more research in the women's game. I'd like to now draw your attention to a project from the Swedish Ice Hockey Federation. You know, Sweden always does things a little bit differently, and of course, they did it during COVID, and so they came up with a project four years ago, and they wanted to try it out in the Swedish Women's Professional Hockey League that allowed a certain amount of body checking. Started in 2018 for three seasons and allowed more body checking along the boards, but not in open ice, and I think we could perhaps talk about it a little bit later during the panel, a little bit comparable to what the Professional Women's League is doing, and the way they did it is they hired a safety manager, project manager, worked with the referees, and interpreting the rules, the new rules, but making sure that they educated the players and the coaches on giving a hit only when they could, and especially increasing awareness for players receiving a check. As you well know, because there's no body checking, women have their head down, they don't have to worry about getting hit, and so in this case, they really paid special attention to the players getting the hit, and this is what they found. Prior to the project, they had 35, and then the three years following decreased the number of concussions by about 75%. Needless to say, the last two years were really what we consider COVID years, but had the same number of games, so we are told. So they evaluated three seasons, decreased the number of concussions, they've introduced body checking now in all the senior leagues, and they will be introducing body checking in minor hockey in the year 24-25. We are still waiting, and we've been in contact with them to get their data, and we've encouraged them to have a research PhD person, and we've actually encouraged them to to get that research peer-reviewed, because I think it interests the International Ice Hockey Federation, because all the federations except for Canada, and the US, and now Sweden, follow the rules that are in place by the IIHF. So I think that brings about one of the questions and challenges for the future. First of all, we should have a standard definition of injury if we're going to be together on this. What is the definition of body checking? How much body checking are we going to allow? Do we allow it for all leagues? Do we allow it for all ages? Obviously, we're gonna not go down all the way down to, you know, 9 and 10 year olds, or even 11 and 12 year olds, as we do in the boys. How about removing the face mask in women's senior hockey? We have had a group in the UK that is considering pushing us to remove the face mask, which all brings to mind, should the playing and the equipment rules be different or the same for women's hockey as it is in men's hockey? And I think what I think we're seeing now is we've come a long way with women's hockey. I think the future looks bright, not only for women's hockey, but for all sports. But I think we need to do it in a way that's safe, is fair, and shows respect for all those that play the game. Thank you. Thank you, Mark. That was excellent. I'm gonna try to take over here sharing my screen. And your timing is excellent, friend. I think going into this next lecture about the PWHL and how the new rules and injury patterns happen this year, it's kind of perfect timing. Just a note, I'm pinch-hitting. This talk was going to be given by Tina Atkinson, who's the chief medical officer of the PWHL. But Tina's time in Paris with the Canadian canoe and kayak team didn't line up right so that she could give the talk. So over the past few weeks, I've been talking with her and talking with some of the administrators in the league just to try to get some information so we could present this forward. I have no financial disclosure conflicts of interest. The PWHL is the first league of its time, of its kind, excuse me, but that is not to say it's the first women's professional league. It's the first professional league to allow players to play hockey as their primary job, all of the players. It's not the first time they've tried to put something together, though. This is a little bit of a history. In 1999, the National Women's Hockey League was started primarily in Quebec and Ontario. They did occasionally play in Western Canada as well. When that league folded, it became the Canadian Women's Hockey League or the CWHL. They competed for a Clarkson Cup. The league was a non-profit and there were no salaries for the players. There were occasional stipends and bonuses. The practice times were erratic and the games were reasonably well attended. What I recall from this time with some of my national team players is that they were having to sell tickets, for example. They had a requirement of how many tickets they had to sell. They were not getting paid in many situations to play, though they were thankful to have places to train. They had a lot of volunteer coaches and people involved to help them, but there was no sort of good, solid financial backing. In 2015, the Premier Hockey Federation was born in the U.S. and it expanded to Canada in 2020. It occurred concurrently with the CWHL, which made things a little confusing for a while. A majority of the highest of the level players or the national team players stayed with the CWHL at first, deciding essentially not to go over to the PHF because of dissatisfaction and how it was being operated. Essentially, it was being operated a little bit as a part-time job or an additional thing that you could do in addition to your regular job, but the players were in pursuit of a unified, financially stable league. So in 2019, a group of the most elite players created the Professional Women's Hockey Association, the Players Association, PWHPA, or the P-Dub, as it was called, and that was a risk to them, but they were following their hearts. They played exhibition games. They had some pressure from the PHF, which was occurring, of course, at the same time, but they really believed that they deserved a better place to play and believed that there was a fan base to support them. Again, their goal was to ultimately be able to do this as a full-time job or masses, so to speak. In 2022, the Mark Walter Group, which included Billie Jean King and her wife and some of the older groups from the Los Angeles Dodgers, they joined a venture to create this new women's league. They purchased the PHF and they formed the PWHL, and I know this all sounds like alphabet soup. Hopefully, someday it won't. Hopefully, someday this PWHL is the league that we all talk about. There was a collective bargaining agreement put in together with the PWHPA, and the new league was announced in 2023, and that's where I came into play a bit. I don't have, just my disclaimer, I don't have a position with this league currently, but I was asked to be a part of a team to put together the medical standards for the league. Credit to Jaina Hefford, who is the Senior Vice President of Hockey Operations. She asked for the gold standard, most evidence-based, most forward-thinking standards that we could provide, basically saying that, give us exactly what you think you need, and we're gonna try to get as close to that as we can. So that group that put that together, included myself and Tina, who were the USA Hockey and Hockey Canada team positions, as well as our head athletic therapist from Canada and head athletic trainer from USA Hockey. We used the best practices in our experience with our national team level and professional hockey that we had seen thus far. My personal experience with professional hockey was men to that point, so I used that line also as a bit of a gorilla gold standard. We followed carefully that collective bargaining agreement, making sure that we matched the goals of the players, as well as the league. We did parallel some other professional leagues, and the timing was great when the consensus conference for concussion from Amsterdam came out last June, and we were able to build that into our recommendations for screening and medical guidance. And our primary focus was really on player safety and optimizing their physical and mental health. It all came together really fast. That was August. Gina asked if we would do that. We got it to them by the end of September, which was a quick turnaround, given that everybody on that committee had a full-time job. The league was putting together an incredible amount of things. But in addition to that, there really was a focus on making this their own league, sort of forward thinking started, not just trying to create the NHL for women, but rather really create their own league. And as part of that, they looked into some changes to the rules. Compared to other women's professional and international competitions, the rules were changed to attempt to enhance the game. Players and fans alike were interested in the molar physical game. And the league understood that this was an entertainment product, that in order to have this be successful, that we were needing fans in the seats. And so if that was going to happen, we needed to try to meet people where they were. So the players were pushing for this as well. One of the first rule changes, and there are three big ones I'll talk about, was the jailbreak. This was arguably probably the most exciting and fun part and best well-received, if you will, part of the changes. This was where a shorthanded goal would end the penalty so that it freed your player from the penalty box. And these players from the Boston team, if you look on the right-hand side, were attempting to free their teammate from the penalty box. And I have a video if you could play it. It's the second video that I gave you. And this is of the goal that scored. So this is Amanda Pelkey. It scores two to one. She fires up the game. And the crowd goes wild in a short celebration. Just as evidence, this was new, but this was all ready for the playoffs in May when this happens. The players have to go to the penalty box and have to hang on the glass to try to get kids from their player out. They're trying to free their player out. And this was a trademark before that. This sort of demonstrated that to directly. Go back to my screen here. One moment, please. All right, another rule is body checking. So they did add contact. And the contact with the boards is allowed. No open ice hits were allowed, but this resulted in a much higher level of contact. And it really recently been seen in women's hockey before that. It was very enjoyed by fans. I spoke to a few of our players. And then after that, I spoke with Jaina. And there was a post-season player summary where 90%, excuse me, more than 90% of the players were satisfied and excited about the rule changes. We're gonna review in a moment the injury patterns. But as Jaina said to me, if my chief medical officer had any concern about injury, we would have made changes, but we really didn't see a concerning injury pattern come about despite the body checking. Much like Mark just described with the Swedish League, the injury patterns weren't dramatically different just because of the checking. The other exciting thing was 3-2-1 scoring. So you get three goals for a win, one for a tie. And if you win in overtime, you get two points. This gave sort of an increased intensity or intensity around the playoffs by allowing teams to close the gap. And in overtime, they didn't need to play it safe so they could put a push and be more offensive. And it, again, created an entertainment product that was well-received. Remember this year, there was a new electronic medical record. If you guys have ever gone through a new electronic medical record implementation in your office, you know that it's a challenge all around. There was a new medical staff at each of the six sites as well as new league management. Tina was sort of an N of one in her CMO job. There was not a team of people deciding on medical decisions. And so she used multiple people and had to use a lot of resources to ask around, if you will. She and I talked quite a few times this year. They were working to track injuries within the new EMR, though in tracking them, they were not looking at exposures necessarily, not total practice time or weight room time or even just games, but sort of injuries overall. As Mark alluded to as well, the data input has not been perfectly standardized yet as far as the characterization of injuries. And just to clarify for you, each team had a medical staff that included a team doctor or two. They usually had a primary care doctor and an orthopedic surgeon involved. Two team athletic therapists or trainers, massage therapy and strength and conditioning. This was the dashboard that was put together by the PWHL looking at the injuries. They had total number of players in this league was 157. The most common injury, as you can see on the left here, it was a contusion followed by sprain. And then one sort of, if you will, red flag in the league was the third most likely injury was other, not further characterized. In talking to Tina, these seemed mostly to be in the realms of dermatology, mental health and gynecologic troubles or problems. Recall please that this is a snapshot only. This is one year of data and it's really difficult to make any strong conclusions. However, you notice that our rate of concussion, and I'll remind you that this is the most physical women have played with the exception of the Swedish league. The number of concussions was extremely low for this year, only 10 overall for the entire league. If we break it down into teams, you can see that a couple of the teams had far fewer injuries recorded than other teams. And those being New York and Toronto. And I spoke with some players from the New York team just to gauge whether they felt like it was a good year or bad year from an injury standpoint. And they did feel like their team had a very healthy year. So it may just be by chance that this happened. Also could be the method of recording, but we won't know that until we look into this a bit further. Sprains are high on each of the lists, as you saw. And somewhat anecdotally, there were quite a few chromiopublicular AC joint sprains this year. And the suspected reason may be the increased contact and the contact with the board, so it's not clear. We're certainly hoping that the injury type and the incidents can sort of inform our needs for each team in the future. Along those lines, the definition of other needs to be established a little bit better so that again, maybe it's necessary for each team to have a team dermatologist or to have a team gynecologist. It's not clear yet whether that's important. We look at the injuries by body location. It fits also with what the IHF has seen that knee and shoulder tend to be the highest across the board for the most part. We do have one team, of course, that medical illness was listed. And if we looked at this during COVID, I hate to say what we would see, but I'm not sure exactly what that illness was. Right, if we thought about some other variables that happened in this league this year compared to other years, just trying to, again, make some assessments about this injury pattern. Travel was a lot different for many of the players. There were some long bus rides, some flights that were not necessarily charter, in most cases, not charter flights. Some, a flying day, a game day, and then a fly home the next day with late hours, long time. And that was different for a lot of the players. Many of the players compared to the last few years have played a lot more games than they'd been playing previously, maybe other than the rookies in college. More practices, more overall exposures. And while fitness probably made injury less likely because they probably were more fit than usual, if you think about the increased amount of load on the body, some of the injuries could have come within to overuse as well. So there was lots of work on adapting to this new schedule on the player side. And I also question whether they may have benefited from not having a second job that maybe that, this allowing them to have this be their job may have benefited as well. We talk about our injury conclusions. I put those completely in quotations because as I said, I'm not the one who has access to this data and I don't want to make any statements of fact here, but it seemed like it would help to have identification of what an injury is in order to make sure that we're capturing each of them. And classification to clarification of what the other category is would certainly be helpful. And then exposure data, it might be helpful as well, just understanding whether some teams have a higher exposure level, perhaps by having more practices or more weight room time, et cetera. Interesting with concussion, I would say overall fewer than we expected. We know that ice hockey is considered a high risk sport for concussion. In 2015, it was, according to the NCA injury surveillance, it was the highest concussion incident rate, though that has changed since that time. It's not at the top anymore, but it is still very commonly seen in hockey. And in the PWHL this year, I was asking Tina about the idea of a concussion spotter, and that will be for a future year, potentially this upcoming year, there'll be a spotter as an independent observer. But for this year, since things came together so quickly and that wasn't possible to put together, they made sure that everyone as affiliated with the league was trained in concussion recognition so that if they saw signs or symptoms, they would say something and the players and staff signed forms stating that they would disclose symptoms if they were a player or a concern, if it was a staff member, if they saw something that made them concerned about concussion. Looking ahead to the 2024 season, there's an expansion gonna happen for 30 games for each team, so a little bit longer season. Rule changes are not, the current ones that are in place seem to be well received by the players. As I mentioned, the survey seems to be about 90% acceptance rates. So it's not clear whether there'll be any additional rule changes, but the players I spoke with really enjoyed being asked their opinion with the changes and the league I think is very good at trying to engage the players in the process. There is a rules and competition committee that's been put together, trying to bring together multiple different parts of the team, the players, the coaches, medical league officials, trying to determine kind of what next steps might be and acknowledge that importance of player input on this entertainment product that they're trying to create. Every team enjoyed success this year in the PWHL, as you can see from these slides, and I hope you get a chance to take in the game. My next speaker, sorry, stop sharing this. My next speaker is Laura Benyon. Laura and I have come in contact with each other a lot over the years because of our interest in women's hockey. Laura is the current head team position for Hockey Canada. So we are at games concurrently or together. She's a family and sports medicine doctor from Vancouver originally, but lives in Calgary. I'll let you tell her a little bit about her practice and her interest in maternity care. Thanks, Laura. Hi, Ellie, thank you. Thank you very much for the opportunity to be involved. Just sharing my screen here with you. And starting my slideshow, hope that works well. Please let me know if you can't see that properly. So I'm gonna talk about postpartum return to play. So interesting topic, probably something that many of us haven't thought about all that much, but it's definitely an evolving landscape and we're gonna see more and more of our athletes coming back to play. I have no disclosures except for the fact that this is where I am right now at Whistler, and I'll be riding my mountain bike while I'm here. My affiliation, so I'm primarily a family doctor from Calgary. I've got 23 years experience in labor and delivery, delivered almost a thousand babies. And through all that time working in low-risk maternity, I also had a concomitant practice in sports medicine. Never thought the two would converge, but they are. And it's been a great journey for me. I also work with Hockey Canada and I'm affiliated with University of Calgary. So the objectives today, we'll just talk briefly about the history of exercise, advice and pregnancy. We'll talk about the return to play stages and postpartum phases, risks to the postpartum athlete, creating a plan for your athlete and then next steps in managing the postpartum athlete. So why is this topic important? Well, as we all know, the peak athletic performance potential usually coincides with the optimal window of fertility in female athletes. And in past decades, choices, difficult choices have had to be made about whether to interrupt a career or more commonly end a career in order to start a family. But now more and more athletes are giving birth during their athletic careers rather than afterwards. And here's some pictures of some well-known athletes who've done that. And our teams, medical teams have to be ready to support our postpartum athlete in their journey back. So Serena Williams up on the top, Kendall Coyne-Schofield and Natalie Spooner, more recent hockey athletes. Alison Felix in the bottom, who's a highly decorated track and field athlete who's done so much in this area. And in the bottom left, Keekan Randall, I'm not sure if I'm pronouncing her first name properly, but an American cross country skier. And I mentioned her just because there was a big group of female athletes who gave birth after the 2014 Olympics. And a number of them came from the cross country skiing sport. And many of whom, if not even all of them, have come back and Keekan Randall came back to win a medal at the subsequent Olympics in 2018. So I shouldn't talk about postpartum without talking about a bit about pregnancy first. So just one slide here about the history of exercise advice in pregnancy. So before 1984, do not exercise if you're pregnant. 1984, okay, it's okay to be physically active and to exercise, but keep your heart rate below 140. In 1994, that heart rate guideline was abandoned, which is surprising because I still get questions about heart rate today. In 2002, the American College of Obstetricians and Gynecologists recommended 30 minutes per day of physical activity or exercise most days of the week for pregnant women. And in 2008, the Society of Obstetricians and Gynecologists of Canada in conjunction with the Canadian Society of Exercise Physiologists said yes, that 30 minutes of aerobic activity is helpful and also we recommend strength training. And then fast forward to 2019 and we see the most comprehensive guidelines in the world created by a great Canadian group led by Dr. Margie Davenport in Edmonton at the University of Alberta, the Canadian Guideline for Physical Activity Throughout Pregnancy published in the BJSM in 2019. And that said that exercise goals are the same in pregnancy as for all adults. So that means 150 minutes per week of moderate aerobic activity plus two resistance training exercises per week of about 30 minutes each. Now, we all know that most of our elite female athletes are far exceeding these conventional exercise recommendations. And for those of us who work in this field, we know that that's okay. I could talk for a whole hour just about that, but since it's supposed to be a postpartum talk, we'll skip that for another day. The history of postpartum return to play guideline is a lot shorter. It's not quite crickets, but it's close. So in 2019, that BJSM guideline started the discussion, but was really high level and common sense based. And so really we're at the stage of understanding return to exercise for the average woman, and we're learning very slowly about the nuances for the elite women. And we're learning from our athletes, to be honest. And the BJSM in July of 23 commented on that, that there's a long way to go yet. What we do know is that each athlete has an individualized process for return to play. However, there are some overarching themes emerging that I'll touch on. Objectively, we don't have much data. The best data we've got is U.S. Army data that showed a study of fit military professionals needed two to 24 months to return to pre-pregnancy fitness levels with a mean of 11 months. And that on Army physical fitness testing, 19% of women performed equal or better on the six month postpartum test compared with the pre-pregnancy test. So not very high numbers. Now, since this data came out, and I'm sorry, I don't have the year on here, but it's probably about 10 years old, because in 2015, they changed their postpartum testing to 12 months. And they have a very comprehensive return to work protocol in the U.S. Army website that's readily available. One of their overarching themes though, was as I've already said, the return to fitness is an individualized process. So in general, what's the goal of return to play? It is not to get back sooner per se. It is to get back to play safely and without injury. And so for this group, the how is more important than the when. And there is no badge of honor in returning quickly. Many women I've spoken to said getting back too quickly backfired on them. And personal experience included there with my own patellar dislocation at seven weeks postpartum. I don't know why I was on the ice, but I was. Anyway, return to play questions are a very common reason for visits to my office. And the most common theme that I see, and this is in all comers, is tendinopathy or overuse injuries of the upper extremity. We'll talk about that more in a second. So return to play models for this, there's a few different ways we can think about it. We could use an injury model with various stages. So with this, I added the weeks, and then I took out the weeks, and then I added weeks and I took out the weeks. I decided to add them back in just as a guideline. This is not set in stone at all. So stage one, just recovery from the acute labor and delivery event. Some women will be up and functioning within a week, others it will take much, much longer. Stage two, return to activities of daily living and physical activity. For example, just going for walks. Stage three, return to exercise and training. Stage four, return to sports-specific movement. Stage five, return to practice and progressing that into gameplay situations. And then stage six, return to play. And I haven't put a weeks necessarily on there, again, because everyone is different. Some people are gonna be ready earlier, some later, and everyone is different. Here's another framework we can use. This is called the 6Rs, relatively new from the BJSM in 2022. This is a biopsychosocial model that helps to explain the journey. So at the top in the light blue is readiness. And so that's making a plan prior to delivery, sitting down with your pregnant athlete to say, hey, let's look at the calendar, let's look at what competitions you have coming and make an intelligent return to play guideline for you and individualized. And then after the birth, down to the right, taking stock of that plan again and saying, hey, is there anything we know now based on your labor and delivery experience that we need to change that plan? And then restore in the bottom right is a period of just natural healing, and time to recovery. Down in the bottom in yellow, reconditioning. So that's your actual rehab time with progressing from pelvic floor up to orthopedic physio and then return to play, sports-specific movement. And then on the left side, return to sport, getting the athlete back into the full training environment and competition environment, and then not stopping there, but refining it finally to say, okay, now you're back in the competition environment, how are you doing? What do we need to tweak? And we're not just talking about the athlete, we're talking about the baby too, and their sleep and their home life and everything. And then a third way to think of this is what are the different phases of postpartum experience? So like the last slide, there's a phase of recovery, thinking more scientifically, relaxing levels are still up, but they're dropping. There's a breastfeeding phase, this can go on for a long, long time. And then finally, a full resumption of pre-pregnancy weight and cardiovascular fitness. In some cases, the weight might be lower and that could be a pro or a con, and these phases can overlap. And this is a picture here of Megan Mickelson, a long time Canadian national team defenseman who had not just one, but two babies while she was an athlete. And she lives in Calgary, so I had the great privilege of following her through her pregnancies and being at her deliveries and following her through her postpartum period. And she has a great insight in that her two experiences were so vastly different. Also relaxing is something we don't really talk about all that much because we don't really test it, we don't know exactly how it works, but we do know that it's responsible for ligamentous laxity and that this laxity may not resolve until one year after the cessation of nursing. So this is an important thing to keep in mind. So if someone nurses for a full year, it might be two years before they're starting to really feel like their body is back to what they recognize from a pre-pregnant state. And just, again, a reminder that all of this is expert opinion. It's hard to get good randomized controlled trial data on this stuff. So just different ways to think about it. So postpartum injury patterns, I see both the acute and the subacute. On the acute side, we have a five times higher risk of ACL tear in nursing athletes, and that's data from Australian soccer. Increased risk of joint dislocation, primarily shoulders and patella, and increased risk of groin and hip flexor strains, particularly in skating athletes. On the subacute side, higher risk of overuse changes, mostly, I mean, just starting from carrying the baby around. There's a lot of luggage when it comes to being a new parent, but that can be compounded if your athlete's in a repetitive sport, like a racket sport, for example. Upper extremity tendinopathies, I'm gonna talk about on the next slide, and pelvic girdle problems. Again, more unique to skating athletes and hockey players' SI joints and pubic synthesis problems. So recent lessons. So, you know, we think about, maybe athletes have said to me, maybe I can get back to play quicker if I have a natural birth versus a C-section. I think we should just be careful with that, that pelvic girdle problems can happen even when the birth was a normal vaginal birth without significant trauma. Generally, we can say that a C-section birth is more likely to take longer, but just because everything was fairly straightforward and normal in a vaginal birth situation doesn't mean they're gonna get back sooner. The upper extremity tendinopathies are really common, everything from the wrist all the way up the kinetic chain to the neck. And I just look at this picture on the right here of a nursing mom and the position that they're sitting in with the neck laterally flexed and slightly forward flexed. And for those of you who are parents, you know that you tend to carry your kid around on one side and do everything else with the other side. So there's lots of asymmetries. I see everything from de Quervain's to extensor tendinopathies of the elbow, rotator cuff tendinopathies, neck pain, upper back pain, scapular dysfunction, all related to newborn care. And then those ligamentous tears, I was interested to hear previous comments about ACL tears being more common in female hockey players than male hockey players. And I'm not surprised to hear that. They're also more common in the postpartum group. So I included this slide. I know most of us in this audience are probably not doing that six-week postpartum exam, but I just want you to make sure that you ask your athlete if they had one. In my opinion, there's not enough six-week postpartum physical exams happening and that a postpartum woman may come in and say, you know what, I'm healed up. I feel like everything feels normal in the pelvic region. I'd still encourage that woman to have a physical exam because even if everything seems okay on the outside, there may not be full healing and certainly wouldn't be full healing at that stage on the inside. So it's a good idea to do a physical exam. And in most cases, women appreciate having had a physical exam. So you're checking, check-checking, double-checking for the healing of the laceration, for tenderness along the pelvic floor, for a diastasis, for their ability to contract the abdominal muscles and the pelvic floor contraction. Now, I don't expect most team physicians would have expertise in this area. So I would ensure the athlete sees someone who can, whether it's a maternity physician or a primary care physician or a pelvic floor physio is often very helpful. The diastasis rectus gets a lot of attention and maybe because it's an easy, outward, visible sequelae of pregnancy that so many women have, does it deservedly get that attention or not? Well, athletes will get a diastasis just the same as a non-athlete will. Being an athlete does not increase or decrease the risk. And in some literature, it's considered a marker for ligamentous laxity and that a one finger, a greater than one finger separation between the rectus muscles at six weeks is considered to be, or sorry, eight weeks considered to be abnormal. However, up to 40% of women will have a diastasis long-term and it does not mean they will not regain normal abdominal muscle function. And that's from Michelle Motta, a good postpartum researcher from Ontario in 2014. Ultrasound studies also show ability to generate tension across that linea alba with ab contraction, even in a wide diastasis. So the presence of a diastasis does not necessarily mean those abs won't function as they should. Lately, in the last, oh, I don't know, 10 years, perhaps there's been an interest in abdominal binding in late pregnancy and the early postpartum period, such as in the bottom right graphic there, to encourage, just encourage those muscles to stay together. There's no research to support this, but there's certainly no harm either. And one thing I wonder about is whether having that belt on just encourages gentle core muscle activation, you know, something's there giving you that counter pressure. Maybe it makes women just engage those muscles a little bit more. That may help, hard to know. What it looks like is most important is working on abdominal muscle strength, starting with the transverse abdominis, which really I think are hard to identify sometimes, especially after you've had a baby. So having our postpartum athletes working with that pelvic floor physio to identify where those muscles are and how to activate them is really important. I have to comment on mental health. Athletes have the same risks of mental health struggles as any postpartum woman does, and related to these factors, so the trauma of the birth, super important, responsibility of parenthood, sleep deprivation and fatigue, of course, hormonal change, so estrogen levels plummet. Some women will even have hot flashes akin to menopausal change in those first few weeks. Breastfeeding, number of things related to breastfeeding that can be very difficult, not the least of which is societal expectation. And then finally, expectations in all those regards, but also as it pertains to return to sport. So I've interviewed a few women for this talk and talking about expectations of the sport organization, thoughts about losing standing at the national team level or at any team level. All of these things weigh heavily on people. Having said that, exercise does protect against postpartum depression, and so our women who are active overall do a little bit better. So who's on your care team? So the following people, the pregnancy physician or midwife, primary care physician, those could be one and the same as they are in my case, and the sports medicine physician are all important. Pelvic floor physio is hugely important, as is the orthopedic physio at the strength and conditioning coach. And then depending on what the athlete needs, a dietician, lactation consultant, psychologists, and of course, don't forget the home supports, the extended family, the caregivers, crucially important. I wondered whether or not to include this picture. I don't love it. I wouldn't recommend my pregnant athlete achieve this position, nor my postpartum athlete, especially in the early days. As time goes by, sure, but not early. So I hummed and hawed about this one too. Ultimately, we wanna get them back to this level, and I'd love to talk to a power lifter who's a postpartum athlete and get their take on this. I don't know of one yet, but it'll happen. As I said, I did a few interviews for this to prepare for this talk, and some of the athlete comments were really interesting. A theme that came up over and over again was don't rush back. So almost everybody said that. Planning the return to play before the birth was helpful and helps us set the expectations. Collaboration with the healthcare team was super important is another comment, and that included the physician, the pelvic floor physio, and the strength and conditioning coach. The strength and conditioning coaches are learning too, and it can be hard to find the right people, but my experience in Calgary is that our CSI strength and conditioning coaches have pivoted and adjusted and learned really quickly and have done a great job with our postpartum athletes. Gradual progression of load was crucial. That was an interesting comment, and that was from Megan Mickelson, who went through this twice. The first time she loaded too quickly, too early and paid for it. The second baby, it was slower, more careful, and she did much better. Heavy lifting is not necessary right to the end. I did not lose as much strength as I thought I would. I think that's a really interesting comment, and I'd love to explore that a little bit more. There comes a time when you're doing more harm than good by pushing yourself. And here's another one from Megan. You can't expect to go Mach 10 in a workout if you haven't slept. Be prepared to modify, and it's okay. And again, she was commenting there about feeling as if she couldn't miss a workout, and that if she did miss a workout after baby number one, that she was catastrophizing what that would mean for her place on the national team, et cetera. The second time, she stepped back and did just as well, if not better. And then a mentorship program would be great, which is a lovely comment and something worth considering. Athlete requests, a climate of acceptance and collaboration, protocols if we can offer them. So when to stop skating during pregnancy, when to stop shooting, then when to start lifting, when to start skating after the baby's born, how to train off ice during pregnancy, what are the do's and don'ts, how to manage and progress load upon return. And I recommend using wearables like the catapult data. This is from the BJSM of 2024 here just a few months ago, talking about return to play postpartum. Interestingly, this proposes a 12-week return to play, obviously 12 weeks plus or minus. This is a common timeframe framework. I think it's maybe a bit too aggressive for dynamic sports. And then system change. So we need to evolve. I think the Paris Olympics has done really, really well. Alison Felix was crucial in that regard in pushing for areas for families, for nursing, for inclusivity. And in Milan in 26 and before that, the IIHF should consider the needs of the postpartum athlete or official in the same regard. Also, we need the increasing support of national sport organizations and overall the climate is improving. So the bottom line is for me, there are no hockey specific guidelines, but we're getting closer. Return to play plan should be individualized according to those six hours or what other framework you prefer to use. And in my opinion, the more time, the better. Six months is ideal, depending on the athlete and be prepared to adjust the plan. So thank you. And that's all for me. Thank you, Laura. I will take control back if I can. You can Laura, if there's a place to... Yeah, thank you, friend. Perfect. All right, welcome back. We have, Laura, that was excellent. I appreciate you. We have a really special moment here. We're gonna be able to talk here with Kendall Coyne who's one of our current US team players. One moment while I get my slides going. Awesome. Kendall's a US team player currently. She's been around a while. She's been involved in three Olympic games with the US and has played in 10 world championships, winning gold in six of those. She was the captain of the Walter Cup champions this year for Minnesota, the PWHL. She's a Northeastern graduate and she's a player development coach with the Chicago Blackhawks. There's a video I'd like you guys to show if you could. I want you all to remember exactly who Kendall is. It's the third video that I gave. Kendall Coyne, up first, an Illinois native out of Northeastern University, to score two goals for the United States. Kendall went to this competition expecting to be part of the accuracy in shooting, and someone dropped out. Aiden McKinnon had an injury, couldn't participate, and they asked her, what do you think about performing in the fastest computer competition you've ever prepared for? It wasn't something they had asked her to do. She said, oh, sure, that's a very Kendall thing to do, so why not? Three, four, six, she beat her time yesterday. She was here practicing, talked to her before the events got started. She was a little nervous about it, and who wouldn't be? But an outstanding job by Kendall Coyne. Watch the feet move there. The angles are terrific. The edge work is outstanding. And the stride is just amazing. You can watch the miles per hour up top there. At 22 miles per hour was the peak. Some great stuff there, and having some fun with the guys as well. And her talent level. So I'm going to unshare. Well, actually, you guys don't have to. Sorry, Dr. Howell, it was hard to hear your voiceover since the audio was on the video, so I don't know if you wanted to repeat anything you just said in the last couple seconds. We couldn't hear what you guys had going on. Just wanted to make sure you remembered that was Kendall Coyne, who participated in the 2019 NHL All-Star Fastest Skater competition and came in seventh out of eight, so she's fast enough to be in the NHL. We're lucky enough to have her with USA Hockey. She hasn't taken a contract with them yet. She's a three-time Olympian, ten-time World Championship participant with six gold medals out of those ten. She was the captain of the Walter Cup champions for Minnesota, the PWHL. She's a Northeastern graduate and currently a player development coach with the Chicago Blackhawks as well. Hi, everyone. So I prepared some questions. Kendall has been involved in women's hockey and sort of promotion of women's hockey for a long time, but I wanted to give you guys a chance to get to know her a little bit. Kendall, as long as I've known you, you've always believed in the dream of something better for female athletes. You work so hard to be an inspiration to others. Given the fact that women's sports have not always been afforded the same opportunities as men's sports for most of your life, what was it that made you so certain of the success of the Professional League for Women? I think it was recognizing the gap, the dream gap. Growing up, for me, pretty much having the only opportunity was to play boys hockey and being surrounded by incredible boys who became men, many of whom have played in the NHL. But boys was really the only option for me if I wanted to play the sport I loved and fell in love because that was a sport my brother fell in love with. But growing up alongside them, I listened to them, and their dream was to play in the NHL. And for the longest time, mine was too, until I realized that that reality, that dream may not become a reality, but what is my dream? And then in 1998, when women's hockey made its debut in the Olympic Games, I don't remember watching that. I was a little bit young, but I remember what happened after it, and that was meeting Kambi Granato, holding her gold medal, seeing her Team USA gloves, her hockey bag, meeting some of her teammates, and going to a camp filled with girls. And that was really the first time I had that opportunity to see other girls who played hockey, to see a woman who looked like me, and that was why my dream became competing in the Olympic Games because that's what I saw. But as I continued to get older, you kind of start to see the discrepancies, you see the inequities. And just hearing from so many young girls, as I've had a long career with the national team, saying, I want to be like you. And then recognizing that I don't want them to be like me. I want them to be better than me. I want them to have more opportunities than me. Knowing that there's so many people who have fought for the opportunities that I've had in my career, and I'm so thankful for that. And I think it's just a responsibility that we carry when we see that there's a gap, when we see that there's an inequity, in anything that we do. For me specifically, obviously, it's hockey that's been my love, my passion, and something I've done pretty much every day of my life since I was three years old. And I definitely have thought about it, whether I'm doing it or not. But it was recognizing that all these young girls, they can't have the same dream as all those young boys in the sport. And that needs to change. And by that dream, that means being afforded the opportunity, the resources, the support to be truly professional in what you do. There's been a numerous amount of iterations of women's professional hockey, and we stand on the shoulders of those iterations. But the reality is that in those iterations, women had to have other jobs in order to continue to play professionally. And at some point or another, that had to change. And so what gave me hope, what gave me inspiration, and all of us, there were a couple things, two things. I will say it's one, the advice, the guidance, love, support, strength, from Billie Jean King. It's looking to those who have done it before you. You look at the equality within tennis. I mean, that's the inspiration you need right there. If you tune on at the U.S. Open in a month from now, you'll see the men's final just as packed as the women's final. You'll see the prize money just the exact same amount as the men and the women. And it's seeing that equality, it's seeing that landscape and recognizing that we can get there too, but we have to start somewhere. And so Billie Jean and her partner Alana have been tremendous supporters. They've provided us guidance. And one of their biggest pieces of advice was to have one voice. And for the best players in the world to come together and recognize that, hey, we need to change this landscape forever. It's going to take all of us. It's going to take us to work together, in which we did. It took us a while to get here, but we're here. And we're so proud of what year one of the PWHL has created and succeeded in. Nice, awesome. I get chills, I swear, every time you talk. It's so awesome. Now that you've finished the first year of the PWHL and won the championship, what do you want people to know about the PWHL? What are the things that excite you about the upcoming season? And in what ways does the league need to continue to grow to meet the needs of the players? I think just to give you a little snapshot of inside of what is the PWHL, it's exactly what the P stands for, professional. When you look at our landscape, it's having two athletic trainers. It's having two team doctors. It's having a massage therapist there on a weekly basis. It's having a strength coach, a chiropractor come in, three hockey coaches, a skills coach, a goalie coach, an equipment manager, to name a few. It's having the team behind the team that allows us to be professional, that allows us to wake up every day and for this to be our job, allows us to be the best that we can be, to be proud and excited of moving to a new city that drafts us or picks us up as a free agent and being a part of that adopted city and helping bring a championship to that city. I think it's been a long time coming, but to finally feel truly professional and be professional in what we do and be treated as so, I think that's what's extremely important for everyone to know and to recognize. What am I excited about in year two? I think for everything that we experienced in year one, to be even better in year two. Year one, that came together in almost six months to date from the moment that the CBA was signed July 1st up until the first puck drop January 1st of 2024. And now that there's been a longer runway and there's been a whole year under our belt, I think we're only going to keep getting better. We learn from mistakes. If it was a perfect year, I'd be actually concerned because then we are doing something wrong. We're learning from our mistakes in year one. We've had the opportunity to learn from other leagues, whether that's the NHL, the WNBA, the NWSL, and asking them if you could go back to day one of your league, what would you do differently? And just being able to lean on specifically the WNBA and the NWSL in that regard of things that they're proud of, things that they would like to do differently if they can. And then the last part of your question was... In what ways does the league need to continue to grow to meet the needs? Yeah, so I think next year we're going from 24 games to 30 games, but I think there's so many areas in which it needs to continue to grow. Of course, we signed an eight-year CBA, so there's a lot of things that we're locked into for the next seven years. But one area that excites me, obviously as a player in the league, but a fan of the league, is merchandise. You saw the merch just flying off the shelves, which was super cool. But I think the elite has announced that they're going to be seeing nicknames come up in the next month or so, so that's going to be exciting. But yeah, I think it's just continuing to keep up with the demand. This demand has been a long time coming. It's continuing to ensure that all games are visible, there's an awareness of all games. Last year, all games were available in the regional sports markets or on YouTube. So it didn't matter if you were in Minnesota or not, you could watch PWHL Minnesota from anywhere, on your computer or in market. So I think just continuing to be accessible to anyone and everyone who wants to watch us play. I love it. Specifically, this medical conference, surgical conference, what do you think we could do, if anything, to grow the medical, mental health, strength and conditioning, rehab kind of side of the game to support women? The first thing that comes to mind is shared resources. I think for a lot of you maybe in this room, maybe some of you have worked only in men's sports, men's hockey. And now looking at the evolving landscape of women's hockey, maybe it's looking across the table saying, how can I support the PWHL? How can I support our women athletes as much as I've supported our male athletes? I think the thing I think about of all those categories you just mentioned is thinking of a stool and how it has four legs, and if one of those legs is broken, the stool is going to fall over. So all aspects of health is important, whether it's mental, physical. We talk about tactical, technical development of an athlete. And I think for me specifically as a player who had a child 13 months ago, Dr. Lohr just spoke so well about the postpartum return to play. I think that's another area, whether it's coming at it from the strength and conditioning standpoint, the medical, physical therapy standpoint. There's so many areas in which I think we all can support each other and make each other better, whether it's the men's side of the game, women's side of the game. It's sport. It's a microcosm of society and just being able to support each other, no matter what background we come from. Cool. And my last question before we go on to our next talk. You've had a dream of growing the game and giving back to the game for your whole life. And I personally have witnessed you passionately explain why women deserve the attention that your teams weren't getting, and I've watched you work consistently and tirelessly towards a goal of something better for the next generation. Where do you see women's hockey going? The brightest future ever. I'm so proud of where this game has come since I started playing. I'm proud of where it's at right now, and I think I'm most proud of where it's going. Just as an example, I hosted my hockey camp right before our training camp here in Lake Placid. There were over 100 girls there, and their phone backgrounds were the PWHL. You know, I had my PWHL jersey and my USA hockey jersey there for the kids to, you know, play with, put on, whatever they want to do, and just to see the significance to them of touching that purple jersey and asking all these questions about the PWHL. And, you know, some of them had an Apple Watch on, and they would flip it, and I see the PWHL logo on their Apple Watch, and it kind of just hit me, like, how, you know, the dream that has finally been born for so many of these athletes to grow up and say, yeah, that's what I want to do. And knowing that, you know, there's so many more dreams versus I feel like when I was growing up, it was you dreamed to be on the Olympic team, and that was the pinnacle of the sport, and that's really, there's only 23 players, and back then it was 21 players before 2014 who could be on an Olympic team. And now you think about the landscape of women's professional hockey. Yes, so the dream, there's still a dream to go to the Olympic Games, but there's also a dream to be a professional hockey player, and there were 158 players in the league this year. I could be off on that number, but roughly 158 players, and you think about that, and that's going to be every single year, and that number is going to get bigger. I'm so confident in that. There has to be expansion at some point or another. I have no idea when. Don't ask that question in the panel. I have no idea when, but it's going to continue to grow, and the dreams are going to continue to grow, and I'm so excited to see where this game goes. And, you know, I think about the opportunities that this game has provided me beyond the medals, the wins, the losses. It's the relationships, you know, with you, Doc, our teammates. It's the places we've gone, the experiences we've had, being able to get an education, and, you know, most recently, I was in a Disney Pixar movie, and I'm like, how the heck did the Game of Hockey bring me here to Disney and Pixar? But it's just like, you know, seeing all these young kids, knowing the incredible things in my life that this sport has brought me, I'm so excited for those opportunities and experiences to be even more and more for the next generation, and I think that's what excites me. Yeah, so cool. In third grade, when I told my third-grade teacher that I was going to go to the Olympics, I pictured it as a soccer player, if I'm honest, but going as a doctor was thrilling, and if she had said to me, don't worry, someday you're going to sit next to Kendall Coyne, and she's going to love sitting next to you, and you guys are going to know each other for a decade and be, you know, really connected. I don't think I would have believed her, so thanks for being a part of my dream, too. So we have a great speaker coming next, Keri Aprick. Both Kendall and I are huge fans of Keri as well. Keri is our team dietician for USA Hockey. We went to Pyeongchang and Beijing Olympics with her. She's become more recently the winter sports dietician. Basically, Keri is so good, everybody wanted a piece of her, for the United States Olympic and Paralympic Committee, and she's going to talk to us about optimizing the nutrition of female athletes. Hi, everyone. I am just going to get my slides up here. Thanks, Doc and Kendall. Let's see here. All right. We in business? Slides up? Great. Okay. So I will talk briefly about fueling culture and priorities for female athletes with some perspectives from having been a dietician on this team now for about 10 years, and I want to say a lot of what we're going to talk about here of course applies to female athletes but it's not just female athletes that experience some of the issues we'll talk about and it's not just female athletes who really need a good sport culture and a good culture around food and nutrition and bodies in their spaces so just want to throw that out there as well. No disclosures to share and I thought it would help just to kind of describe my approach and my mindset towards the Women's National Team Fueling Program and that first thing as I mentioned is the team culture and environment that we want to create here. Every piece of food, every item that ends up on our snack table and on our meals is intentional and some of those intentions are specific to fueling energy systems and iron levels and carbohydrates and some of those intentions are foods that we enjoy and make us feel good and feel familiar to being home. So there's a lot of different intentions behind the foods that we serve. We try to be inclusive and varied in the food that we make available and make sure that that's adequate to meet everyone's needs. It's critical to me and I could spend three hours talking to you about the language that we need to use around nutrition and bodies and using performance based language and not judgment in our spaces and making sure that we're integrated and collaborative with our players, with our medical team, with our performance team, with our coaches, with our leadership. All of those pieces play a role in nutrition culture. We offer individual care and I think it's essential to point out that that individual care is available but it's also optional. Not everyone has to do everything that we offer and it's not appropriate for every single person to do that and the fact that it's optional I think is a critical piece of the cultural component. But that individual work revolves of course around performance, recovery, and hydration. We also have medical nutrition therapy that comes up regarding injuries, blood levels, disordered eating, those types of things that are a little bit more clinical in nature. We do body composition testing but more importantly we track that over time so we're not focused on individual numbers but rather someone's trends and how those correspond to their individual goals. We do blood work and then as I mentioned all of this involves collaborative care as well. And from a team standpoint we have fueling stations everywhere. There's always food around. We do some special pre and post game fueling things and again the intentions behind that of course are to fuel for the game adequately but also things that may be more ritualistic, things that make people happy when they see them and they taste really good. Travel planning and packing is always something that is interesting and varied depending on where we're going and what we have available. Our meals planning whether that's at hotels, different venues, at the Olympic Games, we try to make those as performance based as possible. And education for me is a key component of all of these things and it's not just sitting in front of the team and lecturing which they unfortunately have to put up with once in a while but for me it's also about we're educating through what we provide. Everything that's on our fueling station is a component of education that we hope they will learn from and take home and try in their own spaces. We do hydration testing, we have signage, there's different things and we're always trying to evolve and do something new each season. So those are kind of my thought process behind these different components to our fueling program and again it's important for female athletes but all of these components apply to male athletes as well. And my philosophy regarding nutrition in general here for the athlete is this kind of hierarchy here so this bottom layer of energy balance, energy management throughout the day and throughout the season and hydration are the critical bottom of our pyramid. If that's not on point everything above that matters a little bit less and we'll get really dig deep into energy balance here in a minute. Next step are our macronutrients and we really try to adapt recommendations for carbohydrate, protein, and fat to the specific energy systems and specific goals that the athletes have. Next on that list are micronutrients so that's referring to kind of the quality that the food choices we make provide us in terms of vitamins, minerals, antioxidants, fiber, phytochemicals, so making sure that we're choosing within those macronutrient groups the foods that provide us the most micronutrients when we can. And that last piece of the pyramid is supplementation so our protein powders, our vitamins, fish oils, creatine, all of those things which absolutely can be a piece of the puzzle provided we do it in a really safe and purposeful way. So energy availability is that kind of bottom piece of the puzzle. Energy availability is this dietary energy left over and available for optimal body function of body systems once we account for the energy expended from exercise which is a very fancy way of saying we're worried about how many calories we're taking in versus the amount of calories we're expending and ideally we're as balanced there as we can possibly be. So anyone that's heard me talk about sport nutrition knows that I spend a lot of time on energy balance and probably wonders why she talked about this non-stop and why do I care so much about that piece and it relates to this syndrome called REDS relative energy deficiency in sport and the easiest most simple way to explain this is that it's this chronic under fueling syndrome. Way back in the day we used to talk about this as the female athlete triad and how it connected bone health, hormone function to female athletes overall health. We know it is so much more complicated than that now and it's not just females that chronically under fuel and develop different symptoms associated. So a low energy availability or a mismatch between the energy we take in and the energy we expend and that happens chronically over time to different severity levels can affect every single system in our body as well as so many components of our performance as well. So you can see these two different wheels the one on the left refers to the more medical physical mental pieces of the puzzle and on the right are talking about all of the effects of this chronic syndrome on the performance aspects. So a low energy availability again is that mismatch and it also exists on a spectrum so we can do our best to calculate this as much as as well as we can although it's always an estimate. Optimal is somewhere in the ballpark of 45 calories per kilogram of fat-free mass. All the way to problematic is more like less than 30 calories per kilogram of fat-free mass. And reds can really occur in a lot of different ways. I think the first thing we think of with chronic under fueling is oh this person must have an eating disorder. There's so many other reasons why they may be under fueling. Lack of planning and lack of knowledge are huge. Limited resources. Scheduling challenges. I think collegiate athletes really struggle with this a lot. They don't have time to fuel adequately. Medical challenges. I see and hear so often some sort of GI dysfunction that limits what they feel like they can take in at different times and that is kind of reinforced under fueling can cause more of that GI dysfunction as well. Then mental health challenges. Depression and anxiety can really wreak havoc on appetite and also on digestive capabilities. So there I'm going to skip forward a little bit just for the sake of time here. Kind of a key piece of the reds puzzle is menstrual cycle dysfunction and it's something that we have a lot of conversations about in this space and I think there's a lot of misconceptions. One of which is that it's you know a validation of hard work to not get our menstrual cycle. It's a rite of passage. Everybody goes through it. On the other end of that spectrum it can be viewed as a personal failure. I did something wrong. What's going on? Athletes hear quite often that this is this is totally normal. Don't worry about it. It's not normal functioning for our body but it is common. So it's something that we want to be aware of. We want to empower our female athletes to follow their menstrual cycle and be aware of when it changes. It's not always related to under fueling but if it is we can fix it. We can talk about it and they are going to feel and perform better with a regular menstrual cycle. We also think it's really important to educate on the menstrual cycle and the different phases of the cycle. There's so much new information and research out there about performance and the cycle and what's come out of that which really gets misconstrued especially on social media is that there's specific strategies that we can put in place for these different phases. That may be true on the individual level but it's highly variable and it's not something that we can say from a research perspective every female athlete needs to do such and such during the mid blue deal phase for example. So what athletes can do is track and this is an example of a fitter woman app. There are quite a few tracking apps out there now. This is one of them that I think is pretty good and they can track things like their cycle length, how these different symptoms may occur on different days and begin to see patterns over time. You know every you know five days before my menstrual cycle my appetite really kicks up and it kind of empowers them to say that that's normal part of my body functioning and we can learn how to create strategies and solutions around those different patterns that they're seeing. They can then use that to communicate with their coaches and trainers kind of what their needs are during that time to help maximize their performance. These are just some examples of strategies. When it comes to hunger and cravings it always starts with giving themselves permission to eat when they feel hungry and getting ahead of that. Not trying to fight it off until we're so hungry later at night that we end up overeating at dinner for example or reaching for foods we wouldn't typically be eating. Validate the hunger, feed the hunger, give yourself permission to feel satisfied. And then those different GI feelings that they may experience can really be modified by playing around with portion sizes, salt intake, fiber intake, fluid intake and those are all things that we can play around with again for the sake of people feeling and performing better but also empowering the athlete as well and viewing their menstrual cycle in a different way. Again these are just some other thoughts on symptom management, the types of foods, validating these changes and how people are feeling and this is just a piece of resource that I wanted to share here that the USOPC nutrition team put together so feel free to scan that code. We're also happy to share these slides so that you can access these resources later as well. And when it comes to Red's prevention and treatment I think a key piece of the prevention puzzle is education and continuing to arm our athletes with reliable information as well as teaching them to balance their intake and expenditure, paying attention to body cues, paying attention to changes in their training that require more energy or carbohydrate, more overall volume so that as that volume of training increases our nutrition matches. Treatment really requires a collaborative team and that treatment for Red's is correcting the low energy availability so how can we either eat more, move less or do a combination of both of those things. And here's some more resources. Red's in sport is more geared toward athletes and parents. That position statement obviously on the left is more geared toward us in the the medical and performance field but those are great resources to make sure that you have available to yourselves. I think we have a lot of focus on numbers like weight and body composition but I would love female athletes to pay more attention to numbers like how many grams of carbohydrates do I need, how many ounces of fluid do I need, how many milligrams of iron do I need, what's my schedule, what time do I need to be eating. So those are more again empowering things athletes can do to maximize and optimize their fueling plan and their performance versus focusing so much on numbers like body weight. All right so I again I'm gonna share all of these slides with you so I'm gonna skip forward a little bit. These are some targets for the micronutrients that are really important for female athletes. Calcium, vitamin D and iron as well as the serum blood levels that we're looking for. And I'll just wrap up by saying everything you know scientifically is very important but it's not as important as the culture and the environment that we create around food and nutrition that is lifelong and athletes will take with them for the rest of their lives. Thank you. Thank you Carrie that was so thank you Carrie that was excellent we've really enjoyed it. You're gonna come to this side of the room. Carrie Kendall and I are all gonna be on the same screen. We're gonna start a panel. I am understanding that some people may need to leave for the airport so I don't want to delay us in any way. Marisol if there's anything you can do to help guide me as to how this works best I'd appreciate it. We have Laura back on. Mark somewhere, Mark's in the room. So Marisol, or someone in the room, Anil maybe, can you guys let me know if there are any questions or I can ask a question if we don't have any yet. Yeah, this is Anil. That was an amazing session. I have a first question, I guess, for Allie, you, Mark, and maybe Laura too. So do you think there's more injuries, more ACL injuries because there's more ACL injuries in women's soccer because of the biology of women or something specific about women's hockey in the sense of how the game and the rules are played? Is it more biology or is it more environment? I think, first of all, we have to admit the biology is an important part of it. I think when we looked at the data, we found that approximately 11% of our knee injuries were ACL injuries. So there is certainly something about the environment. I would hope that the, and although, and then the other thing that we have seen over the last 10 years was a marked decrease in knee injuries, including ACL injuries, and trying to figure out the reason was we have had a lot of development camps, a lot of coaches. I think our players are becoming more skilled. I think they have better neuromuscular control over their bodies, better strength, and I think that accounts for certainly the decrease and the prevention. But I think that overall, hockey's probably a less risky sport than, for example, soccer or basketball. There's a question from the virtual world asking about why do you think you're seeing less injuries when you introduce body checking, when the Swedish project introduced body checking and injury rate went down. That's not really what we saw in the Canadian youth studies. So I would say, first of all, we've encouraged the Swedish group to publish their results in a peer-reviewed publication. Our feeling is certainly at the International Ice Hockey Federation is that, number one, if you introduce body checking, even along the boards, you're gonna get more injuries. I think it just stands to reason. I think that our data has shown that our concussion rate has decreased substantially over the years, and when we compared the Swedish data, and the only way we could compare it is on the number of concussions and certainly looking at how we calculated the injury rate, we still had, at the IIHF and our competitions, a lower concussion rate than what the Swedish group had. But I think that it is important for all organizations to release their data, and I think, hopefully, scientifically, we can come to some kind of, perhaps not compromise, but idea that how much body checking can we allow. Kendall, can you, question from the, first of all, that was the most amazing talk, and you are an incredible role model. What's your perspective? When you ask your teammates, whether American, Canadian, whatever, do they want the physicality, do they not want the physicality, or is it okay to maybe see joints? Yeah, I think it's- What are your thoughts? Yeah, I think it's been finding a healthy balance. Obviously, we went from kind of one extreme to the other, and I think, I'm hopeful, in year two, that we'll find that balance between the two of what we were playing before the Pro League and what we played in the Pro League. You kind of saw that style of play in the International Women's World Championship this year, so I think it's kind of evolving alongside us. I think if there is one benefit to introducing, hitting along the wall like we had this year, it's that we are adults and, I think, fairly built. Being strong helps us. I'm not a doctor, so I can't say prevent injuries, but I think that it does help a little bit. So I just think, for us, it's finding that balance. I'm very curious to see what year two brings, but I think, I don't like the full fledge of it, and I think we've grown from where we were prior to the Pro League, so I think we're working on that balance. Aaron, in the college game, you've been doing this for some time now. What's your feeling about changing injury patterns over the last 10 or 15 years? Yeah, I think we're definitely getting more physical, even if boarding isn't allowed or checking isn't allowed. I think they find other ways to have contact still with each other, and I think that they're learning how to get those hits in a way that they are protecting their bodies more. So the more that they're allowed to do that and learn how to protect themselves, they're gonna have less injuries. But I don't think that they're ready for full checking or anything like that at the college level, especially because they haven't learned it from a younger age. So I think if you could start teaching how to absorb those hits from a younger age, you're probably gonna have less injuries as you get older, too. Yeah, I would also add that one of the injuries that we saw that probably increased over the last 10 years was the AC joint sprain. And as you can see, our shoulder injuries have increased, and I think a lot of it has to do with allowing, perhaps, a little bit more body checking along the boards, because I think that's what the game wants, that's what the women's game wants. And I think because of the increased skill and the increased speed and all the things that go with it, perhaps we're trading off what is a better game to perhaps a small increase in the number of shoulder injuries that we're seeing. Kendall and Erin, maybe, what are your feelings about taking off the full face mask for women's hockey and moving to a visor similar to the men's international game? What do you think, Kendall? I mean, I like the way my teeth look, personally. Erin spent a lot of money on braces as a kid. But if that's where the game goes, that's where the game goes, but I'm happy with the way it is, personally. I would say kind of the same thing. I think we've probably seen less facial injuries, less teeth injuries. We still do get the injuries, and especially from the side, we'll get jaw injuries. A lot of the sticks, that'll still go up when they have cages. But I think, overall, you're probably getting less of the dental injuries with having that. Yeah, I mean, that's what the data would show, right, Mark? Yeah. But we, the medical committee, on one of our recommendations, tried to bring back the full visor in the under 20, and unfortunately, it was rejected by our council because of TV and all the other stuff that goes with it. But there's no question about it. And again, we had that debate in the college game in the States, that as soon as you remove part of the face mask, you're gonna get increased dental injuries and increased lacerations. And I'm not sure it's worth the increased injuries at the expense of how the game is played. One thing I just wanted to point out, when I did speak with Jayna Hefford, who's the VP of the league, she made it really clear when I asked her about this, where are we going next? Are we gonna add more physicality or change in equipment? And her comment was, we're not trying to create the NHL for women. We're trying to create a league that makes sense for women or makes sense for hockey players. And she gave us, again, with our medical standards kind of guidance, she wanted a gold standard. She wanted something that was safe and also allowed the players to have some input. So I think this may change a little bit over time, but I don't think it has to. I think we don't have to go to full body checking in order to have an entertainment product here. I think that's what we've been able to show. And if the women are comfortable in a cage, you might see more kids wearing cages because they wanna be like their role models. So that could be cool. There was one question in the chat I wanted to say, can some of you share, I'm gonna say this is gonna go mostly to Carrie if possible. Can you share how you approach athletes, female athletes who request hormone testing to guide their supplementation? Yeah, I would say there's definitely not research-based information that tells us and guides us in that. So I would steer away from hormone testing for that purpose. Also, hormones are so variable throughout the day, throughout the menstrual cycle. That's not what I typically would use to guide supplementation. We use kind of daily nutrition habits. What are the goals? What are the areas for improvement and opportunity? And of course, blood work helps us drive those decisions. Laura, just a question for you. How about you talk to postpartum? It's Duran, by the way. What about if a player is pregnant? Are they safe to play hockey? Yeah, good question. Certainly depends on gestational age, of course. I mean, the uterus is small and tucked in behind the pubic symphysis there till 12, 13 weeks. And certainly from a trauma perspective, even a puck or a stick into the abdomen is unlikely to cause any great harm. Otherwise, in terms of safety, it would be more just related to how that pregnant athlete is feeling from a fatigue and nausea perspective. And if they're feeling well, generally they can continue to play through that first trimester. Certainly there is the baseline risk of miscarriage that any woman is going to carry. And it's about educating her about that and so I usually play it by ear in terms of where they're at in the season and what their goals are. And I would say that the risk is fairly low until that 12, 13 week timeframe. Thank you. I was hoping maybe Kendall could give her perspective on this too, if that's okay as well. Yeah, I can chime in. As I played through my first trimester last year and that was a conversation that Doc Howe had with my two OBs back in Chicago about can I keep playing? At what point should I stop? For me, it was obviously what is safe to do so and won't jeopardize the health of the baby and obviously the health of me as well. And for my process and pregnancy, it was 12 weeks. So I remember that last game against Canada. It didn't feel too hot, but it was pretty cool to play in it. Looking back now, having a 13 month old baby and being able to still play through 12 weeks. Amazing, thank you. Yeah, Laura, thank you very much for the recommendations as regards to the Olympic Games. And I think it would be worthwhile if maybe we had a list of things that you would see or that all of you could see. Ali, Kendall and Kerry that going forward. And the other thing is in terms of nutrition and for our championships, that we have a sort of a whole full dietary menu that we pass on to our championship organizers. And I'm afraid it's a little bit outdated in terms of some of the things we talk about, reds and also supplement use. So certainly might be something to help us with as we move down the road. I love that you mentioned this. This is a hot button for me, especially at the Olympic Games. There are not IOC criteria for food service provision at the games. And I think like IHF tournaments, there's not typically a standard provision of meals that's required by the local organizers. And this is something that's been on my mind for a long time that I would love to help develop those standards and encourage performance-based menu planning, minimum quality standards, food safety standards that players can trust and bank on no matter where they are in the world. So thank you for bringing that up. Food is horrible at the Olympics. Like actually there is. The dieticians at the Olympic and Paralympic Games deserve significant raise because they are the only way we are able to fuel ourselves. And it's no secret. And there's no standardization. So what they receive in the Village Cafeteria, what's served at the venues, what countries bring themselves, it is just all over the map. And there's nothing that athletes can safely rely on other than what we bring ourselves. We'll bring that up at the next meeting. And we have Mike Stewart, who is also part of your group to make sure that he's aware of it as well. I just wanted to say thanks to all of you on the panel. Again, this was a great session. Something new for us really in this meeting. We've done it a number of years and I think it's extremely valuable. So I really appreciate you all taking your time to share your expertise with us. Thank you.

women's hockey

advancements

medical aspects

sports-related aspects

PWHL

injury trends

safety

postpartum care

nutrition

energy balance

macro and micronutrients

menstrual cycle management

professional environment

injury prevention

full-face masks