ESSKA helps making a change: the example of handball medicine

Handball is one of the most popular team sports and overhead throwing sport in Europe. It is spectacular, fast and dynamic and enjoys an ever-growing popularity with the introduction of beach and street handball in recent years. Rarely in the headlines for excesses or scandals in doping or finance, it is still considered a healthy sport. It is also one of the first sport disciplines providing valuable and high level of evidence on injury prevention in general and prevention of anterior cruciate ligament (ACL) injuries in particular [10].

Nevertheless, handball is still one of the pivoting team sports where players are mostly affected by injuries. In comparison to other sports, it can be found in the top five in terms of number and gravity of injuries [3, 7]. Concussions are not rare, as are acute joint injuries, mostly of the knee and ankle. The rate of ACL injury in handball has been recorded as high as 0.84 injuries per 1000 h of exposure while the rate for women is even higher, with up to 1.82 injuries per 1000 h of exposure [7]. These rates are at a constant risk of increasing with the growing numbers of matches played every year, especially at the highest levels. Despite these high rates, the light at the end of the tunnel is that approximately 50% of the most frequent non-contact ACL injuries can be prevented if the existing prevention programmes are implemented [4]. However, data on compliance to these prevention programmes are sparse. Many efforts have been made on the medical side in Scandinavian countries to develop these programmes and make them accessible to both the players and coaches; however, so far it still seems to be a struggle to translate them to the handball court. The main reasons for this seem to be a lack of information and the gap between health protection on one side and the pressure to achieve the highest levels of performance in the allotted training time on the other, emphasizing the misconception that one comes at the expense of the other.

Recent research in handball medicine has shown increasing evidence of the protective effect of the medial hamstrings in the prevention of the so-called valgus collapse considered to be responsible for so many non-contact ACL injuries [18]. Although these findings need to be supported by additional research, it has the potential not only to increase our understanding of the non-contact ACL injury mechanism, but it may also have a significant impact on the graft choice in ACL reconstruction surgery. In that sense it would confirm the early evidence of increased re-tear rates with the use of hamstrings autografts [5, 9], especially in younger athletes.

There is also a growing interest in the role of overloading in handball and its effect on injury types and occurrence. Early data suggested that during a season, 66% of players at a high amateur level develop overuse-related symptoms [14], and this has been confirmed in later years [2]. The number one affected joint when it comes to overuse injuries is the shoulder [1]. This is not surprising since a player performs approximately 50,000 throws per season in high-level handball [12]. As a consequence, the prevalence of structural abnormalities in the shoulder has been reported to be as high as 93% after an average professional practice of 9 years [6]. Precise data on the long-term evolution of these structural lesions in terms of prevalence of shoulder osteoarthritis (OA) or rotator cuff tears in throwing sports in general and handball in particular are sparse [13]. To our knowledge, few data also exist so far on handball-related long-term knee prospects such as OA of the knee [11]. It may be anticipated that it is strongly depending on the occurrence of a cruciate ligament injury and the preservation or not of the menisci. Interestingly, however, studies have shown that handball players have an increased risk of developing OA of the hip in the long-term [8, 16]. This is surprising because hip pathologies are rarely reported in handball, although probably underdiagnosed. Further research is needed to assess the magnitude of these degenerative problems and to develop preventive strategies. But in order to do so, it seems mandatory that the medical and scientific communities produce efforts to monitor repetitive joint loading and its association with subjective symptoms.

Despite some of the existing quality research based on handball players, the sport is lagging behind when it comes to producing evidence-based medicine and science. This is accentuated when looking at the evidence in handball medicine and science in the literature compared to other sports. Examining the number of scientific publications in handball using PubMed in December 2016 reveals less than 770 publications, a disappointing finding compared to around 9000 publications on football, over 3000 on basketball and volleyball. These findings far from correlate with the popularity of the sport around the world and the demands of the sport. Adhering to the model introduced by van Mechelen [15], proper epidemiologic data are necessary to identify risk factors associated with injuries, implement prevention programmes and re-evaluate their efficiency. While there has been sound epidemiologic data collected in major international competitions in handball [7], this merely provides a snapshot on acute injuries in a condensed period of overload as opposed to the true epidemiologic nature of the sport. There is lack of consistent and continuous epidemiologic data research which is necessary to properly follow the van Mechelen model and improve the players’ safety in an ever changing sport environment. At the highest levels, combining national and international competitions, players play up to 80 competitive matches per year at high intensity, with plans to even increase these numbers.

Considering that high-level handball is associated with at least as high injury risk as football, the most popular sport worldwide, further injury surveillance and prevention research as well as new/updated guidelines on player safety and medical support are warranted. The good thing here is that there is no need to invent the wheel. For example, the Union of European Football Associations (UEFA), launched already in 2001 an injury study on the best football clubs in Europe [17], and a similar study in handball would almost certainly draw much attention in the sports medicine world. Furthermore, UEFA has recently also worked with introducing minimum medical requirements at UEFA competition matches and guidelines for medical screening as well as medical education such as the Football Doctor Education Programme (

In order to strengthen the overall medical support in handball, there could be great potential benefit if national and international sports representatives would take a similar path to the one previously paved by UEFA. By spotlighting one simple example in this editorial, it would be highly appreciated among handball physicians and other medical practitioners in the sport if the number of team officials on the bench could be increased as has been done in football. In the UEFA Champions League manual, the regulations state that “seven team officials, one of whom must be a team doctor, and seven substitute players are allowed to sit on the substitutes’ bench, i.e. a total of 14 persons”. In our opinion, a similar initiative in handball increasing the number of authorised team officials on the bench from four to five, one of whom must be a team doctor, could be an easy way to increase the players’ safety and improve medical support. Although these are rare events, when it comes to sudden cardiac arrest and severe head trauma with unconsciousness, every second counts and having the team doctor close to the field could make the difference between life and death.

ESSKA’s mission is to raise the level of care and achieve excellence in the field of orthopaedics in Europe, especially in sports medicine and degenerative joint diseases with the intention to improve musculoskeletal function and quality of life of patients. Following this strategy, ESSKA and its newly created sports medicine section ESMA recently helped to stimulate the debate by bringing together orthopaedic surgeons and other medical professionals for a medical symposium around health-related issues in handball. This was hosted by the the European Handball Federation (EHF) at its 2015 annual congress in Bucharest. It was followed by a symposium at the 2016 ESSKA congress in Barcelona and the patronage of the first Scandinavian Congress in Handball Medicine in Gothenburg organised around the Women’s European Championship 2016 in Sweden. In line with these initiatives, the EHF has recently recognised the growing need to protect athletes’ health. It has launched a medical and science group, aiming to identify and target immediate needs in order to improve the science in the sport as well as the medical aspects and the players’ safety. In some years from now it can be expected that the medical aspects around handball will be as thoroughly organised as in football and that the science emerging from this improved structure will be beneficial both for the sport and the players’ health in the short and long run.


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Correspondence to Romain Seil.

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Seil, R., Laver, L., Landreau, P. et al. ESSKA helps making a change: the example of handball medicine. Knee Surg Sports Traumatol Arthrosc 26, 1881–1883 (2018).

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