Alex Pietrangelo: How Far Back Should We Look?

Alex Pietrangelo: How Far Back Should We Look?

When Alex Pietrangelo stepped away from hockey because of severe problems with both hips, the discussion understandably centred around the hips.

His condition had progressed to the point where bilateral femur reconstruction was being discussed. After more than 1,100 NHL games, that can easily be viewed as the price of an extraordinarily long career playing one of the most physically demanding sports in the world.

And maybe that’s exactly what it is.

But when I started going backwards through Pietrangelo’s history, I found myself wondering whether the story of his hips actually began much earlier.

How far back should we look?

Pietrangelo entered the NHL with St. Louis as an 18-year-old in October 2008.

In just his second NHL game, he was hit from behind into the boards and sustained what was reported as a head injury. He subsequently missed six games.

I think it’s important to be precise here. I haven’t found enough reliable contemporary reporting to definitively label that injury a diagnosed concussion. What we know is that there was significant head trauma followed by missed time.

For the purpose of looking at his injury history, that’s enough to get my attention.

Not because I believe that hit caused what happened to his hips 16 years later.

It didn’t suddenly damage his femurs.

What interests me is whether an event like that can influence what happens next.

What happened below the head?

This is where Pietrangelo’s history becomes more interesting.

Over the years that followed, lower-body problems begin appearing in his injury record. There were foot and lower-body issues, and in 2016 he sustained a right knee injury significant enough to miss multiple games. Other lower-body absences followed during his career before the hip problems eventually became the dominant issue.

Taken individually, none of those injuries is particularly remarkable for an NHL defenseman.

Put them together and I become more curious.

There is now a growing body of research showing that athletes who sustain concussions have an increased risk of subsequent musculoskeletal injury, particularly through the lower extremity. Studies have found changes in gait, postural control, reaction time and neuromuscular function that may persist after an athlete has returned to sport.

That doesn’t mean Pietrangelo’s head injury caused his knee injury.

And it certainly doesn’t mean it caused his hips to deteriorate years later.

But it does challenge the idea that once the symptoms of a head injury disappear, everything below the head necessarily returns to exactly the way it functioned before.

That’s an important distinction.

An injury can resolve while an adaptation remains

This is something I’ve become increasingly interested in throughout my career.

We tend to organize injury histories according to body part.

Head injury.

Resolved.

Knee injury.

Resolved.

Foot injury.

Resolved.

Hip injury.

New problem.

But the body doesn’t necessarily experience injuries as isolated chapters.

It adapts.

After an injury, the athlete finds a way to keep moving. Usually that adaptation is incredibly effective. That’s one of the reasons elite athletes are elite athletes.

But what if a small part of that adaptation remains?

A subtle change in visual or vestibular processing. A different cervical strategy. A small alteration in balance or proprioception. A change in how the athlete positions the trunk over the pelvis or distributes force between the legs.

None of those things has to produce pain.

In fact, the athlete may perform at an elite level for years.

But then we add something important.

Repetition.

An NHL player doesn’t perform a skating movement a few hundred times. Over a career like Pietrangelo’s, we’re talking about an extraordinary amount of repeated loading.

Small adaptations become much more interesting when they’re repeated for 15 years.

The lower-body injuries may be part of the story

This is also why I wouldn’t draw a straight line from Pietrangelo’s head injury to his hips.

There are other stops along the way.

His knee matters.

His foot and other lower-body problems matter.

Every significant injury potentially changes the way an athlete loads, moves and compensates. A knee injury can influence the hip. A foot restriction can change rotation through the entire leg. A hip can compensate for something below it just as easily as it can compensate for something above it.

So perhaps Pietrangelo’s eventual bilateral hip pathology wasn’t the result of one thing.

That’s usually not how I see complex cases anyway.

Maybe we’re looking at layers.

Head trauma.

Lower-body injury.

Compensation.

More injury.

Thousands of hours of skating.

Age.

Structural anatomy.

Training and competition load.

And eventually a system that can no longer compensate.

The final diagnosis may simply be where all of those layers finally became visible.

Why both hips?

This is the part of Pietrangelo’s story that interests me most.

We’re not talking about one hip that was injured during a particular play.

Both hips became severely problematic.

When I see bilateral findings, I start thinking centrally.

What is influencing both sides?

How is the pelvis positioned and moving? What is happening at the sacrum? How is the lumbar spine interacting with the pelvis? How is the thorax positioned above it?

And then I keep going.

The cervical spine.

The cranial base.

The visual and vestibular systems.

The nervous system.

My osteopathic background makes the relationship between the cranium and sacrum particularly interesting to me. There are anatomical, neurological, fascial and mechanical relationships extending from the head through the spine toward the pelvis and sacrum.

That doesn’t mean a head injury mechanically caused Pietrangelo’s hip pathology.

I’m not making that claim.

But if I’m assessing someone with significant bilateral hip problems and I know there was substantial head trauma earlier in their history, I’m absolutely going to investigate it.

Why wouldn’t I?

If I treat or correct something around the cranial base or cervical spine and nothing changes at the pelvis or hips, I’ve learned something.

But if hip rotation changes, pelvic mechanics change, balance changes or the athlete suddenly organizes movement differently, I’ve learned something too.

That’s what reassessment is for.

There’s another part of Pietrangelo’s story

In 2017, Pietrangelo and his wife, Jayne, went through something far bigger than hockey.

Their infant daughter became critically ill and was eventually diagnosed with a rare neurological condition. Pietrangelo stepped away from the Blues to be with his family while his daughter was fighting for her life.

She ultimately recovered.

I include this for a reason, but probably not the reason some people might assume.

I’m not suggesting emotional trauma caused Pietrangelo’s hip problems.

I’m suggesting that when we take someone’s history, life belongs in the history too.

Professional athletes aren’t collections of joints and muscles.

They’re people.

Fear, stress, lack of sleep, uncertainty and prolonged emotional strain affect the nervous system. They affect recovery. They affect autonomic state. They can affect muscle tone, breathing, pain perception and the ability to recover from physical load.

How significant was that period physiologically for Pietrangelo?

I have no idea.

Neither does anyone looking at his medical history from the outside.

But if he were sitting in front of me, I’d want to know.

Because I’m not only interested in what happened to his knee in 2016 or what an MRI eventually showed in his hips.

I’m interested in what his body has experienced.

Eventually, the hips couldn’t keep going

By the 2024–25 season, Pietrangelo was requiring increasing amounts of preparation and treatment simply to practice and play. Eventually those interventions provided less and less relief.

The problem had reached a different level.

When he later discussed his hips, Pietrangelo acknowledged that the issue probably started a long time ago.

That statement sticks with me.

Because that’s often exactly what happens with complex problems.

The day someone can no longer play isn’t necessarily the day the problem started.

The MRI isn’t the beginning of the story.

The surgery isn’t either.

Sometimes you have to go backwards.

I don’t know where Pietrangelo’s hip problems started

That’s the important conclusion.

Maybe they started with his anatomy and the demands of skating.

Maybe decades of NHL hockey explain almost everything.

Maybe previous lower-body injuries changed how he loaded his hips.

Maybe there were adaptations following his early head trauma that deserve consideration.

Maybe physical load and emotional load interacted at different points in his career.

Or maybe some of those things had absolutely nothing to do with his hips.

From the outside, we can’t know.

But that’s exactly why the history matters.

I wouldn’t look at Pietrangelo’s history and draw a line from his head to his hips.

I’d draw a lot of lines.

Then I’d start assessing which ones actually matter.

That’s Reconditioning to me.

Not deciding where the problem came from before you’ve assessed the person.

It’s being willing to look beyond the diagnosis, understand everything that came before it, implement a corrective solution and then let reassessment tell you whether you’re moving in the right direction.

Because when both hips eventually become the problem after more than 15 years of injuries, adaptations, load and life, I’m not satisfied simply knowing what’s damaged.

I want to know what the body has been adapting to all along.