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12.1 Characteristics of the Sport

Handball is a worldwide popular Olympic ball sport and one of the most popular ball sports in Europe. Today, handball is played in 199 countries with 19 million players worldwide in over 800,000 teams played year-round at professional level. Combining international competitions with club and national teams, elite players play between 70 and 100 matches a year. While some countries remain stable in regard of members, some countries have risen to over double in just some years, such as Hungary (2011–2017) from 24,000 to 65,243 registered handball athletes (Fig. 12.1).

Fig. 12.1
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The increase of the number of competitive handball players in Hungary (Bardóczy, Hungarian Handball Federation, Annual Report 2017)

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During the last decades, the game of handball went through several changes (i.e., rules, court, and shoe design) which made it much faster and dynamic. Handball is characterized by intense body contact, frequent intermittent running, demanding one-on-one confrontations, and quick direction changes and cutting movements in combination with challenging technique and coordination elements like catching, throwing, passing, and dribbling. Aggressive contact is an integral part of the game and often used not only to stop the opponent but also to intimidate opponents from approaching the goal. The changes of the game and increased number of players and games played annually have resulted in higher number of traumatic and overuse injuries. The physiologic load that each player is exposed to varies depending on their age, playing level, playing position, and total number of players in the teams [1].

Handball is in the top five sports in terms of number and severity of injuries. Apart from being a throwing sport during which a high number of loads are transferred to the upper extremity in general and more particularly to the shoulder joint, handball is also a contact and pivoting sport. It involves lots of running, turning, and jumping during the game, exposing the joints of the lower extremity to high levels of mechanical stress. Contact-related injuries represent a large fraction of all handball injuries. All these factors predispose handball players to develop osteoarthritic changes of the upper and lower extremity.

In children and adolescents, the sport is going through a phase of increasing professionalization as well. Handball schools and academies are being created in many countries and international competitions have been implemented in youth players. Fortunately, the benefits of handball on the health and social development of these young athletes exceed its disadvantages. However, a major problem is the large number of young players affected by serious ligament injuries, mainly of the knee joint. Many players suffer from injuries very early in their handball career. In the long term, such severe injuries may lead to early-onset degenerative changes and osteoarthritis (OA) [2].

12.2 Physiological and Biomechanical Demands on Athletes

To become an elite handball player, next to high level of skills, good speed and acceleration, muscle strength and endurance, power, agility, flexibility, balance and coordination, reaction time, and cardiovascular endurance are required. Besides the physical parameters’ mental abilities, like analytic and tactical ability, motivation and self-confidence and coping with pressure situations are determining as well. To set up an optimal body composition and stamina for a handball player we have to follow the evidence-based age- and sex-based formulas to avoid the undesired medical overuse conditions [3]. The training of handball players should target the ability to perform specific high-intensity actions throughout the game and to rapidly recover during the less intense periods. To evaluate the effectiveness of the training methods periodical physiological and biomechanical screening is recommended. Throughout the annual training program elite players typically practice once or twice a day, and in competition phase they play 1–2 games/week.

The mean height of players varies among different nations and can range for males from 178 ± 4 cm to 194 ± 2.1 cm and in females from 164 ± 4.3 cm to 178 ± 3.4 cm. Information on physical characteristics of players playing different positions can help coaches match the training program to the specific attributes of players who play similar positions. To date, taller players have better chances to play on the highest level. Mean body mass ranged from 77 ± 7.5 kg to 107 ± 7.9 cm in male players. In females there is also a wide range detected in body mass from 60 to 72 kg [3].

Motion analysis has shown that depending on the playing time and playing position handball players cover a distance of up to 6.5 km per game; therefore aerobic capacity is needed as they are constantly running up and down the court during the games. In addition, high levels of anaerobic power allow the players to achieve explosive acceleration or power when it is needed. This potential may be needed in numerous situations in handball such as when athletes sprint to receive the ball, then recover quickly, and sprint again with many repetitions occurring in a single match. Unfortunately only a limited published data exists on the on-court physiological demands of the handball players, but it appears that especially the explosive capacity decreases in the last 10–15 min. The activity pattern of the different playing positions’ players varies on a wide range [3].

The study by Póvoas et al. aimed to analyze elite handball players’ physical and physiological demands during match conditions. Different locomotor categories were defined: standing still, walking, jogging, fast running, sprinting, backwards movement, sideways medium-intensity movement, and sideways high-intensity movement and playing actions studied were jumps, shots, stops when preceded by high-intensity activities, changes of direction, and one-on-one situations. They found that during the games average distances covered were 4370 ± 702.0 m. Around 80% of the playing total time was spent standing still (43.0 ± 9.27%) and walking (35.0 ± 6.94%), and only 0.4 ± 0.31% accounted for sprinting. Effective mean HR was 157 ± 18.0 bpm (82 ± 9.3% of HRmax) and total HR was 139 ± 31.9 bpm (72 ± 16.7% of Hrmax). Most intense periods of the game were higher during the first half than during the second half (p ≤ 0.05). Handball is an intermittent exercise that primarily utilizes aerobic metabolism, interspersed by high-intensity actions that greatly tax anaerobic metabolism. Additionally, exercise intensity decreases from the first to the second half of the match, suggesting that neuromuscular fatigue may occur during the game [4].

Wagner et al. have tested specific physical performance in male team handball players and the relationship to general tests in team sports. It was demonstrated that general and handball-specific performances are separate components. Recommendations to strength and conditioning professionals and coaches in handball were presented.

To conclude, handball is a physically demanding complex game for both sexes. Playing handball includes powerful upper body movements such as maximal ball throwing and tackles of opponents as well as forceful lower limb muscle actions during vertical jumping, sideways and backwards running, rapid sprinting, and directional changes during fast breaks during the entire match. The physical training of different positions’ players should be organized in a more individualized manner in the future according to specific requirements in defense and offense. Considerable sex-specific variations in the physical demands exist in handball. Physical training of female handball players may potentially benefit from a greater focus on aerobic training elements. Conversely, male elite players would seem to benefit from an increased training focus on anaerobic exercise elements and strength training. Additionally, the physical demands differ greatly between various playing positions both in offence and defense, reflecting almost similar trends in both male and female elite players.

To find the optimal biomechanical and exercise physiological screening program is still controversial. Several laboratory- and game-specific telemetrical instruments are available, but the effectiveness and cost benefit are still controversial [5].

Some nations have implemented a mandatory screening program for their (elite) handball athletes. One example from Hungary is as follows (Figs. 12.2, 12.3, and 12.4):

Fig. 12.2
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Mandatory screening program for an elite Hungarian elite handball player

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Fig. 12.3
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Exercise physiology: treadmill test methodology for elite handball players

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Fig. 12.4
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The medical report to the green color deviation from the optimal range, the yellow color with slightly suboptimal, and the red color represents a significant departure. The colorful web shows the average values seen until the last page of the rating which is determined by the colors of the worst modular indicator

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The possible positive fitness effects of handball for recreational players were studied as well.

The participation in regular recreational handball training was associated with positive cardiovascular, skeletal, and muscular adaptations, including increased maximal oxygen uptake, increased muscle enzymatic activity, and improved bone mineralization as well as lower fat percentage. These findings suggest that playing handball on recreational level may be an effective health-promoting activity for young adult men [6].

12.3 Epidemiology of Injuries

Handball injuries are diverse in terms of the mechanism of injury, how they present in individuals, and how the injury should be managed. Although the rules of handball try to make it fair and safe, acute and overuse injuries are very common. The risk of injury is significantly higher during matches than during training; most probably the reason is higher speed and intensity during matches, and more contact with opponent players. According to basic epidemiological studies the knee and ankle injuries are the most common sites for acute injuries, with the ankle being more common in most studies; however the most sever acute injuries involve the knee (i.e., ligamentous injuries). The knee, shoulder, and lower leg are common sites for overuse injuries [3].

Epidemiological data on handball-specific injuries have been generated either through retro- and prospective cohort studies or from observational studies during international tournaments. The used term for “sport injury” is problematic and not consistent; therefore to compare the data of different studies is difficult [5]. There are many ways to classify sports injuries based on the time taken for the tissues to become injured, tissue type affected, severity of the injury, and which injury the individual presents with. Depending on the classification the severity and prevalence of handball injuries vary.

Some data have been generated from federation or insurance-related injury registries and from specific injuries such as the anterior cruciate ligament (ACL) reconstruction registries. Aman et al. reported on large number and incidences of injuries as well as injuries leading to permanent medical impairment (PMI) from the Swedish national injury database [7]. Giroto et al. investigated the incidence and risk factors for handball injuries in 21 handball teams participating in the two main Brazilian championships during a season (n = 339 elite Brazilian handball players). Three hundred and twelve injuries were reported in 201 athletes. The injury incidence rate during training and matches reached 3.7/1000 h and 20.3/1000 matches, respectively. Ankle (19.4%) and knee (13.5%) were the body regions most affected by traumatic injuries; shoulders (44.0%) and knee (26.7%) were the body regions most affected by overuse injuries. This study showed that athletes with previous injury have a high risk of developing an overuse injury [5].

Tatrai et al. compared their Hungarian injury register data to those from the German. According to the regulation of the national federation, all first league male and female teams have to use a compulsory injury register. The results of the 2017/2018 season show that the most vulnerable joints are knee and ankle in accordance with the international data. The frequency of injuries was 15% higher than that in Germany (98 injury/1000 h vs. 78 injuries/1000 h). The injury prevalence per player for 1000 playing hours was 2.8. The weakness of the Hungarian injury register is that it focuses only on the game injuries, providing no data from the training session. German registry data found that 54% of all injuries occur during training circumstances.

Nielsen et al. reported the injury incidence of 221 players in one season with 4.6 per 1000 playing hours and 11.4 per 1000 match hours. The upper extremity was involved in 41% of the injuries including 21% finger sprains. Ankle sprains were the most common injury (33%), and overuse injuries accounted for 18%. The risk of reinjury was 32%. Contact mechanism was 31% of all injuries. Forty percent of the injuries were minor injuries, treated by the players themselves. 73% of the players were absent from handball for more than 1 week, and 41% of the players had complaints 6 months after the end of the season. This study shows that injuries in handball are serious and cause long-term consequences for the players. In most of the injuries both intrinsic and extrinsic factors were involved, and prophylactic intervention in these cases demands changes in more fields [1]. Mónaco et al. studied the influence of position, category, and maturity status on the incidence and pattern of injury in handball players, across two seasons. The 164 players were categorized into youth (133) and adults (31), and per position: 27 goalkeepers, 67 backs, and 70 wings and pivots. Injury incidence in youth was 6.0 per 1000 total hours [CI 95%, 4.8–7.2] (14.9 match [9.7–20.1] and 3.7 training hours [2.7–4.6]; n = 142 injuries), and in adults 6.5 per 1000 total hours [4.4–8.6] (22.2 match [8.8–35.6] and 3.0 training hours [1.3–4.6]; n = 48 injuries). There were significant differences in knee (P = 0.01) and cartilage injury (P = 0.05) according to the playing position. There were significant differences according to age category in ankle (P = 0.03), head (P = 0.01), thigh (P = 0.05), muscular injury (P = 0.02), and apophysitis (P = 0.04) for biological maturity state. Adult handball players had more ankle and muscle injuries than youths. Pivot and wings (second line) had more knee and cartilage problems. A higher incidence of apophysitis was found in immature youth players [7]. Lindblad et al. registered 570 handball injuries prospectively in a well-defined geographic area of 124,321 inhabitants. The incidence of handball injuries was 46 per 10,000 inhabitants per year, and the ratio was twice as much in women (61 per 10,000 per year) than men (31 per 10,000 per year). Nearly two-thirds of the injuries were ligament sprains and tears, and 12% were fractures. Sixty-eight percent of the injured players were not able to return to handball within 1 week. Surprisingly, 8% of the minor injuries resulted in a sick leave of more than 6 days [8].

12.4 Rehabilitation and Return to Play (RTP)

Once an injury occurred, one of the most burning questions from the player and coaching staff is regarding “when can they return to play.” Management of a safe RTP is a challenging task and varies from injury to injury. Returning too soon can increase your risk of reinjury or developing a chronic problem that will lead to a longer recovery. Waiting too long, however, can lead to unnecessary deconditioning and it can also influence the results of the team.

The rehabilitation strategies are constantly improving. The basis for a safe RTP and adequate rehabilitation is a fast and correct diagnosis. Once the team physician sets up the diagnosis, the healing process is led by the physiotherapists, addressing the normal tissue biologic and biomechanic requirements for healing, gradual restoration of muscle strength deficits, and building towards handball-specific training, with or without contact initially, when appropriate, before full RTP [2].

Addressing the player’s conditioning status during the rehabilitation process is important in facilitating a timely and safe RTP. The team physician can determine the best time for returning to play. Basically, two main principles exist, the time based or criteria based. All strategies are aim for being pain-free, no swelling, full range of motion, and full or close to full (90%) strength. It is important to keep in mind that even when all criteria are present, biology—like graft healing after ACL reconstruction—still plays a crucial role. It is extremely important to take extra care with the injured part for several months. The time-based return to sport limit for the most frequent serios knee injury—ACL—has increased by 50% in the last few years, from a minimum of 6–9 months. RTP for different injuries and different body sites varies on a wide spectrum. Most handball injuries have evidence-based RTP protocols. Compromises to decrease the minimum RTP time are sometimes required with elite players at the most important (AC, WC, Olympics) tournaments, during intense competition; however, it should be avoided in other scenarios.

12.5 Prevention Strategies

Injury prevention in handball has been shown to be successful over the years, with handball being one of the sports leading the way in this field. It is one of the only sports where such strategies have been shown to be effective for both lower limb injuries and shoulder injuries. The knowledge and understanding regarding prevention of especially acute lower extremity injuries in handball have improved substantially in the last two decades. More is known about injury mechanisms, who is injured, and, most importantly, how these injuries can be prevented. The risk of sustaining an acute lower extremity injury, including ACL injuries, has been shown to be reduced by 50% through implementing injury prevention exercise programs (IPEPs) as structured warm-up program on a regular basis in handball [9].

Overuse injuries in handball are also a well-known problem, and recent work has shown that it is possible to reduce the risk of shoulder overuse injuries in handball by 28% by performing a set of exercises during the warm-up [9].

The elements of injury prevention in handball aim to address identified risk factors for injuries in the sport as well as high-risk situations and mechanisms, through improving elements of coordination, strengthening, stabilization, and proprioception, contributing to performance enhancement as well as injury prevention. Structured warm-up programs including neuromuscular training, agility, balance, strength, and playing technique exercises, designed to improve knee and ankle control during landing and pivoting movements, have been shown to reduce ACL injuries and proven to be an efficient way of implementing such strategies. Success highly depends on the compliance of players.

It is recommended to have regular preseason screenings to detect potential risk factors for injuries, e.g., cardiovascular problems, muscular imbalances, and athletic and neuromuscular deficits. Moreover, performance diagnostics that identify the athletes’ individual needs for improvement can assist in increasing physical condition and general performance and thus contribute to reducing acute and chronic injuries.

It is recommended to have all national associations to include an injury prevention module in their trainer education curriculums and to designate an official staff member as “safety promotion ambassador” of the federation. And last but not least, all sustained injuries should be reported to trainers and coaches and should be systematically recorded at club and national level, in order to identify individual and situational risk factors, to monitor injury trends, and to evaluate the effects of the measures taken [10].