Here's Bergeron, clearly not suffering at all.

Here’s Bergeron clearly not suffering at all.

Teams are always cagey about injuries during the playoffs, but Boston took it to entirely new heights this year when they revealed that Patrice Bergeron had a body injury. Not upper body, not lower body, just body. The injury turned out to be multiple upper body injuries (a broken rib, torn cartilage, a separated shoulder, and a pneumothorax) none of which could be considered minimal by any standards, and none of which prevented him from finishing the series.

Cartilage! Ribs!

The fun started in game four when Bergeron tore cartilage in his chest on a check from Michael Frolik. He then left game five in the second period, due to what was later revealed was a broken rib and concerns for a spleen inury. The cartilage in your chest has an important job, namely holding your ribs onto your sternum. The cartilage is highlighted in red below to point out just how heinous the pain is when you tear it. Generally people with costochondral injuries (costo = rib, chondral = pertaining to cartilage) sit very still, breathe very shallowly, and try not to do anything that would move their chest in any way. Try that. It’s impossible. What do you do for the injury? Nothing. Seriously, nothing. You wait it out, you take pain pills, and you suffer.

The red parts hurt when you rip them.

The red parts hurt when you rip them.

 

It was his spleen! Just kidding, it wasn’t his spleen.

The Bruins were worried enough about Bergeron’s pain to take him out of game five after six minutes for a visit to a Chicago hospital to ensure that his rib fracture and the trauma that caused it hadn’t affected any of the important bits that live under the ribs – namely the spleen. The spleen, as you may recall from Peter Forsberg’s experience in the 2001 playoffs is an important little organ that filters out and recycles old blood cells, so of course it has a massive blood supply. In blunt trauma it’s the most often injured organ, and it can kill you in a hurry when it bleeds. Wisely the team elected to get Bergeron to a hospital for further evaluation when he skated off the ice with pain to the left side of his chest. Obviously his spleen was fine, because he was released and flew home with the team. That hospital visit kicked off speculation about what exactly Bergeron’s injury was. Anything from spleen to kidney stones to concussion, but he was kept day-to-day by the team, so at that point it seemed clear at least that it wasn’t a life threat.

 

This wasn't Bergeron's problem (sorry, Kypreos).

This handsome little fellow wasn’t Bergeron’s problem (sorry, Kypreos).

 

Game six really, really hurt!

Before game six, Bergeron had an intercostal block for the pain from his broken rib. A needle is inserted under the rib in question, and anesthetic is injected. It works quickly, and reducing the pain makes it easier to move and breathe. The theory has been floated that the nerve block is what could have caused Bergeron’s pneumothorax, which is a collection of air between the lung and the chest wall. The problem with that theory is that it’s likely incredibly wrong. The needle used to do the block is a small one, and the rate of pneumothorax after intercostal block is about 1% for each nerve blocked. Not to mention Bergeron has said he had a chest x-ray after the initial block that was normal, and he didn’t start to have problems until the third period.

 

It's so tiny and cute!

It’s so tiny and cute!

 

The other theory is that Bergeron’s broken rib poked a hole in his lung. I’d like to call bullshit on that as well. While a pneumothorax can absolutely be caused by rib fractures (and they frequently are), a broken rib would have to be really, really broken to punch a hole in a lung. So broken that the ends don’t line up. So broken that if anyone saw that on an x-ray there’s no way Bergeron would be playing, Stanley Cup or not. And again, Bergeron himself has said that he didn’t start getting short of breath until after game six – well after the initial rib fracture which happened in game five. The term “punctured lung” is getting thrown around a lot, which is problematic because it implies that Bergeron’s lung had a huge, gaping hole in it. Huge gaping holes in lungs tend to cause something called a tension pneumothorax, which is quickly deadly. Air gets into the space between the lung and the chest with every breath, and it can’t get out. This causes tension on the lung, heart, and all the important chest things, causing them to shift away from the pneumo as it gets bigger. That quickly leads to a heart that can’t pump, lungs that can’t fill, and death. The treatment is to let the air out of the chest via a pleural decompression (sticking a big needle in there to drain it) followed by a chest tube – a big tube inserted between the ribs that keeps that air from getting back in, and drains any blood or other fluid that might have accumulated. Eric Lindros ended up with a chest tube after a pulmonary contusion led to a hemothorax, which is the same as a pneumothorax except blood is filling the space instead of air.

 

Tension pneumothorax: Bad, bad, bad.

Tension pneumothorax: Bad, bad, bad.

 

Not a tension pneumothorax, but still bad.

Not a tension pneumothorax, but still bad.

 

A simple (non-tension) pneumothorax is air between the lung and the chest wall. It’s fairly common in blunt chest trauma, and often pneumothoraces that are a result of non-penetrating chest trauma happen with no rib fracture at all. The mechanism is thought to be that the sudden increase in pressure in the lung from compression of the chest during the hit blows out some alveoli (the tiny little chambers at the ends of the airways where gas exchange happens), causing an air leak. If the patient is healthy, has stable vital signs, the pneumothorax isn’t getting bigger, and it isn’t huge to begin with, it can be treated with observation and supportive care alone. If those conditions aren’t met, then the chest tube comes back into play. In Bergeron’s case, his pneumo ended up being big enough to buy him a chest tube. He had a second nerve block during the second period of game six, and after the game began feeling short of breath. X-rays at TD Garden were inconclusive, which I’ll interpret as meaning he didn’t have a huge tension pneumo that was shoving his heart over onto the wrong side of his chest.  He was taken to Mass General Hospital where they found out his lung had “collapsed” (another misleading term I hate) and he had the chest tube placed. The chest tube you usually get when you’re acutely dying from a tension pneumothorax tends to be the size of a thumb, and gets forcefully shoved between the ribs after a hole is sliced in the chest wall with a scalpel. The chest tube you get in a more controlled setting for a simple pneumothorax is likely to be a pigtail catheter, which not only has an adorable name, but is small, flexible, and doesn’t require giant holes or fingers being poked inside your chest. Considering Bergeron is out of the hospital after three days, didn’t require surgery, and is saying he’ll be ready for training camp would seem to indicate he won the chest tube lottery with a pigtail (which is still a truly crappy prize).

Fun pneumothorax side note: A spontaneous pneumothorax is a different beast than what we’re talking about with Bergeron. That’s a pneumothorax that happens spontaneously (whoever named this really nailed it), usually in tall slim young men or people with COPD or other lung pathology. It’s non-traumatic, and is a result of problems with the lung tissue itself as opposed to damage from outside forces. It’s quite similar to traumatic pneumothoraces in that it also sucks hard.

 

Oh yeah, the shoulder too.

Torn cartilage, broken rib, pneumothorax, no Stanley Cup, and a shoulder separation to cap it all off. In the first period of game six, Bergeron fell on his right shoulder and separated it. According to him, he fell awkwardly because he was trying to protect the broken rib on his left side. A shoulder separation, also known as an acromioclavicular or AC separation is when the end of the clavicle (collar bone) is pulled away from the acromion, which is the part of the scapula (shoulder blade) that makes up the front part of the shoulder. Most commonly AC separations are just simple sprains involving stretching of the ligaments that hold the two bones together, and don’t require anything more than standard rehab – antiinflammatories, physiotherapy, and not doing anything to aggravate it.

 

Those parts outlined in blue shouldn't be that far apart.

Those parts outlined in blue shouldn’t be that far apart.

 

Disclaimer!

Is it possible that the second intercostal block caused the pneumothorax? Sure. Is it likely? No. Is it possible his rib poked a hole in his lung? Sure. Is it likely? No. Is it possible he had a tiny pneumo that slowly developed into a big pneumo as a result of the nerve block/second nerve block/broken rib/any number of hits to the chest area/a fall that didn’t start to really bother him until after the game? Sure. But I don’t know. I wasn’t there. All of this is speculation, but generally speaking a pneumo from a nerve block is rare, and a pneumo from a rib lacerating a lung is serious enough that you don’t get out of the hospital after three days.

 

“Playing through it”

As usual there’s been plenty of squawking about how careless it was to let Bergeron play with these injuries. I can easily argue either side. I’m a notorious bleeding heart. It kills me to see players lose their careers over preventable injuries, and I hate seeing players on the ice that aren’t 100% healthy. I’m also a realist in that I know you can’t force a competent adult to do something they don’t want to do. So while the Bruins could have shut Bergeron down, they no doubt had on their hands a player who was telling them the pain isn’t that bad, just give me a shot and I’ll be fine. It’s not like they knew he was going to develop a pneumothorax, or separate his shoulder. On the other hand, the NHL is badly broken in terms of weighing out player safety versus the importance of GOING FOR IT. That’s a huge discussion we’ve had a million times before, and will continue to have until something changes. Hopefully it will be a policy change before it’s a catastrophic injury.

Comments (23)

  1. Thank you, Jo. Great stuff as usual.

  2. proof that hockey players (an canadian to boot) are the toughest S.O.B.’s in any sport, period.

  3. Would a team doctor be able to refuse giving a player a shot for the pain if they felt it was too dangerous to have him play with the injury? Not that this would be the case here, but I’m curious at what point a team doctor can and will say “no.”

    My own personal theory on Bergeron playing through this is that the fact that it wasn’t a head injury kind of makes players take the injury as a whole less seriously. Bergy would never play through even the slightest symptom of a concussion, thankfully. Do they just approach all other types of injuries differently because they compartmentalize them differently as not being a long-term danger or…some shit like that.

    So many questions about what goes on between players and doctors. But another great article. Thank you!

  4. I’m on the bleeding heart side too. Bergeron is going to be 28 later this month. Safe to say he is in the prime of his career which, at times, he is a point-per-game player. I would hate to see that career cut short.

    Bergeron exemplifies Canadians and hockey players. A tough S.O.B. for sure!

    • Calling someone a point-per-game player ‘at times’ is profoundly stupid and equivalent to saying that he’s not a point-per-game player that sometimes gets points. The term point-per-game implies a statistic calculated over time. Saying ‘point-per-game at times’ is idiotic.

  5. Even if you think there’s a need for protocol to prevent injured players from continuing to play, I don’t think it would be effective. The Canadian/Hockey mindset is to play through and go for it. Injuries would be hidden so players could go on.

    • The hockey mindset needs to change. There are just too many guys who you find out after the playoffs were playing with fairly significant injuries – and they’ve gotten a bit better about concussions but they’re still not there yet in terms of taking them seriously enough in all situations, imo. (Hint: A concussion doesn’t know if it’s a playoff game.)

      I mean yes, they’re adults, blah blah blah, but that doesn’t mean I can’t tell them if I think they’re doing something stupid, or complain if I think the organizing body (the NHL in this case) isn’t doing enough to control what happens in the game, or bitch about the media glorifying players making stupid decisions by going on about how brave or heroic it is to play through a serious injury.

      (And even as adults I don’t think it would be unreasonable for someone to study if they’re actually able to make well-considered decisions DURING a game. Depending on which brain chemicals you have running around your ability to think logically and rationally can be quite compromised without you having a clue. If that applies to the state players are in during a game, particularly a high-stakes game, then the teams need to be taking that into consideration when the player is saying he’s fine to play – because maybe he’s not fine to be assessing his condition and the risks to his health from playing.)

      • BINGO. It’s a farce, now. Winning a Cup isn’t worth killing yourself. And it’s not “war” – it’s a game. Especially these guys with families. If you need more proof that they’re not thinking clearly, there you go. Jeopardize your ability to support your family? Really? That’s being heroic? Not so much. And are you really that much more useful to your team when you can barely breathe – elite player notwithstanding? The answer is no, you are not. It’s not about how elite you are even if you’re injured. It’s about choice television ratings during the the playoffs, and about the franchise wanting you on the ice during a high profile media and advertising bonanza that is the Stanley Cup – especially in Canada. Don’t forget agents. Agents want their clients in the lineup as well, for potential endorsement exposure.

        Players just want to play, and we love them for it but they’re not necessarily in the right frame of mind or body to make that decision themselves because of their heightened competitive drive – before, during and after games. I know it sounds condescending but a regulated system of checks and balances that actually works is necessary here. These guys don’t want to be “told what to do” yet they have an expectation that insurance will kick in if something catastrophic happens to them as a result of their stupid, wiener-waving decisions made in the heat of the moment in front of the boys. Again, what about their family? Instead of what the boys will think, how about considering what their families will think of them if their careers are done at 30 because they played through an injury that never healed properly? Couldn’t stand the idea of a Black Ace taking your roster spot, eh? Even and especially if it might have improved your team’s shot at winning? It’s all well-intentioned, but it’s ego, it’s pride but it’s also delusional. Sometimes players need to take a seat if they’re injured.

        As somebody who grew up with the sport and adores it, I am not interested in seeing anybody be a jackass and willingly destroy their career in front of me at any time, for any reason. I don’t care if it’s the Stanley Cup, the Olympics, Worlds, World Junior, Memorial Cup. I don’t care. Just don’t do it. I don’t want to see it. You’re not doing me any favors and don’t think you’re doing your teammates any favors, either. Nobody’s asking you to be a martyr. All we’re asking is for you to show up, play your best and to know your limitations. A consummate teammate knows that it’s not just about you – it’s about your team. So consider what’s best for your team – on and off the ice! If you can’t do your best you’re not quitting. Hockey players never quit. That’s why we love them.

  6. Awesome stuff, Jo.

    Knowing what we know of Jeremy Jacobs, maybe Bergeron didn’t want to play at all. Maybe Jacobs had Bergeron’s family held hostage, forcing him to play…

    Kidding aside, though, ” On the other hand, the NHL is badly broken in terms of weighing out player safety versus the importance of GOING FOR IT. ” is an excellent point.

  7. Hi, Jo. How does his injury compare to Mark Wahlberg’s in the movie ‘Three Kings’. Thanks.

  8. Is a player really tough if he can’t feel anything? I’m not saying he isn’t gutsy to play with the injuries but if you can’t feel anything or your numb to the point it’s manageable, is that really tough?

    Also I’d like to challenge the fact that there is no way he could have played to level he did without the injections, does that sentence not sound a lot like a P.E.D. problem? He did it to win, so do steroid users. He wasn’t healthy and cheated with injections to enhance his performance capabilities. The NHL and its mentality of warriors is putting players in bad positions to do long term damage

    • I will also say, take away freeze injections and players wouldn’t play through risky injuries, they just wouldn’t be able to perform or risk longer term harm

    • I think it would be fair to say that the injection didn’t “enhance” his performance. Instead it allowed him to play through pain, at a level somewhere between his peak and curled up on the ice wincing in pain. Given the extent of injury, and his performance subsequent, i’d say it was closer to the latter.

      With that said, I could sort of get on board with disallowing players to play with pain blocking injections.

      • Firstly I’ll admit that its not identical to steroids but its fairly similar and something I wouldnt mind the league looking at, but to respond to your comment:

        It isnt enhancing like a steroid does, but if the pain from tearing cartilage is so severe that you can barely move and this injection allows him more mobility and perform more like a healthy player then yes its enhancing his performance. I have long appreciated the toughness of players (especially Gregory Campbell) but to find out that they arent feeling most of what they are battling through takes away from the lore that has been created.

        • There is a key difference between steroids and these shots.

          One is illegal per the US government (and I assume Canada’s)
          The other is a legal medication administered by a trained medical professional.

          • actually doctors prescribe steroids too, not necessarily to build muscle or the same ones being abused by athletes, but these pain blocking injections are not really supposed to be used for being able to play sports either. they are supposed to be used so that you can actually rest without being in excruciating pain so that you can recover from the injury.

  9. Sports medicine has never sounded so cool! Loved the article.

    One point, though, about this “toughness” discussion. Regardless of whether or not professional hockey players are brave or dumb, the fact that Bergeron himself claims he was trying to protect his rib in the corners (and I’m guessing this is deliberate protection as opposed to just getting ready to absorb a hit during the healthy moments), doesn’t that show that he wasn’t able to play at 100% and should have taken himself out of the game (and in a way, he did!)?

    I respect Julien defending his roster decision by saying he won’t deny a player’s request if they have that fire-in-the-belly desire to win, but he wouldn’t have been able to dress a scratched player in the middle of the game had Bergeron’s ‘protect the rib’ injury been more serious. So, yeah, on one hand I respect Bergeron’s sacrifice in order to keep on playing, but I also think it was a stupid risk given that he would have contributed to his own injuries at that point.

    • No doubt that Bergeron wasn’t at 100%. But honestly, what player in that series was still at 100%?! I’d be surprised if any of them were.

      Fact is, Bergeron at 75% is better than the healthy scratches. Heck, Bergeron at 50% is probably still better than Caron, Pandolfo and Daugavins (their scratches). The whole ‘hurting the team by playing injured’ argument is garbage. It is only valid if there is a close to comparable replacement. Had it been a guy like Thornton or McQuaid then I could see the argument applying but not for the top tier guys.

      • Absolutely right, and compounded by the fact that the B’s were already missing a starting center (Campbell). Not only would the replacement player be worse than a 75% Bergeron, but their centers would have been Krejci, Kelly, Soderberg, and Peverly. No. Just no.

  10. Players can take care of themselves. We don’t need to nanny them.

    Unless the injury puts the player at serious risk for death or severe disability, then the league/team should have no say in whether the player suits up or not.

    The team should only sit the player if they think that a backup would give them a better chance to win.

    A cracked rib and torn cartilage is pretty damn far from grievous, career-ending injury. And the team did due diligence by sending him for imaging. I’ve played with a broken rib, including full-contact games, and while it hurt — sometimes a whole fucking lot — I wasn’t about to die. I knew what could go wrong, and was smart enough to identify it. Professional hockey players spend 11 hours a day conditioning their bodies. They know when things are wrong.

    That said, teams should still have an escape clause to recover a contract if a player goes against team recommendations and suffers a career-ending injury. Let the players decide.

  11. LOVE these posts, Jo. You are really great at explaining complicated medical situations in a way that is easy to understand.

    Would love to hear what you think about Havlat’s pelvic floor injury. That just boggles the mind.

  12. i punctured my lung this morning. On purpose. I don’t see what the big deal is.

  13. Shame shame,,,,,to le him play?…..why…..careless bosses Michel b….

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