“DON’T LET WHAT YOU CAN’T DO INTERFERE WITH WHAT YOU CAN DO.”

- John Wooden

– Written by Gergely Kis, Qatar

Handball is a dynamically developed sport, which has been a part of the Olympics since 1972, making it one of the most popular team sports¹. Since the early appearance on the Olympic program, the sport has become faster and more physically and mentally demanding. Due to the nature of the sport (requiring numerous high-speed changes of direction, full body contact, rapid deceleration and acceleration and throwing with maximum effort in different body positions, including jump throws) injuries are common during matches and practice sessions. A study conducted during the 2015 World Men’s Handball Championship in Qatar reported that 58.3% of the injuries were in lower extremities while 16.7% affected upper extremities⁴. Since Injuries are very common, it is very important for all practitioners to consider training solutions to retain and/or improve general fitness while players are injured.

INJURIES AND DETRAINING: WHAT SHOULD YOU CONSIDER?

When a significant injury occurs, handball players often stop training and competing resulting in significant reduction of physical activity. Reduced training activities limits or removes the training stimulus and could lead to deconditioning. The effect of detraining can be categorized as short-term (less than four weeks) or long-term (more than four weeks). Endurance capacity is one of the physiological qualities affected by detraining. Research findings have reported that the VO₂max for highly trained athletes decreased by 4-14% after short-term detraining and decreased by 6-20% after long-term detraining^5,6. For this reason, it is paramount to ensure that no matter the injury, handball players keep training with adequate (and safe!) activities to make minimise loss of physical fitness.

KEEPING PLAYERS FIT DURING INJURY: THE ASPETAR APPROACH

Physical conditioning during injury rehabilitation is essential for restoring physical function, preventing detraining, improving physical fitness, stability and balance, and enhancing flexibility and range of motion. In addition, physical conditioning during injury rehabilitation helps to address any factor that could contribute to future (re)injury.

After the initial physiotherapy assessment, the athlete is usually referred to physical coaches on the same day. When the injury requires surgery, the athlete is referred to physical coaches 3-4 weeks post-surgery. For an in-depth understanding of our long-term (ACL rehabilitation) physical conditioning approach at Aspetar, please consult the special issue on ACL rehabilitation³ .

The Aspetar physical coaches’ responsibility for athletes with long-term injuries, is to establish a strong foundation of general athletic fitness. In short-term injury rehabilitation, physical coaches focus on maintaining and enhancing fitness qualities while integrating handball-specific and position-specific activities into the program. At this stage, physical coaches, sport rehabilitators and physiotherapists collaborate closely to assist the athlete in returning to sport as quickly and safely as possible (Table 1).

General Fitness Development

The first objective of a rehabilitation programme is to build general athletic fitness¹⁷.  General athletic fitness is important when working with handball players recovering from long-term injuries or surgeries. The components of general athletic fitness include general muscular strength, general flexibility, muscular endurance, cardiorespiratory endurance, and body composition¹⁷. These are the components that the physical coaches assess at the beginning and over the course of a rehabilitation programme. General athletic fitness is important because it forms the base on which sport-specific athletic fitness is built. In the tables below, we provide examples of training objectives and training prescription guidelines (Table 2 and 3).

Every training plan should start with assessing the injured player’s general fitness qualities. Normative values can provide some indication of general fitness qualities of handball players and be used as a reference. However, it is important for practitioners to assess those qualities in their players and develop their own reference values according to the players’ levels and age to make sure the fitness goals are adequate for their population (Table 4).

Handball Specific Fitness Development

The second objective of a rehabilitation programme is to gain sport-specific athletic fitness, which is achieved by targeting specific fitness components for handball. This is done by emphasizing exercises targeting specific muscle groups, specific biomechanical patterns, Handball and position-specific metabolic demands and technical skills/movements¹⁷. Understanding the physical demands and characteristics of handball is crucial for optimizing physical training and minimizing the risk of future injuries.  During short term rehabilitation, physical coaches work together with sport-rehabilitators to maintain sport specific athletic fitness. Focusing on long-term rehabilitation, physical coaches shift their focus to sport specific athletic fitness 4-6 weeks before discharge/return to training with the team (Table 5 and 6)

ASSESSING INITIAL STATUS AND PROGRESSION

An initial assessment is crucial for developing an appropriate conditioning program as it helps determinate the initial fitness level of the player/patient. A high percentage of athletes, from all competitive levels, start their conditioning program with different musculoskeletal deficits that may slow down optimum conditioning¹⁷. Physical coaches should always perform an initial assessment of the player’s physical fitness. To assess progress and individualize interventions, fitness assessments are performed every four weeks during the rehabilitation process (Table 7).

Upper Body Strength tests

The Concept2 Dyno is a dynamometer and reliable to assess athlete strength¹². It is widely used by athletic clubs and the police force as well as by researchers for strength assessment^13,14 (If there is no access to a dyno machine there are several other ways to assess upper and lower body strength such as using a chest press or leg press machine to determinate 1RM).

Initial Strength Assessment (5 rep test):

(See Figures 1, 2, and 3)

Upper body endurance test:

1 min Push Ups

Core Stability test:

(See Figures 4, 5, 6, and 7)

Cardiorespiratory Fitness Tests

An incremental submaximal test on the upper body ergometer or leg cycle ergometer (depending on the injury) is used for assessing cardiovascular fitness when starting the rehabilitation program. The incremental exercise test is determined by different variables. These include the: (i) starting stage, (ii) consecutive work rates, (iii) increments, (iv) duration of each increment and (v) athlete’s heart rate. These variables can be modified extensively to suit the purpose of the training program or the individual and have proved useful in identifying and monitoring individuals or team’s adaptation to training¹⁵.  Depending on the specific case, strength and conditioning specialist and/or exercise physiologists can conduct maximal or submaximal tests.

Upper body ergometer (UBE) increment test

Outcome measures:

• Total time (min)
• Effort level (power/watt)
• Heart Rate (bpm)
• Heart rate recovery (1min/2min)
• Rate of Perceived Exertion (RPE)

(See Figure 8)

Cycle ergometer Increment submaximal test

Outcome measures:

• Total time (min)
• Maximum mean power (MMP)
• Power to weight ratio (w/kg)
• VO2max estimate (ml/kg/min)
• Heart rate (bpm)
• Heart rate recovery (1min/2min)
• Rate of Perceived Exertion (RPE)

(See Figure 9)

Yo-Yo Intermittent Recovery test 1

Outcome measures:

• Total time (min)
• Total Distance (m)
• Maximal Aerobic Speed (Km/h)
• Average Heart rate (bpm)
• Heart rate max (bpm)
• Heart rate recovery (bpm)
• Rate of Perceived Exertion (RPE)

(See Figure 10).

SUMMARY

In conclusion, the path to recovery for an injured handball player highlights the importance of teamwork between medical professionals, clinical staff and physical coaches. Together they create tailored plans and closely monitor progress to ensure safe return  to court and optimal performance. This collaboration not only promotes injury healing but also prevents detraining and reduces the risk of future injuries. Effective physical preparation during injury rehabilitation plays an important role in supporting and prolonging handball players’ careers. (See Table 8 on the next page).

Gergely Kis

Physical Coach

Aspetar Orthopaedic & Sports Medicine

Hospital

Doha, Qatar

Contact: gergely.kis@aspetar.com

References

1. Clanton & Dwight, 1997; Marczinka,1993
2. Medicine & Science in Sports & Exercise, 2001
3. Aspetar Sport Medicine Journal 2023 Volume 12
4. Bere,T.; Alonso,J.M.; Wangensteen,A.; Bakken,A.; Eirale,C.; Dijkstra,H.P.; Ahmed,H.; Bahr,R.; Popovic,N. Injury and  illness surveillance during the 24th Men’s Handball World Championship 2015 in Qatar. Br. J.SportsMed.2015,49,1151–1156. 
5. Mujika and S. Padilla, “Detraining: loss of training-induced physiological and performance adaptations. Part I: short term insufficient training stimulus,” Sports Medicine, vol. 30, no. 2, pp. 79–87, 2000.
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8. Vila,H.; Barreiro,A.; Ayán, C.; Antúnez,A.; Ferragut,C. The Most Common Handball Injuries: A Systematic Review. Int. J.Environ. Res.PublicHealth2022,19,10688.
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11. M. Hübscher, A. Zech, K. Pfeifer, F. Hänsel, L. Vogt, W. Banzer Neuromuscular training for sports injury prevention: a systematic review Med Sci Sports Exerc, 42 (2010), pp. 413-421
12. Bampouras TM, Marrin K, Sankey SP, and Jones PA. Test-retest reliability and sensitivity of the Concept2 Dyno dynamometer: practical applications. J Strength Cond Res 28(5):1381-1385, 2014
13. Graham-Smith P, Burgess K, and Ridler A. The relationship between strength, power, flexibility, anthropometry and technique and 2000m and 5000m roweing ergometer performance. In: Kinantropometry X. M. Marfell-Jones and T.Olds, eds New York: Routledge, 2007. Pp. 135-150
14. Jones Pand Bampouras, TM. A comparison of isokinetic and functional methods of assessing bilateral strength impalance. J Strength Cond Res 24: 1553-1558, 2010
15. Bentley DJ, Newell J, Bishop D (2007). "Incremental exercise test design and analysis: implications for performance diagnostics in endurance athletes". Sports Med. 37 (7): 575–86.
16. Functional Rehabilitation of Sports Injuries: Alyssa Marulli, MD, Esme Irvine, DO, Hector Moreno Rojas, MD Originally published: September 20, 2014 Last updated: September 6, 2018
17. Sport-Specific Conditioning W. Ben Kibler,* MD, FACSM, and T. Jeff Chandler, EdD, CSCS, FACSM From the Lexington Clinic Sports Medicine Center, Lexington, Kentucky, 1994
18. Playing Level and Position Differences in Body Characteristics and Physical Fitness Performance Among Male Team Handball Players  Souhail Hermassi1, Kevin Laudner and René Schwesig 2019
19. Physical Demands during Official Competitions in Elite Handball: A Systematic Review Carlos García-Sánchez,1,* Rafael Manuel Navarro,2,* Claude Karcher,3,4,5 and Alfonso de la Rubia1 Int J Environ Res Public Health. 2023 Feb; 20(4): 3353.
20. Physical and physiological characteristics of male handball players: 1 influence of playing position and competitive level Thomas A. Haugen1,2, Espen Tønnessen1, Stephen Seiler2 1 Norwegian Olympic Federation, Oslo, Norway  2 University of Agder, Kristiansand, Norway
21. Anthropometric and physical performance characteristics of professional handball players: influence of playing position René SCHWESIG 1, Souhail HERMASSI 2 *, Georg FIESELER 3, Lars IRLENBUSCH 1, Frank NOACK 4, Karl-Stefan DELANK 1, Roy J. SHEPHARD 5, Mohamed-Souhaiel CHELLY 2

Header Image by Doha Stadium Plus Qatar (Cropped)