Injury Incidence Before and After the Introduction of Body Checking in Elite Women’s Ice Hockey: A 7-Year Prospective Insurance-Based Study

Injury Incidence Before and After the Introduction of Body Checking in Elite Women’s Ice Hockey: A 7-Year Prospective Insurance-Based Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Injury Incidence Before and After the Introduction of Body Checking in Elite Women’s Ice Hockey: A 7-Year Prospective Insurance-Based Study Amanda Lahti, Emelie Stenman, Anton Grundberg, Kristina Sundquist This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8951107/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Objectives In 2022, the Swedish Women’s Elite Ice Hockey League (SDHL) became the first women’s league to introduce bodychecking. Using insurance data, this study examined injury incidence before and after the implementation of this rule. Method Since 2019, the SDHL has comprised 10 teams with 20–25 players on each. All players in SDHL have license insurance to take care of ice hockey injuries. All injuries that lead to contact with the insurance company are registered in a database. The insurance covers accidental injuries occurring during matches, organized team practices, hockey school sessions, and direct travel to and from these activities. Injury data from all seasons between 2019–2020 until 2024–2025 were analyzed. Injury rates (IR) per 1,000 player game hours were calculated and compared across seasons and between pre-implementation (2019–2022) and post-implementation (2022–2025) periods. Results A total of 120 injuries were recorded. IR per 1,000 player game hours increased sharply from 6.6 (95% CI 3.8–10.7) in season 2021–2022 to 16.7 (11.6–23.2) in 2022–2023, with moderately elevated rates remaining in subsequent seasons. When grouped by period before and after bodychecking implementation, IR increased from 6.0 (4.4–8.1) pre-implementation to 11.0 (8.6–13.7) post-implementation (p < 0.05). The injury incidence was highest during the first season with body checking and a decline in injury incidence was found post-implementation. Conclusions The introduction of bodychecking in the SDHL was associated with a significant increase in injuries recorded through the insurance system, indicating that this rule change may lead to a higher injury burden. Future studies should evaluate strategies for introducing body checking in women’s ice hockey in ways that minimize injury risk. Figures Figure 1 Figure 2 Figure 3 Background Women's ice hockey has experienced significant growth in the number of participants during the recent decades ( 1 ). A major milestone occurred during the season 2022–2023, when the Swedish Women’s Elite Ice Hockey League (SDHL) became the first women’s league in the world to permit body checking. Body checking has previously been restricted to men’s ice hockey, with permitted age limits typically ranging from 13 to 15 years, depending on the country and region. Although most SDHL players support the introduction of body checking ( 2 ) and potential benefits of aligning women’s ice hockey more closely with the men’s game have been proposed ( 3 ), this rule change also raises important concerns regarding its association with injuries. Compared to other team sports, ice hockey experiences high injury rates (IR) ( 4 , 5 ). When considering the differences in checking rules, it is not surprising that overall IRs are lower in women’s games than in men’s games ( 6 ). However, although body checking historically has been prohibited in women’s ice hockey, female players experience higher rates of concussions ( 7 ). Considering previous research from men’s junior ice hockey showing that disallowing body checking among 13–14-year-old players in Alberta, Canada, resulted in a 55% reduction in IR ( 8 ), it is reasonable to hypothesize that introducing body checking in women’s ice hockey may lead to a new injury panorama. Despite extensive research on body checking in men’s and youth ice hockey, there is a lack of prospective data on injury incidence following the introduction of body checking in elite women’s ice hockey. Insurance-based injury registries provide a unique opportunity to capture medically treated injuries across an entire league, independent of team medical staff or self-reported time-loss definitions. In Sweden, insurance registries have long been used for injury surveillance. All Swedish ice hockey players are insured by the same company (Gjensidige Insurance) ( 9 ), which registers all injuries that result in contact with the insurance provider. The insurance covers accidental injuries occurring during matches, organized team practices, hockey school sessions, and direct travel to and from these activities. Within this insurance registry, these injuries have been prospectively recorded from 2019 to 2025. The introduction of body checking in the 2022–2023 season created a natural experiment within a stable league structure, allowing longitudinal comparisons before and after the introduction and within the same competitive context. Against this background, the aim of the present study, using nationwide insurance registry data, was to describe time trends in injuries among female elite ice hockey players and to compare injury incidence before and after the introduction of body checking. Method This prospective cohort study is based on insurance registry data from the Swedish insurance company Gjensidige Insurance. All elite female ice hockey players in the SDHL have, since 2019, been covered by a mandatory base insurance provided through Gjensidige, the principal insurance partner of the Swedish Ice Hockey Association and a long-standing main partner of Swedish ice hockey. This licensing insurance is automatically included for all registered players, including those of SDHL. In the season 2022–2023, body checking was introduced in the league. Study population The study includes all licensed female elite players in the SDHL between 2019 and 2025. No exclusion criteria were applied. The league consists of ten teams with approximately twenty to twenty-five players per team. The teams in the league have been largely consistent throughout the study period, with only occasional changes due to relegation and promotion based on sporting results; the only notable exception occurred in the 2022–23 season when one team withdrew from the SDHL mid-season due to financial difficulties and challenges meeting player requirements, which also affected the total number of matches during this season. The temporary reduction in the number of matches during the 2022–2023 season due to team withdrawal was accounted for in the exposure calculations. In addition, because players may transfer between teams or to other international leagues, the composition of each team and the league also vary over time. Calculating injury rates (IR) The IR was estimated by calculating the number of injuries per 1000 hours of game participation. The insurance registry did not allow the separation of injuries sustained during games and those sustained during team practices. Consequently, all recorded injuries were included, whereas the exposure was based only on game hours (not training hours). In elite ice hockey, however, previous epidemiological studies consistently demonstrate substantially higher injury incidence during games compared with training sessions ( 10 ). Therefore, it is reasonable to assume that most insurance-registered injuries occurred during games. Because the same registration procedures and insurance conditions applied throughout the entire study period, this methodological constraint is unlikely to differentially bias comparisons between pre- and post-implementation periods. Nevertheless, absolute IR that are based only in game hours should be interpreted with caution. As in previous studies, we defined participation as the time when six players per team were on the ice for a 1-hour game (20 min for three periods, ignoring ‘penalty minutes and overtime minutes): 6 players × 2 teams × 1 hour × number of games ( 11 , 12 , 13 , 14 ). During the 2019–2020 season, 195 game hours were played, with 198, 203, 175, 204, and 207 hours recorded in the subsequent seasons 2020–2021, 2021–2022, 2022–2023, 2023–2024, and 2024–2025, respectively. For each season, we used the dates from first to last match played to define the seasons. Data collection Injury claims were registered prospectively from the 2019–2020 season and onward for all injuries that led to contact with the insurance company. Representatives from Gjensidige Insurance recorded and classified all injuries according to standard internal procedures. The Swedish Ice Hockey Federation assisted in identifying players registered in the SDHL during the seasons 2019–2020 through 2024–2025 to enable the insurance company to define the study cohort, where data on the individuals was transferred pseudonymized to the research group. Gjensidige performed only the initial data processing and pseudonymization and was not involved in any statistical analyses for the present study. Definition of an injury The Gjensidige insurance covers accidental injuries occurring during matches, organized team practices, hockey school sessions, and direct travel to and from these activities, including international participation for up to 45 consecutive days. Only injuries that were covered by the Gjensidige insurance were included in the present study. Pre-existing injuries that occurred before getting the insurance were not covered and therefore not included in this study. If a player sustained multiple injuries, each injury was recorded as a separate injury. The insurance company covered incurred injuries and provided compensation for permanent disability following acute injuries requiring medical treatment, acute injuries necessitating physiotherapy, or dental care in cases of dental trauma. The insurance terms, eligibility criteria, compensation structure, and injury reporting procedures remained unchanged throughout the entire study period (2019–2025). No modifications were made to coverage policies in connection with the introduction of body checking. Injury types In the insurance registry, injuries were originally recorded using detailed injury codes specifying the anatomical location and injury subtype. In their original form, each code represented a distinct injury category, resulting in a large number of narrowly defined groups. For the present study, these detailed codes were aggregated into broader injury categories to facilitate meaningful analyses and prevent sparse data within individual categories. The main categories were Concussions, Face, Dental, Shoulder, Hand, Knee, Foot and “Other”. Each main category comprises several related, detailed insurance codes that reflect specific anatomical structures within the same region. This aggregation strategy was chosen to ensure clinically meaningful group sizes. Statistical analysis The injury incidences were presented as IR per 1000 player-game hours with 95% confidence intervals (CI). The distributions of injury type before and after the introduction of body checking were test using Fisher’s exact test. The significance level was set at p-value < 0.05. All statistical analyses were done in R version 4.4.2 (R Core Team, 2024). Ethics This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval for the project was obtained from the Swedish Ethical Review Authority (Approval number 2025-02641-01) The research is based solely on previously collected and pseudonymized registry data obtained from the Swedish Ice Hockey Association and the players’ mandatory licensing insurance company (Gjensidige). No direct contact with the athletes occurred, and no clinical interventions were performed. Only variables necessary to address the scientific aims of the study were processed. Because the study involves registry-based research posing only a negligible risk to participants’ privacy and using data already collected by third parties, the requirement for informed consent was waived by the Ethical Review Authority. Results In total 120 injuries were registered among 92 players. Descriptive statistics of the study population are presented in Table 1 . Table 1 Descriptive characteristics of injured players in the Swedish Women’s Elite Ice Hockey League (SDHL) who filed an insurance claim during the study period (2019–2025). Characteristics By injury, n = 120 By player, n = 92 Age (years), median (Q1–Q3) 20.5 ( 17 – 25 ) - Position, n (%) Forwards 76 (63) 58 (63) Defensemen 32 (27) 24 ( 26 ) Goalkeepers 12 ( 10 ) 10 ( 11 ) Number of injuries, n (%) 1 - 72 (79) 2 - 15 ( 16 ) 3–5 - 5 ( 5 ) Across all seasons, there was a statistically significant increase in the IR during the first season when body checking was introduced (2022–2023; p < 0.05), followed by a recovery in incidences (Fig. 1 ) (Table 2 ). However, a clear overall increase in injury incidence was observed for all subsequent seasons (2022–2025) compared with the pre-implementation period (2019–2022) (Fig. 2 ) (Table 2 ). Table 2 Injury rates (IR) per 1,000 player game hours in the Swedish Women’s Elite Ice Hockey League (SDHL), by season and by pre- and post-implementation periods of bodychecking (2019–2025). Season N IR (95%CI) 2019–2020 10 4.3 (2.0, 7.9) 2020–2021 17 7.2 (4.2, 11.5) 2021–2022 16 6.6 (3.8, 10.7) 2022–2023 35 16.7 (11.6, 23.2) 2023–2024 22 9.0 (5.6, 13.6) 2024–2025 20 8.1 (5.0, 12.4) Season dichotomized N IR (95%CI) 2019–2020–2021–2022 43 6.0 (4.4, 8.1) 2022–2023–2024–2025 77 11.0 (8.6, 13.7) The distribution of injury types before and after the introduction of body checking is presented in Table 3 and Fig. 3 . No statistically significant differences in injury type distribution were observed between the pre- and post-implementation periods. Descriptively, shoulder injuries accounted for 3 (7.0%) of injuries before implementation and 11 (14.3%) after implementation. Knee injuries accounted for 9 (20.9%) and 15 (19.5%), and face injuries for 2 (4.7%) and 9 (11.7%), respectively. Table 3 Distribution of injury types before and after introducing body checking in the Swedish Women’s Hockey League (SDHL) during 2019–2025. Data is presented as n (%) and injury rates (IR) with 95% confidence intervals (CI). Injury type/location n (%) p-value* IR (95% CI) Before body checking, n = 43 After body checking, n = 77 Before body checking, n = 43 After body checking, n = 77 0.36 Concussion 9 (20.9) 10 (13.0) 1.6 (0.6, 2.4) 1.4 (0.7, 2.6) Dental 0 (0.0) 2 (2.6) 0.0 (0.0, 0.5) 0.3 (0.0, 1.0) Face 2 (4.7) 9 (11.7) 0.3 (0.0, 1.0) 1.3 (0.6, 2.4) Foot 6 (14.0) 6 (7.8) 0.8 (0.3, 1.8) 0.9 (0.3, 1.9) Hand 10 (23.3) 11 (14.3) 1.4 (0.7, 2.6) 1.6 (0.8, 2.8) Knee 9 (20.9) 15 (19.5) 1.3 (0.6, 2.4) 2.1 (1.2, 3.5) Shoulder 3 (7.0) 11 (14.3) 0.4 (0.1, 1.2) 1.6 (0.8, 2.8) Other 4 (9.3) 13 (16.9) 0.6 (0.2, 1.4) 1.8 (1.0, 3.2) * Fisher’s exact test Discussion This study provides the first prospective, league-wide assessment of injury incidence following the introduction of body checking in elite women’s ice hockey. Using nationwide insurance registry data, we observed an increase in injury incidence after the rule change, particularly during the first post-implementation season, followed by a partial decline in subsequent seasons. No statistically significant differences in injury type distribution were observed between the pre- and post-implementation periods, in this relatively small study sample. However, face, shoulder, and knee injuries accounted for a larger proportion of injuries following the introduction of body checking. Although these observations do not prove causality and should therefore be interpreted cautiously, they may provide context for future research on body checking-associated injuries in women’s ice hockey. One plausible explanation for the observed increase in injury incidence is that female players have historically developed their sport-specific skills in an environment without intentional body contact. Limited exposure to body checking throughout development may influence neuromuscular preparedness, bracing strategies, and collision technique when full contact is introduced at the elite level ( 7 ). In addition, protective equipment and rule frameworks in ice hockey have largely been developed based on male physiology and playing patterns, which may offer suboptimal protection for female players as collision intensity increases ( 15 ). In contrast to several previous studies on body checking in youth and men’s ice hockey, which have reported substantial increases in concussion incidence following the introduction of body checking ( 8 , 16 , 17 , 18 ), the present study did not observe a significant increase in concussions in the present study. One explanation may be insufficient statistical power due to the relatively small size of study population. However, the discrepancy may also partly be explained by differences in injury definitions and surveillance systems. Unlike injuries such as dental trauma, facial lacerations, or knee injuries, which almost invariably lead to insurance claims due to the need for imaging or specialist care, sport-related concussions may be managed within team medical settings without activating the insurance system. Concussion is a clinical diagnosis, and routine neuroimaging (CT or MRI) is not recommended in uncomplicated cases ( 19 ). As access to imaging often is necessary for initiating insurance claims, this may result in underrepresentation of concussions in insurance-based datasets. The increased number of facial and dental injuries observed after the introduction of body checking in the present study occurred despite the mandatory use of face grids in women’s ice hockey. This finding indicates a need for improved protective equipment for female players. Importantly, body checking in women’s ice hockey may not necessarily mirror that in the men’s game, nor should they be assumed to do so. This underscores the need for sex-specific research to better understand the body checking mechanism and appropriate safety strategies specifically for women’s ice hockey. The decline in injury observed after the initial post-implementation season suggests a potential adaptation effect over time. This pattern may indicate a short-term transitional phase following rule implementation rather than a continuously increasing injury trajectory. It may reflect improvements in player technique, increased on-ice awareness and anticipation of contact situations, or greater familiarity with physical contact. However, these interpretations are speculative and should be interpreted with caution. Future studies incorporating detailed exposure data and biomechanical analyses are needed to determine whether true adaptation effects occur following the introduction of body checking. Importantly, body checking itself may not be the sole contributing factor to the increased injury incidence observed after the rule change. Rather, changes in match dynamics, such as higher game intensity, increased speed, or cumulative fatigue, may also contribute to injury risk. The rule change may also have influenced the frequency and nature of physical engagements, which could further affect injury risk. Although body checking was associated with a higher IRs in this study, the findings should be interpreted within a broader context of sport development and gender equity ( 3 ). Physical contact is a fundamental component of ice hockey, and the introduction of body checking may contribute to legitimizing women’s ice hockey as a physically demanding and high-intensity sport. Notably, female elite players have expressed positive attitudes toward the introduction of body checking ( 2 ). In elite women’s ice hockey, an IR of 22.0 injuries per 1,000 player-game hours has been reported during the Women’s World Championships, where body checking is prohibited ( 12 ). In men’s elite ice hockey, substantially higher IRs have been reported, including 88.6 injuries per 1,000 game hours in the Swiss professional league ( 20 ) 74.1 in Swedish male elite players ( 21 ), 52.1 during the Olympic Games( 11 ), 47.4 in the Finnish top league ( 14 ) and 49.4 in the NHL ( 22 ). The IR discrepancy may stem from differences in skating speed, facial protection, and fighting in men’s ice hockey. Despite the observed increase in injury incidence following the introduction of body checking, the IRs reported in the present study do not appear higher than those reported in other elite ice hockey leagues, including men’s competitions. However, these discrepancies are likely also explained primarily by differences in injury definitions and surveillance methods, as the present study captured only injuries resulting in insurance claims, whereas most previous studies included time-loss injuries or all injuries requiring medical attention. In addition, structural and contextual differences between women’s and men’s ice hockey may further contribute to the observed differences in IRs. Men’s ice hockey is characterized by higher skating speeds, the allowance of fighting at certain levels, and differences in protective equipment, such as the use of visors rather than full face grids all of which may influence IR ( 6 ). Consequently, direct comparisons of IRs across studies and between sexes should be interpreted with caution. On the other hand, studying temporal trends within the same setting and a comparable population, as in the present study, provides complementary relevant information. In addition, similar increases in injury risk have been observed on the men’s side following the introduction of body checking ( 8 , 15 , 16 , 18 , 23 , 24 ). By making women’s ice hockey more comparable to the men’s game, body checking may represent an important component in the continued development of the sport. Consequently, these findings do not necessarily argue for prohibiting body checking in women’s ice hockey, but rather underscore the importance of carefully designing its introduction to minimize injury risk while supporting the sport’s ongoing development. Strengths and limitations A major strength of this study is the long observation period, encompassing multiple seasons both before and after the introduction of body checking, with consistent data collection procedures and injury definitions applied throughout the study period. The use of a single, nationwide insurance registry including all licensed SDHL players minimizes selection bias and ensures comprehensive coverage of medically treated injuries within the league. The natural experiment created by the rule change enables meaningful temporal comparisons within a stable competitive context. Importantly, this study addresses a notable research gap in female athlete health research ( 25 ), by generating novel data on injuries associated with body checking in women’s ice hockey, an area that has not previously been examined. Several limitations should also be acknowledged. The insurance registry captures only injuries that resulted in contact with the insurance provider and required medical care, meaning that less severe injuries and illnesses that may still have caused time loss were not included ( 26 ). As a result, the reported injury incidence likely reflects more severe injuries and may underestimate the overall injury burden. Illness-related absences were not covered by the insurance system and were therefore not captured. Injury classification was performed by insurance personnel without formal medical training, which may have introduced some degree of misclassification. In particular, it may be challenging for non-medically trained personnel to distinguish between related diagnostic entities such as head injury, skull injury, and concussion. As a result, some degree of overlap or misclassification between these categories cannot be excluded. Similar challenges may apply to other injury classifications within the registry, as diagnoses were based on insurance documentation rather than standardized clinical assessments performed by sports medicine professionals. Consequently, the injury categorization should be interpreted with this in mind. Additionally, some players may have sought care through private insurance or alternative healthcare pathways, potentially leading to underreporting. Another limitation relates to the introduction of the insurance system in 2019, which may have been associated with limited awareness during the early seasons. Increased familiarity with the insurance coverage over time could have contributed to higher reporting rates in later seasons, potentially influencing observed time trends. Although reporting awareness may have increased over time, the relatively stable IR observed during the three pre-implementation seasons suggests that the abrupt increase observed in 2022–2023 is unlikely to be explained solely by gradual improvements in insurance familiarity. As with all observational studies, causality cannot be established; however, the close temporal proximity between the introduction of body checking and the observed increase in injury incidence supports a meaningful association. The inability to separate match-related and practice-related injuries represents an additional limitation. However, because match injuries are known to occur at substantially higher rates than training injuries in elite ice hockey ( 10 ), and because this limitation applied equally across all seasons, the internal comparison between periods is unlikely to be substantially biased. Finally, comparisons of IRs across studies should be made with caution due to differences in injury definitions, exposure calculations, and injury surveillance methods used in ice hockey research. Conclusions The introduction of body checking in the Swedish Women’s Elite Ice Hockey League was associated with an increased injury incidence, particularly during the first season following implementation. Although no statistically significant differences in injury type distribution were observed, descriptive patterns indicated a larger proportion of face, shoulder, and knee injuries after the rule change. The partial decline in injury incidence in subsequent seasons suggests a potential adaptation over time. These findings do not argue against the inclusion of body checking in women’s ice hockey but highlight the importance of carefully considering how such rule changes are introduced. Future studies are needed to evaluate strategies for introducing body checking in ways that support player safety while facilitating the continued development of the sport. Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval for the project was obtained from the Swedish Ethical Review Authority (Approval number 2025-02641-01) Consent for publication Not applicable Availability of data and material The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no external funding. Authors' contributions All authors contributed to the study conception and design. Data analysis were performed by [AG]. The first draft of the manuscript was written by [AL], and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank Gjensidige Insurance Company and the Swedish Ice Hockey Association for their support and collaboration in facilitating this study. In particular, we acknowledge John Lind, Oscar Hallberg and Morgan Johansson for their valuable assistance in coordinating and enabling the research process. The authors declare that there are no financial relationships or conflicts of interest between the research group, Gjensidige Insurance Company, or the Swedish Ice Hockey Association. References Svenska Ishockeyförbundet. 28 procent fler dam- och flickspelare. 2022. Lahti A, Grundberg A, Stenman E, Sundquist K. 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major Revision 30 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviewers invited by journal 04 Mar, 2026 Editor invited by journal 03 Mar, 2026 Editor assigned by journal 24 Feb, 2026 First submitted to journal 23 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Lahti","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYLACHgYGGQYJBoYDHxgYGBvYidTCwyDBzHBwBkgLMylamHmI0cI/7fCzB29qGHj4Z/cfPGybYyPbwMxjwPijArcWidtp5oZzjjHwSNw5zHA4d1uaMUgLM88ZPNbcTjCT5mEDOuxGMkjL4USwFsY23Drkb6d/k+b5x8AjD9Jiue0/WAvjz3+4tRjczjGT5m1j4DEAaWHcdgCshYG3AbcWw9s5ZZJz+yR4DG8kGxzs3ZZs3MbMVnCY5xhuLXK307dJvPlmIyd3I/Hxh5/b7GT72Zs3PvxRg8f7ECCBYLIB8QGCGkbBKBgFo2AU4AUA+OFLNvRtWwAAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-9256-6922","institution":"Lund University: Lunds Universitet","correspondingAuthor":true,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Lahti","suffix":""},{"id":600949260,"identity":"de4d081e-6276-4b8a-9c97-6230564f9c6b","order_by":1,"name":"Emelie Stenman","email":"","orcid":"","institution":"Lunds universitet Clinical Research Centre","correspondingAuthor":false,"prefix":"","firstName":"Emelie","middleName":"","lastName":"Stenman","suffix":""},{"id":600949261,"identity":"1f648a86-d1f3-4573-9361-b0e638982d79","order_by":2,"name":"Anton Grundberg","email":"","orcid":"","institution":"Lund University: Lunds Universitet","correspondingAuthor":false,"prefix":"","firstName":"Anton","middleName":"","lastName":"Grundberg","suffix":""},{"id":600949264,"identity":"0d14b650-6caf-4365-aaa6-eb320bf5b92b","order_by":3,"name":"Kristina Sundquist","email":"","orcid":"","institution":"Lund University: Lunds Universitet","correspondingAuthor":false,"prefix":"","firstName":"Kristina","middleName":"","lastName":"Sundquist","suffix":""}],"badges":[],"createdAt":"2026-02-23 23:17:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8951107/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8951107/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104228991,"identity":"ca6a75b3-92a7-41c7-8b87-9b7623122cfa","added_by":"auto","created_at":"2026-03-09 11:42:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":175356,"visible":true,"origin":"","legend":"\u003cp\u003eSeasonal distribution of registered injuries in the SDHL from 2019–2020 to 2024–2025, with the introduction of bodychecking in the 2022–2023 season\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8951107/v1/3afe03b8b284f723f6bc5b6e.png"},{"id":104228989,"identity":"cc3cf5d5-ec68-4f42-9bff-489b947fcc84","added_by":"auto","created_at":"2026-03-09 11:42:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":130419,"visible":true,"origin":"","legend":"\u003cp\u003eInjury rates per 1000 player-game hours before and after introducing body checking in the Swedish Women’s Hockey League (SDHL) during 2019–2025.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8951107/v1/21ed7e341a71235a703eb69c.png"},{"id":104228944,"identity":"63a65c23-fca5-4793-afa8-4420627b7de4","added_by":"auto","created_at":"2026-03-09 11:42:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":307859,"visible":true,"origin":"","legend":"\u003cp\u003eInjury rates per 1000 player-game hours by injury type/location, before and after introducing body checking in the Swedish Women’s Hockey League (SDHL) during 2019–2025.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8951107/v1/fcd672c8fe3cd5d79c4f02ba.png"},{"id":104229010,"identity":"5f6fad4a-ae6d-44f6-8ebc-c181c2dc45de","added_by":"auto","created_at":"2026-03-09 11:43:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1200426,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8951107/v1/482d2d2a-6eb7-4b56-a28d-7f9725f172d6.pdf"}],"financialInterests":"","formattedTitle":"Injury Incidence Before and After the Introduction of Body Checking in Elite Women’s Ice Hockey: A 7-Year Prospective Insurance-Based Study","fulltext":[{"header":"Background","content":"\u003cp\u003eWomen's ice hockey has experienced significant growth in the number of participants during the recent decades (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A major milestone occurred during the season 2022\u0026ndash;2023, when the Swedish Women\u0026rsquo;s Elite Ice Hockey League (SDHL) became the first women\u0026rsquo;s league in the world to permit body checking. Body checking has previously been restricted to men\u0026rsquo;s ice hockey, with permitted age limits typically ranging from 13 to 15 years, depending on the country and region. Although most SDHL players support the introduction of body checking (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and potential benefits of aligning women\u0026rsquo;s ice hockey more closely with the men\u0026rsquo;s game have been proposed (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), this rule change also raises important concerns regarding its association with injuries.\u003c/p\u003e \u003cp\u003eCompared to other team sports, ice hockey experiences high injury rates (IR) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). When considering the differences in checking rules, it is not surprising that overall IRs are lower in women\u0026rsquo;s games than in men\u0026rsquo;s games (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, although body checking historically has been prohibited in women\u0026rsquo;s ice hockey, female players experience higher rates of concussions (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Considering previous research from men\u0026rsquo;s junior ice hockey showing that disallowing body checking among 13\u0026ndash;14-year-old players in Alberta, Canada, resulted in a 55% reduction in IR (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), it is reasonable to hypothesize that introducing body checking in women\u0026rsquo;s ice hockey may lead to a new injury panorama.\u003c/p\u003e \u003cp\u003eDespite extensive research on body checking in men\u0026rsquo;s and youth ice hockey, there is a lack of prospective data on injury incidence following the introduction of body checking in elite women\u0026rsquo;s ice hockey. Insurance-based injury registries provide a unique opportunity to capture medically treated injuries across an entire league, independent of team medical staff or self-reported time-loss definitions.\u003c/p\u003e \u003cp\u003eIn Sweden, insurance registries have long been used for injury surveillance. All Swedish ice hockey players are insured by the same company (Gjensidige Insurance) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), which registers all injuries that result in contact with the insurance provider. The insurance covers accidental injuries occurring during matches, organized team practices, hockey school sessions, and direct travel to and from these activities.\u003c/p\u003e \u003cp\u003eWithin this insurance registry, these injuries have been prospectively recorded from 2019 to 2025. The introduction of body checking in the 2022\u0026ndash;2023 season created a natural experiment within a stable league structure, allowing longitudinal comparisons before and after the introduction and within the same competitive context.\u003c/p\u003e \u003cp\u003eAgainst this background, the aim of the present study, using nationwide insurance registry data, was to describe time trends in injuries among female elite ice hockey players and to compare injury incidence before and after the introduction of body checking.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThis prospective cohort study is based on insurance registry data from the Swedish insurance company Gjensidige Insurance. All elite female ice hockey players in the SDHL have, since 2019, been covered by a mandatory base insurance provided through Gjensidige, the principal insurance partner of the Swedish Ice Hockey Association and a long-standing main partner of Swedish ice hockey. This licensing insurance is automatically included for all registered players, including those of SDHL. In the season 2022\u0026ndash;2023, body checking was introduced in the league.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThe study includes all licensed female elite players in the SDHL between 2019 and 2025. No exclusion criteria were applied. The league consists of ten teams with approximately twenty to twenty-five players per team. The teams in the league have been largely consistent throughout the study period, with only occasional changes due to relegation and promotion based on sporting results; the only notable exception occurred in the 2022\u0026ndash;23 season when one team withdrew from the SDHL mid-season due to financial difficulties and challenges meeting player requirements, which also affected the total number of matches during this season. The temporary reduction in the number of matches during the 2022\u0026ndash;2023 season due to team withdrawal was accounted for in the exposure calculations. In addition, because players may transfer between teams or to other international leagues, the composition of each team and the league also vary over time.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCalculating injury rates (IR)\u003c/h3\u003e\n\u003cp\u003eThe IR was estimated by calculating the number of injuries per 1000 hours of game participation.\u003c/p\u003e \u003cp\u003eThe insurance registry did not allow the separation of injuries sustained during games and those sustained during team practices. Consequently, all recorded injuries were included, whereas the exposure was based only on game hours (not training hours). In elite ice hockey, however, previous epidemiological studies consistently demonstrate substantially higher injury incidence during games compared with training sessions (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Therefore, it is reasonable to assume that most insurance-registered injuries occurred during games. Because the same registration procedures and insurance conditions applied throughout the entire study period, this methodological constraint is unlikely to differentially bias comparisons between pre- and post-implementation periods. Nevertheless, absolute IR that are based only in game hours should be interpreted with caution.\u003c/p\u003e \u003cp\u003eAs in previous studies, we defined participation as the time when six players per team were on the ice for a 1-hour game (20 min for three periods, ignoring \u0026lsquo;penalty minutes and overtime minutes): 6 players \u0026times; 2 teams \u0026times; 1 hour \u0026times; number of games (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDuring the 2019\u0026ndash;2020 season, 195 game hours were played, with 198, 203, 175, 204, and 207 hours recorded in the subsequent seasons 2020\u0026ndash;2021, 2021\u0026ndash;2022, 2022\u0026ndash;2023, 2023\u0026ndash;2024, and 2024\u0026ndash;2025, respectively. For each season, we used the dates from first to last match played to define the seasons.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eInjury claims were registered prospectively from the 2019\u0026ndash;2020 season and onward for all injuries that led to contact with the insurance company. Representatives from Gjensidige Insurance recorded and classified all injuries according to standard internal procedures. The Swedish Ice Hockey Federation assisted in identifying players registered in the SDHL during the seasons 2019\u0026ndash;2020 through 2024\u0026ndash;2025 to enable the insurance company to define the study cohort, where data on the individuals was transferred pseudonymized to the research group. Gjensidige performed only the initial data processing and pseudonymization and was not involved in any statistical analyses for the present study.\u003c/p\u003e\n\u003ch3\u003eDefinition of an injury\u003c/h3\u003e\n\u003cp\u003eThe Gjensidige insurance covers accidental injuries occurring during matches, organized team practices, hockey school sessions, and direct travel to and from these activities, including international participation for up to 45 consecutive days. Only injuries that were covered by the Gjensidige insurance were included in the present study. Pre-existing injuries that occurred before getting the insurance were not covered and therefore not included in this study. If a player sustained multiple injuries, each injury was recorded as a separate injury. The insurance company covered incurred injuries and provided compensation for permanent disability following acute injuries requiring medical treatment, acute injuries necessitating physiotherapy, or dental care in cases of dental trauma.\u003c/p\u003e \u003cp\u003eThe insurance terms, eligibility criteria, compensation structure, and injury reporting procedures remained unchanged throughout the entire study period (2019\u0026ndash;2025). No modifications were made to coverage policies in connection with the introduction of body checking.\u003c/p\u003e\n\u003ch3\u003eInjury types\u003c/h3\u003e\n\u003cp\u003eIn the insurance registry, injuries were originally recorded using detailed injury codes specifying the anatomical location and injury subtype. In their original form, each code represented a distinct injury category, resulting in a large number of narrowly defined groups. For the present study, these detailed codes were aggregated into broader injury categories to facilitate meaningful analyses and prevent sparse data within individual categories.\u003c/p\u003e \u003cp\u003eThe main categories were Concussions, Face, Dental, Shoulder, Hand, Knee, Foot and \u0026ldquo;Other\u0026rdquo;. Each main category comprises several related, detailed insurance codes that reflect specific anatomical structures within the same region. This aggregation strategy was chosen to ensure clinically meaningful group sizes.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe injury incidences were presented as IR per 1000 player-game hours with 95% confidence intervals (CI). The distributions of injury type before and after the introduction of body checking were test using Fisher\u0026rsquo;s exact test. The significance level was set at p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All statistical analyses were done in R version 4.4.2 (R Core Team, 2024).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval for the project was obtained from the Swedish Ethical Review Authority (Approval number 2025-02641-01) The research is based solely on previously collected and pseudonymized registry data obtained from the Swedish Ice Hockey Association and the players\u0026rsquo; mandatory licensing insurance company (Gjensidige). No direct contact with the athletes occurred, and no clinical interventions were performed. Only variables necessary to address the scientific aims of the study were processed. Because the study involves registry-based research posing only a negligible risk to participants\u0026rsquo; privacy and using data already collected by third parties, the requirement for informed consent was waived by the Ethical Review Authority.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total 120 injuries were registered among 92 players. Descriptive statistics of the study population are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive characteristics of injured players in the Swedish Women\u0026rsquo;s Elite Ice Hockey League (SDHL) who filed an insurance claim during the study period (2019\u0026ndash;2025).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBy injury, n\u0026thinsp;=\u0026thinsp;120\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBy player, n\u0026thinsp;=\u0026thinsp;92\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), median (Q1\u0026ndash;Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.5 (\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosition, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForwards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDefensemen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoalkeepers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of injuries, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72 (79)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAcross all seasons, there was a statistically significant increase in the IR during the first season when body checking was introduced (2022\u0026ndash;2023; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), followed by a recovery in incidences (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, a clear overall increase in injury incidence was observed for all subsequent seasons (2022\u0026ndash;2025) compared with the pre-implementation period (2019\u0026ndash;2022) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInjury rates (IR) per 1,000 player game hours in the Swedish Women\u0026rsquo;s Elite Ice Hockey League (SDHL), by season and by pre- and post-implementation periods of bodychecking (2019\u0026ndash;2025).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeason\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2019\u0026ndash;2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3 (2.0, 7.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2020\u0026ndash;2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.2 (4.2, 11.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2021\u0026ndash;2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.6 (3.8, 10.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2022\u0026ndash;2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7 (11.6, 23.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2023\u0026ndash;2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.0 (5.6, 13.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2024\u0026ndash;2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.1 (5.0, 12.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSeason dichotomized\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eIR (95%CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2019\u0026ndash;2020\u0026ndash;2021\u0026ndash;2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.0 (4.4, 8.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2022\u0026ndash;2023\u0026ndash;2024\u0026ndash;2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.0 (8.6, 13.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe distribution of injury types before and after the introduction of body checking is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. No statistically significant differences in injury type distribution were observed between the pre- and post-implementation periods. Descriptively, shoulder injuries accounted for 3 (7.0%) of injuries before implementation and 11 (14.3%) after implementation. Knee injuries accounted for 9 (20.9%) and 15 (19.5%), and face injuries for 2 (4.7%) and 9 (11.7%), respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of injury types before and after introducing body checking in the Swedish Women\u0026rsquo;s Hockey League (SDHL) during 2019\u0026ndash;2025. Data is presented as n (%) and injury rates (IR) with 95% confidence intervals (CI).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjury type/location\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eIR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eBefore body checking, n\u0026thinsp;=\u0026thinsp;43\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAfter body checking, n\u0026thinsp;=\u0026thinsp;77\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBefore body checking, n\u0026thinsp;=\u0026thinsp;43\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAfter body checking, n\u0026thinsp;=\u0026thinsp;77\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcussion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e10 (13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.6 (0.6, 2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.4 (0.7, 2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0 (0.0, 0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.3 (0.0, 1.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e9 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.3 (0.0, 1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.3 (0.6, 2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.8 (0.3, 1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.9 (0.3, 1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (23.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e11 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.4 (0.7, 2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.6 (0.8, 2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e15 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.3 (0.6, 2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.1 (1.2, 3.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShoulder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e11 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.4 (0.1, 1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.6 (0.8, 2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e13 (16.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.6 (0.2, 1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.8 (1.0, 3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* Fisher\u0026rsquo;s exact test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides the first prospective, league-wide assessment of injury incidence following the introduction of body checking in elite women\u0026rsquo;s ice hockey. Using nationwide insurance registry data, we observed an increase in injury incidence after the rule change, particularly during the first post-implementation season, followed by a partial decline in subsequent seasons.\u003c/p\u003e \u003cp\u003eNo statistically significant differences in injury type distribution were observed between the pre- and post-implementation periods, in this relatively small study sample. However, face, shoulder, and knee injuries accounted for a larger proportion of injuries following the introduction of body checking. Although these observations do not prove causality and should therefore be interpreted cautiously, they may provide context for future research on body checking-associated injuries in women\u0026rsquo;s ice hockey.\u003c/p\u003e \u003cp\u003eOne plausible explanation for the observed increase in injury incidence is that female players have historically developed their sport-specific skills in an environment without intentional body contact. Limited exposure to body checking throughout development may influence neuromuscular preparedness, bracing strategies, and collision technique when full contact is introduced at the elite level (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In addition, protective equipment and rule frameworks in ice hockey have largely been developed based on male physiology and playing patterns, which may offer suboptimal protection for female players as collision intensity increases (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn contrast to several previous studies on body checking in youth and men\u0026rsquo;s ice hockey, which have reported substantial increases in concussion incidence following the introduction of body checking (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), the present study did not observe a significant increase in concussions in the present study. One explanation may be insufficient statistical power due to the relatively small size of study population. However, the discrepancy may also partly be explained by differences in injury definitions and surveillance systems. Unlike injuries such as dental trauma, facial lacerations, or knee injuries, which almost invariably lead to insurance claims due to the need for imaging or specialist care, sport-related concussions may be managed within team medical settings without activating the insurance system. Concussion is a clinical diagnosis, and routine neuroimaging (CT or MRI) is not recommended in uncomplicated cases (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). As access to imaging often is necessary for initiating insurance claims, this may result in underrepresentation of concussions in insurance-based datasets.\u003c/p\u003e \u003cp\u003eThe increased number of facial and dental injuries observed after the introduction of body checking in the present study occurred despite the mandatory use of face grids in women\u0026rsquo;s ice hockey. This finding indicates a need for improved protective equipment for female players. Importantly, body checking in women\u0026rsquo;s ice hockey may not necessarily mirror that in the men\u0026rsquo;s game, nor should they be assumed to do so. This underscores the need for sex-specific research to better understand the body checking mechanism and appropriate safety strategies specifically for women\u0026rsquo;s ice hockey.\u003c/p\u003e \u003cp\u003eThe decline in injury observed after the initial post-implementation season suggests a potential adaptation effect over time. This pattern may indicate a short-term transitional phase following rule implementation rather than a continuously increasing injury trajectory. It may reflect improvements in player technique, increased on-ice awareness and anticipation of contact situations, or greater familiarity with physical contact. However, these interpretations are speculative and should be interpreted with caution. Future studies incorporating detailed exposure data and biomechanical analyses are needed to determine whether true adaptation effects occur following the introduction of body checking. Importantly, body checking itself may not be the sole contributing factor to the increased injury incidence observed after the rule change. Rather, changes in match dynamics, such as higher game intensity, increased speed, or cumulative fatigue, may also contribute to injury risk. The rule change may also have influenced the frequency and nature of physical engagements, which could further affect injury risk.\u003c/p\u003e \u003cp\u003eAlthough body checking was associated with a higher IRs in this study, the findings should be interpreted within a broader context of sport development and gender equity (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Physical contact is a fundamental component of ice hockey, and the introduction of body checking may contribute to legitimizing women\u0026rsquo;s ice hockey as a physically demanding and high-intensity sport. Notably, female elite players have expressed positive attitudes toward the introduction of body checking (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn elite women\u0026rsquo;s ice hockey, an IR of 22.0 injuries per 1,000 player-game hours has been reported during the Women\u0026rsquo;s World Championships, where body checking is prohibited (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In men\u0026rsquo;s elite ice hockey, substantially higher IRs have been reported, including 88.6 injuries per 1,000 game hours in the Swiss professional league (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) 74.1 in Swedish male elite players (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), 52.1 during the Olympic Games(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), 47.4 in the Finnish top league (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and 49.4 in the NHL (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The IR discrepancy may stem from differences in skating speed, facial protection, and fighting in men\u0026rsquo;s ice hockey.\u003c/p\u003e \u003cp\u003eDespite the observed increase in injury incidence following the introduction of body checking, the IRs reported in the present study do not appear higher than those reported in other elite ice hockey leagues, including men\u0026rsquo;s competitions. However, these discrepancies are likely also explained primarily by differences in injury definitions and surveillance methods, as the present study captured only injuries resulting in insurance claims, whereas most previous studies included time-loss injuries or all injuries requiring medical attention. In addition, structural and contextual differences between women\u0026rsquo;s and men\u0026rsquo;s ice hockey may further contribute to the observed differences in IRs. Men\u0026rsquo;s ice hockey is characterized by higher skating speeds, the allowance of fighting at certain levels, and differences in protective equipment, such as the use of visors rather than full face grids all of which may influence IR (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Consequently, direct comparisons of IRs across studies and between sexes should be interpreted with caution. On the other hand, studying temporal trends within the same setting and a comparable population, as in the present study, provides complementary relevant information.\u003c/p\u003e \u003cp\u003eIn addition, similar increases in injury risk have been observed on the men\u0026rsquo;s side following the introduction of body checking (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). By making women\u0026rsquo;s ice hockey more comparable to the men\u0026rsquo;s game, body checking may represent an important component in the continued development of the sport. Consequently, these findings do not necessarily argue for prohibiting body checking in women\u0026rsquo;s ice hockey, but rather underscore the importance of carefully designing its introduction to minimize injury risk while supporting the sport\u0026rsquo;s ongoing development.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eA major strength of this study is the long observation period, encompassing multiple seasons both before and after the introduction of body checking, with consistent data collection procedures and injury definitions applied throughout the study period. The use of a single, nationwide insurance registry including all licensed SDHL players minimizes selection bias and ensures comprehensive coverage of medically treated injuries within the league. The natural experiment created by the rule change enables meaningful temporal comparisons within a stable competitive context. Importantly, this study addresses a notable research gap in female athlete health research (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), by generating novel data on injuries associated with body checking in women\u0026rsquo;s ice hockey, an area that has not previously been examined.\u003c/p\u003e \u003cp\u003eSeveral limitations should also be acknowledged. The insurance registry captures only injuries that resulted in contact with the insurance provider and required medical care, meaning that less severe injuries and illnesses that may still have caused time loss were not included (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). As a result, the reported injury incidence likely reflects more severe injuries and may underestimate the overall injury burden. Illness-related absences were not covered by the insurance system and were therefore not captured. Injury classification was performed by insurance personnel without formal medical training, which may have introduced some degree of misclassification.\u003c/p\u003e \u003cp\u003eIn particular, it may be challenging for non-medically trained personnel to distinguish between related diagnostic entities such as head injury, skull injury, and concussion. As a result, some degree of overlap or misclassification between these categories cannot be excluded. Similar challenges may apply to other injury classifications within the registry, as diagnoses were based on insurance documentation rather than standardized clinical assessments performed by sports medicine professionals. Consequently, the injury categorization should be interpreted with this in mind. Additionally, some players may have sought care through private insurance or alternative healthcare pathways, potentially leading to underreporting.\u003c/p\u003e \u003cp\u003eAnother limitation relates to the introduction of the insurance system in 2019, which may have been associated with limited awareness during the early seasons. Increased familiarity with the insurance coverage over time could have contributed to higher reporting rates in later seasons, potentially influencing observed time trends. Although reporting awareness may have increased over time, the relatively stable IR observed during the three pre-implementation seasons suggests that the abrupt increase observed in 2022\u0026ndash;2023 is unlikely to be explained solely by gradual improvements in insurance familiarity. As with all observational studies, causality cannot be established; however, the close temporal proximity between the introduction of body checking and the observed increase in injury incidence supports a meaningful association.\u003c/p\u003e \u003cp\u003eThe inability to separate match-related and practice-related injuries represents an additional limitation. However, because match injuries are known to occur at substantially higher rates than training injuries in elite ice hockey (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), and because this limitation applied equally across all seasons, the internal comparison between periods is unlikely to be substantially biased. Finally, comparisons of IRs across studies should be made with caution due to differences in injury definitions, exposure calculations, and injury surveillance methods used in ice hockey research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe introduction of body checking in the Swedish Women\u0026rsquo;s Elite Ice Hockey League was associated with an increased injury incidence, particularly during the first season following implementation. Although no statistically significant differences in injury type distribution were observed, descriptive patterns indicated a larger proportion of face, shoulder, and knee injuries after the rule change. The partial decline in injury incidence in subsequent seasons suggests a potential adaptation over time. These findings do not argue against the inclusion of body checking in women\u0026rsquo;s ice hockey but highlight the importance of carefully considering how such rule changes are introduced. Future studies are needed to evaluate strategies for introducing body checking in ways that support player safety while facilitating the continued development of the sport.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval for the project was obtained from the Swedish Ethical Review Authority (Approval number 2025-02641-01)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and material\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Data analysis were performed by [AG]. The first draft of the manuscript was written by [AL], and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Gjensidige Insurance Company and the Swedish Ice Hockey Association for their support and collaboration in facilitating this study. In particular, we acknowledge John Lind, Oscar Hallberg and Morgan Johansson for their valuable assistance in coordinating and enabling the research process. The authors declare that there are no financial relationships or conflicts of interest between the research group, Gjensidige Insurance Company, or the Swedish Ice Hockey Association.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSvenska Ishockeyf\u0026ouml;rbundet. 28 procent fler dam- och flickspelare. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLahti A, Grundberg A, Stenman E, Sundquist K. Physical Characteristics of Swedish Female Professional Ice Hockey Players Allowed Body Checking. J Strength Cond Res. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeaving C, Roberts S. Checking in: an analysis of the (lack of) body checking in women's ice hockey. Res Q Exerc Sport. 2012;83(3):470\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilcox BJ, Machan JT, Beckwith JG, Greenwald RM, Burmeister E, Crisco JJ. Head-impact mechanisms in men's and women's collegiate ice hockey. J Athl Train. 2014;49(4):514\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePierpoint LA, Collins C. Epidemiology of Sport-Related Concussion. Clin Sports Med. 2021;40(1):1\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacCormick L, Best TM, Flanigan DC. Are There Differences in Ice Hockey Injuries Between Sexes? A Systematic Review. Orthop J Sports Med. 2014;2(1):2325967113518181.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbbott K. Injuries in Women\u0026rsquo;s Ice Hockey: Special Considerations. Curr Sports Med Rep. 2014;13(6):377\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmery C, Galarneau J-M, Palacios-Derflingher L, Black AM, Eliason P, Krolikowski M, et al. Does disallowing body checking in non-elite 13- to 14-year-old ice hockey leagues reduce rates of injury and concussion? A cohort study in two Canadian provinces. Br J Sports Med. 2020;54(7):414\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGjensidige. V\u0026aring;rdf\u0026ouml;rs\u0026auml;kring Idrott 2025 [2026-02-20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gjensidige.se/partners/vardforsakring-idrott\u003c/span\u003e\u003cspan address=\"https://www.gjensidige.se/partners/vardforsakring-idrott\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson GR, Melugin HP, Stuart MJ. Epidemiology of Injuries in Ice Hockey. Sports Health. 2019;11(6):514\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuominen M, Stuart MJ, Aubry M, Kannus P, Parkkari J. Injuries in men's international ice hockey: a 7-year study of the International Ice Hockey Federation Adult World Championship Tournaments and Olympic Winter Games. Br J Sports Med. 2015;49(1):30\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuominen M, Stuart MJ, Aubry M, Kannus P, Tokola K, Parkkari J. Injuries in women's international ice hockey: an 8-year study of the World Championship tournaments and Olympic Winter Games. Br J Sports Med. 2016;50(22):1406\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuzuki K, Yoneoka D, Terada M, Kenjo K, Koyanagi T, Suzuki Y. Injury rate and characteristics in Japanese male professional ice hockey players: prospective study of 60 players over 10 seasons. BMJ Open Sport Exerc Med. 2024;10(1):e001720.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHirvel\u0026auml; J. Acute injuries in male elite ice hockey players. A prospective cohort study JSAMS Plus; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeming EE, Sobry AJ, Cairo AL, Williamson RA, Kolstad AT, West SW, et al. Higher Rates of Head Contacts, Body Checking, and Suspected Injuries in Ringette Than Female Ice Hockey: Time to Ring in Opportunities for Prevention. Clin J Sport Med. 2023;33(2):151\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmery CA, Eliason P, Galarneau J-M, Warriyar V, Palacios-Derflingher L, Black AM, et al. Body checking in non-elite adolescent ice hockey leagues: it is never too late for policy change aiming to protect the health of adolescents. Br J Sports Med. 2022;56(1):12\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmery CA, Kang J, Shrier I, Goulet C, Hagel BE, Benson BW, et al. Risk of Injury Associated With Body Checking Among Youth Ice Hockey Players. JAMA. 2010;303(22):2265\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmery C, Kang J, Shrier I, Goulet C, Hagel B, Benson B, et al. Risk of injury associated with bodychecking experience among youth hockey players. CMAJ. 2011;183(11):1249\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport\u0026ndash;Amsterdam, October 2022. British Journal of Sports Medicine. 2023;57(11):695\u0026ndash;711.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunner R, Bizzini M, Niedermann K, Maffiuletti NA. Epidemiology of Traumatic and Overuse Injuries in Swiss Professional Male Ice Hockey Players. Orthop J Sports Med. 2020;8(10):2325967120964720.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePettersson M, Lorentzon R. Ice hockey injuries: a 4-year prospective study of a Swedish \u0026eacute;lite ice hockey team. Br J Sports Med. 1993;27(4):251\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKay CD, Tufts RJ, Shaffer B, Meeuwisse WH. The epidemiology of professional ice hockey injuries: a prospective report of six NHL seasons. Br J Sports Med. 2014;48(1):57\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacpherson A, Rothman L, Howard A. Body-Checking Rules and Childhood Injuries in Ice Hockey. Pediatrics. 2006;117:e143\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlack AM, Hagel BE, Palacios-Derflingher L, Schneider KJ, Emery CA. The risk of injury associated with body checking among Pee Wee ice hockey players: an evaluation of Hockey Canada's national body checking policy change. Br J Sports Med. 2017;51(24):1767\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD'Lauro C, Jones ER, Swope LM, Anderson MN, Broglio S, Schmidt JD. Under-representation of female athletes in research informing influential concussion consensus and position statements: an evidence review and synthesis. Br J Sports Med. 2022;56(17):981\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahr R, Clarsen B, Derman W, Dvorak J, Emery CA, Finch CF, et al. International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE Extension for Sport Injury and Illness Surveillance (STROBE-SIIS)). Br J Sports Med. 2020;54(7):372\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sports-medicine-open","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"smoa","sideBox":"Learn more about [Sports Medicine-Open](http://sportsmedicine-open.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/smoa/default.aspx","title":"Sports Medicine-Open","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8951107/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8951107/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eIn 2022, the Swedish Women\u0026rsquo;s Elite Ice Hockey League (SDHL) became the first women\u0026rsquo;s league to introduce bodychecking. Using insurance data, this study examined injury incidence before and after the implementation of this rule.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eSince 2019, the SDHL has comprised 10 teams with 20\u0026ndash;25 players on each. All players in SDHL have license insurance to take care of ice hockey injuries. All injuries that lead to contact with the insurance company are registered in a database. The insurance covers accidental injuries occurring during matches, organized team practices, hockey school sessions, and direct travel to and from these activities. Injury data from all seasons between 2019\u0026ndash;2020 until 2024\u0026ndash;2025 were analyzed. Injury rates (IR) per 1,000 player game hours were calculated and compared across seasons and between pre-implementation (2019\u0026ndash;2022) and post-implementation (2022\u0026ndash;2025) periods.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 120 injuries were recorded. IR per 1,000 player game hours increased sharply from 6.6 (95% CI 3.8\u0026ndash;10.7) in season 2021\u0026ndash;2022 to 16.7 (11.6\u0026ndash;23.2) in 2022\u0026ndash;2023, with moderately elevated rates remaining in subsequent seasons. When grouped by period before and after bodychecking implementation, IR increased from 6.0 (4.4\u0026ndash;8.1) pre-implementation to 11.0 (8.6\u0026ndash;13.7) post-implementation (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The injury incidence was highest during the first season with body checking and a decline in injury incidence was found post-implementation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe introduction of bodychecking in the SDHL was associated with a significant increase in injuries recorded through the insurance system, indicating that this rule change may lead to a higher injury burden. Future studies should evaluate strategies for introducing body checking in women\u0026rsquo;s ice hockey in ways that minimize injury risk.\u003c/p\u003e","manuscriptTitle":"Injury Incidence Before and After the Introduction of Body Checking in Elite Women’s Ice Hockey: A 7-Year Prospective Insurance-Based Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-09 11:39:27","doi":"10.21203/rs.3.rs-8951107/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revision","date":"2026-03-30T15:02:36+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2026-03-10T15:54:54+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-05T03:07:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Sports Medicine-Open","date":"2026-03-03T08:17:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-24T13:50:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"Sports Medicine-Open","date":"2026-02-23T18:16:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sports-medicine-open","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"smoa","sideBox":"Learn more about [Sports Medicine-Open](http://sportsmedicine-open.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/smoa/default.aspx","title":"Sports Medicine-Open","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a78b2154-d1a8-465b-bdaa-d7ecc7450fea","owner":[],"postedDate":"March 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T13:28:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-09 11:39:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8951107","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8951107","identity":"rs-8951107","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}