The Burden of Shoulder Problems in Handball Players and how can we Minimize it

05-09-2018

Blog Post van Martin Asker PhD

The burden of shoulder problems in handball players and how can we minimize it

Handball is a physical demanding sport with a lot of sprints, side cutting movement, jumps, tackling and wrestling and on top of that a very specific repeated movement; throwing (1-3). In this short blog I will give an overview of the burden of shoulder problems in handball players, why they often get injured and what we can do to reduce the risk of developing shoulder problems.

The prevalence of shoulder problems

If we look at the data register from insurance companies we see that shoulder injuries are very rare in handball. But anyone who has worked with handball players knows that this in not the case. It just that most of the shoulder injuries in handball doesn't get reported to the insurance companies. So it comes down to the definition to a shoulder injury. Recently several studies have used a different definition of an injury than the commonly used “time loss” or “seeking medical care” definitions. One that I would say would suit better for shoulder injuries in handball. One where the player reports if he/she has had shoulder pain, and if he/she has reduced his/her training or performance the last week due to shoulder problems. One of the most commonly used system for this is the Oslo Sport Trauma Research Center Overuse Injury Questionnaire (4). With this definition we see totally different numbers, with a season prevalence of substantial shoulder problems between 23-28% (5-8). Further a majority of players who sustain shoulder problems reports shoulder problems the following season (7).

Why do they develop shoulder problems?

The easy answer to “why” is because they play handball and if they would stop playing handball most of the problems would go away. On a serious note, if we look beyond this, the research on risk factors for shoulder injuries in overhead injuries is scarce (9). The few studies that have looked into this show that shoulder weakness and rapid spikes in handball load is associated with a higher risk of developing shoulder problems (5,6,8,10). Merete Møller and her colleagues nicely showed that a rapid increase in weekly handball load increased the risk of shoulder problems and that the players with shoulder weakness or scapula dyskinesia had lower tolerance to increase in weekly handball load (8). However, if the increase in weekly load was greater than 60% it did not matter if the player had scapula dyskinesia or was weaker in the shoulder, they all had the same higher risk of shoulder injuries. Range of motion (ROM) deficit has been suggested to be a risk factor several studies on overhead athletes but the studies on handball are inconclusive and contradictive (5,6,8). One reason for this could be that a) the ROM we measure on the bench does not necessary correlate with what happens when the players throw and b) it doesn't tell us what structure limiting the ROM. Other factors such as, trunk mobility, joint position sense and posture have also been suggested to be a risk factor but there are today no studies that have evaluated these theories.

Is it preventable?

Based on the current research prevention strategies for shoulder problems in handball should be based on strengthening the shoulder, especially external rotational strength and avoiding rapid spikes in handball load. There is today only one study evaluating the effect of a prevention programme targeting this factors (6), but there are on-going studies as well (11). Andersson et al. showed that elite senior player that performed a shoulder programme as a warm-up routine during the handball season reduced the prevalence of substantial shoulder problems by 28% (6). However, as with many injury prevention programme, it is hard to get the player to comply to the programme and in this case the player on average only did the programme 1.6 times week instead of the recommended 3 times per week. So there is room for improvement.

In summary

Shoulder injuries are a substantial problem in handball, and it starts already at an early age. Shoulder weakness and rapid spikes in handball load seems to be the biggest risk factors for developing non-traumatic shoulder injuries. A 10-min warm-up routine focusing on shoulder strength, coordination and mobility has shown to reduce the prevalence in handball players. But, it only works if the players comply with it!

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2. Michalsik LB, Aagaard P, Madsen K. Locomotion characteristics and match-induced impairments in physical performance in male elite team handball players. Int J Sports Med 2013: 34: 590-9.

3. Michalsik LB, Madsen K, Aagaard P. Match performance and physiological capacity of female elite team handball players. Int J Sports Med 2014: 35: 595-607.

4. Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: the Oslo Sports Trauma Research Centre (OSTRC) overuse injury questionnaire. Br J Sports Med. 2013: 47: 495-502.

5. Clarsen B, Bahr R, Andersson SH, Munk R, Myklebust G. Reduced glenohumeral rotation, external rotation weakness and scapular dyskinesis are risk factors for shoulder injuries among elite male handball players: a prospective cohort study. Br J Sports Med 2014: 48: 1327-33.

6. Andersson SH, Bahr R, Clarsen B, et al. Preventing overuse shoulder injuries among

throwing athletes: a cluster-randomised controlled trial in 660 elite handball players. Br J

Sports Med Published Online Frist: 16 June 2016. doi: 10.1136/bjsports-2016-096226.

7. Asker, M., Holm, L.W., Källberg, H. et al. Female adolescent elite handball players are more susceptible to shoulder problems than their male counterparts. Knee Surg Sports Traumatol Arthrosc. 2018 26:1892. https://doi.org/10.1007/s00167-018-4857-y

8. Moller M, Nielsen RO, Attermann J, et al. Handball load and shoulder injury rate: a 31-

week cohort study of 679 elite youth handball players. Br J Sports Med 2017;51(4):231-7.

9. Asker M, Brooke HL, Waldén M, et al. Risk factors for, and prevention of, shoulder injuries in overhead sports: a systematic review with best evidence synthesis. Br J Sports Med Epub ahead of print: doi:10.1136/ bjsports-2017-098254

10. Forthomme B, Croisier JL, Delvaux F, Kaux JF, Crielaard JM, Gleizes-Cervera S.

Preseason Strength Assessment of the Rotator Muscles and Shoulder Injury in Handball Players. J Athl Train. 2018 Feb;53(2):174-180. doi: 10.4085/1062-6050-216-16. Epub 2018 Jan 17.

11. http://www.isrctn.com/ISRCTN15946352

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