SPORTS SURGERY

SHOULDER ISSUES IN HANDBALL Are there any or are handball players either lucky, well-prepared or just under-investigated?

– Written by Prim. Mladen Miškulin, Željka Jaklinovic, Goran Vrgoc, Croatia

A systematic approach to sports injury The reported estimates of either acute acceleration and stoppage in all directions, investigation has provided strong evidence or chronic shoulder pain incidence in quick changing of direction, jumps of about injury incidence rates in various handball players ranges between 30 and various kinds and body contact. The primary sports revealing that soccer and handball 45% of the population6. However, despite aim of the game is two-fold: to score by are the most risky summer Olympic Games this and the previous point, a search of the throwing, shooting the handball, precisely sports relative to exposure time and injury most acknowledged research databases and powerfully, in spite of the goalkeeper severity1. Both are classified into the group (MEDLINE®, WoS) using the terms ‘handball’, in his/her goal and to prevent the opponent of the most dangerous sports together with ‘shoulder’ and ‘injury’7,8, only a few studies from scoring. ice hockey, American football, Australian have focused specifically on shoulder A handball shooting motion involves Rules football and rugby2. Injuries in injuries or shoulder conditions/issues in the whole body and highly co-ordinated handball, either acute or chronic, have been handball players. This is surprising when we movement patterns that culminates investigated relatively well in general in consider the fierce nature of this dynamic in an accurate ballistic motion of the the last couple of decades, especially during team game as well as the mechanical throwing arm. It exposes the throwing the 1990s3. According to the findings in loads that shoulder structures, especially of arm-related musculoskeletal structures these studies, shoulder injuries in handball the throwing arm, have to sustain during to supraphysiological kinematic loads are either the third most frequent injury, handball competition and training. and motions. Most throwing motions immediately after ankle and knee injuries4, The game of handball imposes strenuous in handball are performed above 90° of or the fourth (fingers, knees, ankles)5. demands on players by combining quick shoulder abduction, thus classifying the

160 Figure 1: Impossible throw (Image provided by the Croatian Handball Federation).

game as an ‘overhead sport’. Mechanisms the goal i.e. jump shots and dive shots), but Last but not least, the phase of attack of overhead throwing and shoulder also because there are many body contacts is not the only phase of the game where medical conditions in overhead sports with the opponent defensive players, who players’ shoulder can be injured. Injuries (like baseball, softball, swimming, weight- are trying to prevent the shooter from often happen while defending, when lifting, tennis) have been investigated and his/her shooting performance using any a defence player tries to prevent the explained rather satisfyingly in general9-16, possible method not prohibited by the penetration of an attacker. In this case the especially in research studies on baseball, rules (Figure 1). Yet, interfering actions shoulder, usually positioned in abduction the American national sport17-21. Basically, very often exceed the borders determined and external rotation, can be literally in regards to the shoulder and the arm, by the rules. Therefore, in an actual game, ‘pushed’ and dislocated by the attacker’s the overhead throwing motion pattern is shooting at the goal is almost never ‘basic’; accelerating body. If the trauma is repeated, usually performed through 5 phases: numerous modifications are applied by the shoulder becomes unstable, a condition 1. wind-up, attackers according to the play situation on which requires surgery followed by a long 2. cocking (early and late), the court and each player’s characteristic, period of recovery. For the two latter injury- 3. acceleration, anthropological and situational playing inducing mechanisms one should refer to 4. deceleration and position. research literature on rugby and American 5. follow through phase. The shoulder is not at risk because football or even judo25,26 since the data from It also recruits the inferior glenohumeral of throwing alone; there are numerous handball, if any, are scarce. ligament and capsule, which act as activities in handball that can cause shoulder the primary static anterior restraint. injury. Body contact with the opponent Furthermore, the deltoid muscle elevates is one of the possible trauma-inducing the humerus while the rotator cuff adjusts situations, as already stated. A player can most throwing the position of the humeral head on the be pushed, or somehow unbalanced, which glenoid. The pectoralis major and latissimus can provoke unexpected and unprepared motions in dorsi power the shoulder forward22,23. landing and fall, or the shooter’s arm may be However, throwing in handball, not pulled during the cocking phase or blocked handball are exclusively overhead, is a much more during the acceleration, deceleration or performed above complex activity than throwing in baseball, follow-through phase. Our investigation not only due to many different types confirmed that the injuries caused by the 90° of shoulder of shooting or passing the ball (it was explained mechanism are rather difficult documented there are more than 40 types and serious, often requiring long-term abduction of either supported or airborne throws at treatment or even surgery24.

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Figure 2: Rope technique in acute acromioclavicullar dislocation, 1 month postoperative.

require a certain period of rest that could last for several weeks before throwing can be resumed. According to our experience, the healing process could be sped up with the local application of platelet-rich plasma (PRP). The highest-grade sprain or acromioclavicular dislocation (4 to 6 Grade according to the Rockwood’s classification), being among the most serious shoulder injuries, have to be approached surgically immediately. The first author’s treatment of choice is arthroscopic acromioclavicular stabilisation using rope techniques (Figure 2). Any delay in treatment leads the dislocation into the chronic phase requiring a more complex surgery using not only SHOULDER INJURIES IN HANDBALL continued afterwards, coupled with rest ropes but also gracillis tendon transfer and, According to the previous studies on and physiotherapeutic procedures. The naturally, a much longer period of recovery handball, other overhead sports and our player will be able to return to the court and absence from the activity. investigation24, we can divide handball immediately or after a few minutes and The next most serious acute shoulder shoulder injuries in two major groups: continue to play, but the next morning injuries are shoulder dislocations and traumatic, acute injuries and overuse he/she will experience stiffness and pain shoulder tendon tears that may cause long- syndromes. Both of these have a large when first trying to perform movements. term absence from the court. There is a spectrum of consequences on quality of life Contusions usually do not cause any consensus among shoulder surgeons that and sport engagement. While the prevalence absence from sport activity, especially even the first dislocation of the dominant and severity of shoulder injury in handball during particular tournaments such as arm shoulder should be treated surgically players was found to be significant, we note national championships, when the rhythm (Figure 3). The risk of the second dislocation that no players ceased participation because of matches is not as hectic as in the regular is age- and sport-related. According to of their injury. tournament competition. McLaughlin and Cavallaro27 and Rowe28 The simplest and the most common Shoulder sprains, very often involving the the risk of the second dislocation is almost injuries are certainly contusions treated acromioclavicular joint, are the next in line, 90% in patients under the age of 20 and on a daily basis by therapists and players not only by incidence but also by seriousness. decreases to a 10% risk in the population themselves. They usually have no negative The major pathological mechanism is a fall over 40 years of age. On the other hand, in effect on a player. A contusion may be on the shoulder. Acromioclavicular sprains contact sports the risk of second dislocation incurred in any phase of the game by are often very painful even when there is is almost 100% if the first dislocation has either contact with another player or a no coraco-acromial ligament lesion. The been treated conservatively and the player fall. The treatment is a rather simple one – acromioclavicular joint is usually swollen wants to continue playing at the pre-injury cryotherapy should be applied immediately and there is no pathological motion in level29. The authors also prefer a surgical in situ, on the bench or on the court between acromion and distal end of the approach, but would like to underline the during the play stoppage, and should be clavicle bone. Even the lowest grade sprains following: both shoulders are ‘dominant’

162 Figure 3: Essential lesion of the instable shoulder. Bankart’s lesion together with Hill-Sachs lesion, both confirmed during arthroscopic capsulolabral reconstruction. Figure 4: Authors’ method of choice in SLAP reconstruction – in handball since a player does not use double loaded anchor arms exclusively for shooting, but also and the ‘saddle’ knots. for the performance of gross movements, SLAP=superior labrum anterior to posterior. landing and many playing-position- specific technical-tactical tasks in attack and defence. In fact, in our study24 more shoulder dislocations were incurred in the phase of defence and involved a non- throwing hand. The authors’ preferred treatment is an arthroscopic capsulolabral reconstruction with the mean time away from sport and full handball activities of about 6 months. Unfortunately, shoulder surgery is not as common as knee ligament surgery and specialised shoulder surgeons are not widely available. Consequently they are less accessible to injured players. Injuries that should be treated shoulder strengthening and stretching In addition, players tend not to be familiar conservatively are mild shoulder sprains, exercises (‘shoulder 10’, scapular with the procedure and postoperative distensions of the long head of the rehabilitation, sleeper stretch etc) aimed recovery and therefore try to avoid surgery biceps tendon or partial supraspinatus at restoring normal mechanisms of the in favour of conservative treatment. Such tendon tears. The usual treatment is shoulder joint. Unfortunately, the period a decision usually initiates the pathology rest from specific activities and a period without activity can be even longer than cascade because, after their return to of physiotherapy followed by specific the recovery period after shoulder surgery. the sport activity, the next major contact may, and usually does, provoke a second dislocation and a vicious circle begins: the shoulder becomes unstable, provoking bony defects that require open surgical both shoulders are procedures (the Latarjet procedure). Rotator cuff tears or SLAP tears (superior labrum anterior to posterior) also require ‘dominant in handball arthroscopic surgery. The authors’ preferred procedure for arthroscopic reconstruction since a player uses their is the utilisation of double-loaded anchors for SLAP reconstruction (Figure 4) and arms in many technical- double row techniques for the rotator cuff reconstruction. The mean recovery time period to full activity is almost the same as tactical tasks in attack after a capsulolabral reconstruction − some 6 months. and defence

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The second big group of shoulder injuries The condition first occurs like a sharp the scapular movement). The treatment is overuse injuries or conditions, described pain when the most powerful throws is conservative and includes rest, the by Burkhart et al in their articles on the are performed. The shoulder pain can be previously mentioned physiotherapeutic disabled throwing shoulder30-32. soothed temporarily with cryotherapy procedures with stretching of the shoulder High level handball players train for application and rest. However, the girdle (sleeper stretching) and progressive more than 1,400 hours a year33. During pathological cascade has been initiated − strengthening of the rotator cuff muscles a season the players in the investigated pain and discomfort become ever stronger and scapular stabiliser. Verna34 and Burkhart, population24 had training sessions twice and the ball release force is considerably Morgan and Kibler30-32 demonstrated that a day for 4 to 6 hours and performed at decreased. The syndrome of the ‘dead hand’ the symptoms of disability and pain were least 30 to 50 shots at the goal per training or disabled throwing shoulder is at the end decreased as soon as the internal rotation session, either freely or against more or less of the spectrum of pathologies. had become even with the internal rotation active defensive player(s), which cumulated Players, team physiotherapists and of the non-dominant arm (acceptable level in an average of 300 to 500 shots a week. If coaches, especially physical conditioning is, according to the cited authors, 20° of this number is multiplied by 45 to 50 weeks specialists, should react immediately when difference between the dominant and non- of pre-, in- and post-season practice, it can pain occurs to prevent this very serious dominant arm). reach an average of 13,500 to 25,000 shots condition by breaking the pathological Finally, Pieper’s study6 must also be per year, not including shots performed cascade. The shoulder should be checked mentioned. He has indicated that the in a match and numerous throws made for range of motion and scapular kinetics. increase of humeral retrotorsion in when passing the ball to a teammate over The most common condition, even in the throwing arm of handball players varying distances. In a study by Pieper6, the asymptomatic players, will be an increased should be recognised as an adaptation to estimated minimal number of throwing external rotation in the shoulder abduction extensive external rotations in throwing motions was reported to amount to 48,000 of 90° and a decreased internal rotation of practice during growth. The increased throws per season. Such a high number of the dominant arm when compared with the retrotorsion allows more external rotation powerful throws (up to and over 100 km/ non-dominant arm, the condition known of the shoulder before the humeral head hour) may lead to the condition described as the 'GIRD syndrome' (glenohumeral puts excessive strain on the anterior by Burkhart and associates30-32 if there is no internal rotation deficit). Sometimes, the capsulolabral complex, thus protecting the optimal shoulder strength and flexibility condition is worsened by the so-called 'SICK joint from anterior instability. The athletes training (as opposed to just fitness and scapula syndrome' (Scapular malposition, who do not exhibit this biopositive response power-enhancing training without focus- Inferior medial border prominence, Coracoid to practice, due to some yet unknown ing on injury prevention). pain and malposition and dysKinesis of reason, seem to have to sustain more strain

164 PRP has opened a new frontier in the treatment of inflammatory problems and pain in the shoulder

on their anterior capsules at an earlier competition activity. The field of research on and various training methods (like degree of external rotation and become handball-related shoulder conditions and resistance training) are applied to enhance prone to developing chronic shoulder pain injuries, to the best of the authors’ insight the power of shots38 by improving technical due to anterior instability. The finding has into the published research reports, appears preparedness, physical condition and not been confirmed yet nor has it been almost intact regarding, for example, fitness of players, who are usually referred elucidated whether the torsional changes retrospective and prospective studies to as ‘decathlon athletes with a ball’. The correlate with the starting age of handball searching for evidence-based epidemiology kinematic chain of shots which involves playing, or with the intensity of training data, preferably using the most efficient the whole body, as well as various types of practice. methodology36. Further research is throws at the goal39 probably contribute to Introduction of PRP has opened a new warranted to clarify the mechanisms, like a lower incidence rate of shoulder injuries in frontier in the treatment of inflammatory detailed biomechanical descriptions of handball than in baseball, but this is yet to problems and pain in the shoulder35. Despite more technical elements, muscular strength be investigated. a lack of research evidence to justify its use, balance/imbalance effects on injury it is the authors’ experience that the addition rates, acute and chronic training effects, References at www.aspetar.com/journal of PRP is clinically worthwhile. These injury-threatening play situations etc, as injections of the autologous rich plasma can well as management of shoulder injuries be made in the subacromial bursa or around and their outcomes. Although seeming the shoulder tendon. epidemiologically less significant than Shoulder pain, acute or chronic, in knee or ankle injuries, shoulder injuries either the dominant or non-dominant and condition issues may have very serious arm may jeopardise not only a promising (postponed) effects on a player’s handball Prim.Mladen Miškulin, M.D., Ph.D. handball career but also a person’s quality career and/or post-competition life37. As Orthopaedic and Traumatology Surgeon of life. Discomfort caused by pain are previously stated, injuries to the shoulder Department of Orthopaedic Surgery major obstacles to handball involvement; it in handball are positioned in the third place University Hospital ‘Sveti Duh’ distorts throwing and shooting technique, regarding incidence rates. The authors thus elevating injury risks and considerably believe, based not only on their experience reduces shooting and passing accuracy. but also on their research, that shoulder Željka Jaklinovic Fresl, M.A. injuries in handball are more severe and Faculty of Kinesiology WHAT IS TO BE DONE? threatening than knee and ankle injuries. University of Zagreb Issues with the shoulder(s), especially Therefore, more information on incidence immediately upon their occurrence, are too risks and the consequences of shoulder often overlooked (by coaches), disregarded injuries should be disseminated among Goran Vrgoc, M.D. (by players) or not properly recognised. Too handball coaches, physical conditioning Orthopaedic Surgery Resident often conservative therapy is recommended, coaches and physiotherapists, as well as Department of Orthopaedic Surgery sometimes because players are afraid of handball players themselves. Fortunately, University Hospital ‘Sveti Duh’ surgical treatment, in spite of the fact that training programmes in handball, especially surgery is necessary and presents a much strength and conditioning programmes, better and even faster option in terms seem to have been well designed and Zagreb, Croatia of health profile or an athlete’s return to implemented; much attention is devoted Contact: [email protected]

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