The Handball Shoulder

The burden for physiotherapy in handball is the shoulder. I chose a complex topic as one of my first posts, but soon or later the question would have come up.

How do we assess shoulder pain in handball athletes?

The answer is complex, and I have still little clinical experience on the topic. I will summarize the findings I found so far, in particular from my experience at the First Scandinavian Congress of Handball Medicine, and citing the article written by Rod Witheley for Aspetar Sports Medcine Journal, "The perils of handball shoulder physiotherapy".

First thing to ask: When does it hurt in your throw? Differentiate:

• "Pain when I throw": player will complain about decreased velocity of throws

• "Pain after I throw": player will not see any changes in the throw and he will not give it importance

What to assess?

• Rotational range: should be assess TORSION and not just GIRD

• Rotational strength

We can differentiate injuries related with throwing, collision or weight-training.

Throwing-related injury

1. Cocking phase/Acceleration phase

Spectrum of “inside impingement” injury. He present with:

Assessment:

• Painful decrease throwing velocity

• During cocking phase sharp anterior pain near the long head of biceps origin

• Possible pain postero-superior with “click/catch inside”

• Possible superior labral injury associated with an undersurface postero-superior cuff tendinopathy

Check:

• Ext Rot ROM - decreased PROM predicts throwing velocity

• Relocation

Treatment:

• Conservative rehabilitation: restoring rational ROM

• Rotator cuff strength

• Scapular position

• Gradual return to throw: overweight (medicine ball)

2. Deceleration phase

• Pain after releasing the ball during a hard throw

• Pain posterior shoulder

• Intensity of pain increases with the velocity of throwing

• Pain progressively worsening over the time

• Pain hurts after every throw

Check:

• Int rot ROM

• Ext rot ROM

• Ext Rot Strength (posterior cuff muscles)

Assessment:

• Wasting in the infraspinosus fossa

• Pain on resisted external rotation

• Reduction internal rotation

• TROM (IR+ER) equal 5° doe dominant and non-dominant arms? Yes no further assessment; no measure humeral torsion bilaterally, if there is difference à the injured arm more retrotorsion (ext rotation target increased y this amount); the injured arm less retrotorsion (ext rot target decreased by this amount)

Evaluation:

eccentric overload of the posterior cuff, decelerator muscles

Treatment:

• Improvement of resilience rotator cuff

• Scapular dyskinesia (scapular assistance test while external rotation)

• Measure rational strength à 30-50% of strength of their body-weight

• Graded return to throwing: built the volume of throws (over a short distance) to 100, he add higher intensity throws into this session. Once he volume is safe, increase the intensity by increasing the distance 5 m per session. 3x20 throws

• Attention to accuracy

Blocking

Cocking phase blocked shot:

Force excessive passive shoulder horizontal abduction (pain in horiz abd or slight ext rot)

Acceleration phase blocked shot

High force in pectoralis major and latissimus dorsi while arm is abducted and externally rotated-_Z anterior instability. Player complain: shoulder “coming out”

Assessment:

• Examine neurological deficit: loss of deltoid function due to axillary nerve will cause a shoulder dysfunction

Treatment:

• Maintain external rot ROM to be able to throw with maximum velocity

Collision and falls

Acromioclavicular joint injury. Persistent problematic AC problems can have symptom resolution with excision of the outer end of the clavicle

Weight room injury

Shoulder pain should document their weight training routine of exercise ingludin sets, repetition and normal weights

Additional considerations:

Chronic rehaber, the player that consistently gets injured because it does not do enough in the off-season