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Acute Injuries in Handball
Chapter · November 2011
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2 authors:
Patrick Luig Thomas Henke
VBG - German Social Accident Insurance for… Ruhr-Universität Bochum
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ACUTE INJURIES IN HANDBALL
Patrick LUIG & Thomas HENKE
Ruhr-University Bochum, Bochum, Germany
Summary
Analysis of injury statistics and literature review indicates that the overall incidence of acute
injuries in handball is around 2/1000h. Match incidences are ten time higher than training
incidences. Lower extremities account for most injuries, followed by head injuries and injuries of
the upper extremities. Sprains and contusions are leading injury types. Women are more
vulnerable for non-contact lower extremity injuries whereas men have a higher share of contact
head injuries. Backcourt players seem to be most at risk.
Keywords: Handball, etiology, acute injuries, injury rates, injury situations
Introduction
Not least because of its thrilling dynamics, handball has become one of the most popular team
sports in Europe. Motion-analysis has shown that depending on playing-time and playing
position handball players cover up to 6.5 km per game1. Regarding these facts the necessity of a
highly developed basic endurance in terms of pronounced aerobic capacities becomes obvious.
In addition, athletes need to establish a proper athletic condition with regard to strength, agility,
acceleration, deceleration, jumping and throwing power as the gameplay includes highly
intermittent running with quick direction changes, frequent jumping and landing alongside with
challenging technique elements like catching, throwing, passing and dribbling. Beside an
intensive load for the locomotor and neuromuscular system this implies the need for a well-
trained anaerobic metabolism in addition to succeed in the game. Even though less intense game
phases and regular substitutions offer breaks for regeneration high-intensity phases during
crunch time play that include repeated sprints up to 18 meters stress the anaerobic glycolytic
metabolism1. Moreover, rules and gameplay clearly implicate intended and unintended body
contact. During frequent one-on-one situations players have to brave a high load of legal and
illegal physical contact. One can conclude that the physiological and technical requirements in
handball are pretty high, calling for perfectly prepared athletes. By implication, athletes with a
bad athletic condition and limited techniques will be at greater risk for acute and chronic injuries.
In fact, it is roughly estimated that in Europe at least 320,000 handball injuries occur each year at
a cost for medical treatment of approx. € 250 to 400 million². The purpose of this paper is to
display the basic aetiolgy of handball injuries as described in recent literature and supplemented
by data from own surveys and injury databases and to conclude with potential key areas for
injury prevention.
Definition of an injury
According to widely accepted consensus agreements a sports injury is defined as any physical
complaint sustained by a player that results from a match or a training. Furthermore, if a player
receives medical attention, injuries are referred to as “medical attention injury”, whereas an
injury that causes a player to miss at least a full part in future training or match play is
constituted as “time-loss injury” 3,4. Bahr5 points out that the time-loss definition is probably the
most commonly used, as it at least covers the most relevant injuries. In addition, time-loss
injuries are quite comprehensible, in particular when recorded retrospectively. If not mentioned
specifically, the time-loss definition is applied for any injuries. Furthermore, there is generally a
clear distinction between acute and chronic injuries. Corresponding to the above-cited consensus
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documents an acute injury results from a specific, identifiable event whereas chronic injuries are
caused by repeated micro-trauma without a unique identifiable event responsible for the injury.
As these definitions were defined for football and rugby, both team sports with frequent contact
between participating players, they may also be quite appropriate for handball. Although chronic
injuries, in particular lower back pain, knee pain and shoulder pain in field players as well as
elbow pain in goalkeeper, frequently occur among handball players overuse injuries are not so
well recorded yet. Hospital records, insurance statistics or national surveys that are mainly used
for data collection tend to focus on acute injuries6. Thus, this paper exclusively deals with acute
injuries.
Methods:
Structured literature & database research
Pubmed, BiSp, SportDiscus and Google were browsed for relevant articles. Additionally,
reference lists of retrieved articles were browsed for further information.
Surveys on sports injuries in handball
The Department of Sports Medicine of the Ruhr-University Bochum owns datasets on sports
injuries, which have been built up in the framework of research projects in collaboration with the
ARAG Sports Insurance (Dusseldorf, Germany) and the VBG (Hamburg, Germany). These
datasets contain:
1. Data from a continuous survey among German sports clubs. Athletes, who report an injury,
receive a questionnaire asking for details of the accident, injury onset and its treatment. In
addition, information on sports activities (club sports and recreational sports) and general
information on surveyed athletes is collected (total n 180,000, handball n 25,000).
2. Data from a survey among German professional handball players, who have been analysed
during one single season by means of a purpose-designed questionnaire (n=293)
complemented by basic data of all injured players (n=1,636). This questionnaire contained 36
questions and provided detailed information about:
• detailed circumstances of the injury
• position on the field
• the injury itself e.g. injured body part, kind of injury, treatment
• sports career und personal background e.g. number of games,
• former injuries
• sociodemographic and anthropometrical parameters e.g. height, weight, age.
Results:
Injury incidence / Injury rate
Acute injury incidence rates in handball are comparable to those in other team sports where one-
on-one situations with inevitable body contact frequently occur, such as in football, field hockey
or in basketball. Research indicates that the overall incidence is at about 1.5 – 2.0 injuries per
1000 hours of exposure. Although one should consider minor methodical distinctions in
calculating training and match exposures, there is a general consensus that match incidences (8.3
- 46.5 injuries/1000h) are at least ten times higher than training incidences (0.6 - 3.4
injuries/1000h). It is striking that professional athletes show notable higher incidences than semi-
professionals or amateurs. It cannot be proved beyond doubts if sex plays a decisive role
regarding overall incidences even though it is absolutely clear that women are significantly more
vulnerable to specific injuries than men. At least Henke et al. (2005)7 indicate higher overall
incidences – in training and match – for male professionals compared to elite female athletes (cf.
Tab.1).
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Tab. 1. Time-loss injury incidences; *studies on professionals only; ** calculated
Training (injury/1000 h) Match (injury/1000 h)
Study Male Female Male Female
Wedderkopp et al. 1997 3.4 40.7
Seil et al. 1998 0.6 14.3
Wedderkopp et al. 1999 1.2 23.4
Petersen et al. 2002 2.6 12.1
Olsen et al. 2006 0.6 1 8.3 10.4
Henke et al.* 2005 0.7 0.2 46.5 8.9
Junge et al.* 2005 40 36
Langevoort et al.* 2007 34 19
Holdhaus et al.* 2008 33.3**
Holdhaus et al.* 2009 31.9**
Generally speaking, about 2/3 of all injuries occur in competition and 1/3 during training. As
table 2 shows, injuries in competition gain more significance with advanced age and
performance level, even though more time is being spent in training compared to time spent in
competition.
Tab. 2. Share of match and training injuries in % with regard to age and gender (n = 5,689)
Age <14 years 15-21 years 22-35 years professionals
male female male female male female male female
(n=515) (n=502) (n=1,207) (n=835) (n=1,531) (n=801) (n=224) (n=74)
Match 49.1 53.6 64.2 66.7 73.7 73.5 85.0 74.0
Training 50.9 46.4 35.8 33.3 26.3 26.5 15.0 26.0
With respect to specific injuries some studies reveal, that in particular knee injuries seem to have
a plainly higher match incidence compared to training. Regarding men, Myklebust et al. (1998,
2003)8,9 report an 8 times higher match incidence which is even topped by a 53 to 93 times
higher match incidence among women.
Injury topography / Anatomical location
The analysis of 8,520 handball injuries among 14 to 45 year old athletes revealed that handball
injuries can essentially be attributed to four main body regions: Regarding the upper body head
(male: 17.4%; female 13.2%) and hand/wrist (male: 19.8%, female 19.6%) are considerable core
regions, whereas when talking about the lower extremities knee (male: 23.0%; female 31.7%)
and ankle joints (male: 18.6%; female 22.1%) are mainly affected. In general female athletes
have higher shares of knee and ankle injuries, whilst among male athletes the head is more
frequently injured (cf. Fig. 1.)
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Fig. 1. Localisation of acute injuries among male and female athletes (n=8,520, 14-45 years)
Going more into details, younger athletes seem to be more prone to injuries of the upper body
regions, especially finger injuries. With advancing age there is an increase in injuries of the
lower extremities, in particular in knee injuries. Almost half of all injuries in the group of players
under 14 years of age relate to hand/wrist or head. In contrast nearly one third of all injuries in
adults relate to knee injuries. In female professionals even every second injury is a knee injury
(cf. Tab. 4).
Tab.4. Localisation of match injuries in % with regard to age and gender (n = 3,777)
<14 years 15-21 years 22-35 years professionals
male female male female male female male female
(n=249) (n=266) (n=759) (n=550) (n=1,121) (n=588) (n=190) (n=54)
Head/Neck 18.5 11.9 18.6 16.9 18.4 16.3 10.3 7.5
Trunk 2.8 1.1 1.7 1.4 1.9 1.2 - -
Shoulder 2.4 1.5 7.1 4.1 8.2 2.7 - -
Arm 12.3 4.8 3.1 1.0 0.6 0.9 - -
Elbow 3.6 2.6 1.9 2.3 0.9 1.2 - -
Hand/Wrist 27.6 33.9 19.2 15.4 18.7 19.5 14.1 13.2
Hip - 0.7 1.2 0.9 0.3 0.3 - -
Thigh 0.4 - 0.8 - 1.3 0.7 - -
Knee 9.5 12.3 24.4 35.2 28.2 34.1 24.9 49.1
Lower leg 2.0 1.1 2.1 1.1 7.6 5.1 - -
Ankle 15.8 27.9 16.6 19.7 11.5 16.8 18.9 17.0
Foot 4.0 1.1 1.4 0.5 1.7 1.0 - -
Recent studies show similar tendencies. There is a general consensus that regardless from age,
gender and performance level the majority of all injuries affects the lower limbs10,11,12,13,17.
Moreover, is obvious that young female athletes have a significantly higher risk to sustain a
severe knee injuries8,14,15,16.
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Injury types
The most common acute injuries are sprains, with knee, ankle and fingers being the most
affected body parts followed by contusions and strains11,17,18,20. Fractures and dislocations are
quite rare. However, younger athletes are typically more vulnerable to fractures, in particular
finger, wrist and forearm fractures, than older athletes. Strikingly, during important elite
tournaments contusions become more frequent21,22,23,34.
Injury situations & risk factors
Studies commonly differentiate between contact situations, whether legal contact or foul play,
and non-contact situations, typically running with quick direction changes, cutting and pivoting,
starts and stops as well as jumping and landing on one or both feet. On closer examination of 293
injuries in German professional handball contact situations, either with an opponent or a team-
mate, trigger injuries most frequently, followed by jumping, landing, and running with quick
direction changes (feints), which are typical non-contact injury situations (cf. Fig. 2.). In the
majority of all cases injuries occurring in contact situations affect the upper body, in particular
head and fingers. In contrast, non-contact injuries mostly are related to the lower extremities
Fig.2. Situations leading to injuries (in %) among elite athletes (n=293)
Seil et al. (1998)17 report 53% of match injuries that are due to contact with opponents whilst in
training only 19% of injuries derive from contact situations. The share of contact injuries is even
higher during major international tournaments (71-92%). Except from 2008 Men’s European
Championships in Norway at least half of these injuries are caused by foul play – independently
from gender21,22,23,24. Several studies have indicated that female particularly young female
athletes are at greater risk for non-contact injuries. This is insofar of great significance as non-
contact injuries are commonly more serious than contact injuries. Almost 90% of ACL ruptures
are reported to happen without the opponent’s or team-mate’s contribution8,9,14. In general
players in offensive actions are more at risk than defence players19,20. Our data show that
attacking backcourt players are mostly affected by injuries, followed by attacking pivot players
and central defenders. Strikingly, pivot players have the highest share of head injuries. Among
female athletes Froböse et al.(1996)20 state a 30% higher injury risk for pivot and backcourt
players compared to other playing positions. Some other studies also demonstrated that
backcourt players have the highest overall incidences, in particular with regard to non-contact
injuries of the lower extremities8,9,11,16. Our data and recent research states that previous injuries
increase the risk for recurring injuries, in particular with regard to injuries of the lower
extremities11,25. Among these ankle injuries are most common to reoccur. Moreover, Olsen et al.
(2003)26 indicated a correlation between playing surface and injury risk. According to them
artificial floors have a higher friction compared to wooden floors and thus can increase the ACL
injury risk for women.
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Conclusions:
Handball is a physical and dynamic contact sport with a noticeable injury risk, in particular
during matches. Even though the highest share of injuries is due to contact, in particular those
severe non-contact injuries seem to be a key area for targeted injury prevention.
Contact injuries are most commonly less severe (i.e. minor contusions) compared to non-contact
injuries. It has to be discussed if contact injuries, especially those that cannot be attributed to
unfair play, are somehow evitable. Passive protection such as mouth guards and prophylactic
finger tapes can probably assist to reduce the incidences of minor contact injuries such as finger
sprains and soft tissue injuries. Certainly, in case of previous injuries, the wearing of protective
devices, for example the application of external ankle stabilization such as tape and ankle braces,
is explicitly recommended.
However, research and practice have revealed good opportunities to tackle the more serious non-
contact injuries. Generally speaking, the various facets of training and physical preparation such
as functional strengthening, core stabilization, agility training, neuromuscular and proprioceptive
training can contribute to the reduction of injuries, if applied regularly and correctly. This
includes technique training for crucial handball movement patterns that typically lead to match
injuries e.g. jump shots, single-leg landings and feints. The discrepancy between training and
match injuries shows up that even today, athletes are still not that good prepared for the demands
of competitive gameplay.
Federations, clubs and coaches are certainly in charge to protect their athletes best possible. This
also includes sufficient preparation and regeneration, especially prior to and after major
international events in professional handball.
Moreover, reinforcing the coaches’ education could be a promising approach to promote
available know-how on handball injuries and how to prevent them.
Despite increasing efforts to propel this issue, the handball community is still not fully aware of
the potential of smart injury prevention, which as a positive side-effect can also improve the
individual performance of athletes – a win-win-situation for all.
Acknowledgement:
Parts of this publication derive from the European project “Safety in Sports” which has received
funding from the EU, in the framework of the Public Health Programme 2003-2008.
____________
patrick.luig@safetyinsports.eu
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