Physical Training Jan 2008

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Dimitris Hatzimanouil¹, Nikos Oxizoglou², Aggelos Kanioglou¹, Kostas Manavis³, Stefas Eleftherios³

¹Department of Physical Education and Sports Science
Aristotle University of Thessaloniki, Greece
²Department of Physical Education and Sports Science at Serres
Aristotle University of Thessaloniki, Greece
³Department of Anatomy, Medical School
Aristotle University of Thessaloniki, Greece

CORRESPONDENCE:
Hatzimanouil Dimitris
Glinou 34 street
T.K. 54352 Pilea
Thessaloniki
Greece
Tel: (+30) 2310925624
Fax: (+30) 2310925624
E-Mail: xatjiman@phed.auth.gr

INTRODUCTION

In sports that require contact with opponents, there exists a bigger probability of injury in contrast to sports without body contact (American Association of Oral & Maxillofacial Surgeons, 1999; Kujala, Taimela, Antti-poika, Orava, Tuominen & Myllynen, 1995). Moreover, sports of contact also have a big risk of injury for both genders (Loes and Goldie, 1988). Some of those carried out indoors are characterized by intense contact and high number of jumps (Backx, Beijer, Bol & Erich, 1991). In this category belongs the sport of handball, which is spread worldwide and has been part of the Olympic Games since 1972 (Pokrajac, 1989). This particular sport includes movements that produce stress to the myoskeletic system and consequently injuries (Andren-Sandberg, 1994; Loes and Goldie, 1988; Tyrdal and Bahr, 1996; Werner and Plancher, 1998). Therefore, the requirements and the particularities of this sport, as for example the frequent and intense contact with the opponent players, often leads to injuries (Andren-Sandberg, 1994; Asembo and Wekesa, 1998; Wolf et al. 1974).

Hoeberigs, van Galen, and Philipsen (1986), suggested that each sport should have its own model of injuries, which can be more or less specialised. The knowledge of this model, can be very important for the planning of medical care that perhaps needs to be given and is useful to define the most important causative factors of injuries in handball. The necessity of knowledge of this model that concerns injuries in this sport particularly, appeared also from the study of Nielsen and Yde (1988), in which it was documented that the knowledge of athletic injuries and their rehabilitation was poor, for both athletes and coaches. Except for the factors that are related to specific requirements of the particular sport, there also exist various exogenous factors, such as the erroneous application of regulations, the material of the court surface and the dimensions of the court that lead to injuries (Boden, Griffin & Garrett, 2000; Jorgensen, 1984; Seil, Rupp, Tempelhof & Kohn, 1997).

One particular characteristic of handball is the high frequency of injury not only in adults but in junior athletes too (Loes and Goldie, 1988; Tittel, Schaetz & Hagen, 1974; Wolf et al, 1974). This conclusion is reached by a number of scientific publications (Backx, Beijer, Bol & Erich, 1991; Bak and Koch, 1991; Engebretsen, Gruntvedt & Bredland, 1993; Fagerli, Lereim & Sahlin, 1990; Hoeberigs et al., 1986; Sorensen, Larsen & Rock, 1996; Yde and Nielsen, 1990). The above mentioned injuries lead, many times, to the individuals being admitted to hospital with injuries of high severity that require medical care (Jorgensen, 1984; Hoeberigs et al., 1986; Maehlum and Daljord, 1984; Menquy, Guillou & Condamine, 1999). The sustained injuries appear to be of high severity because the majority of athletes are absent from training sessions for more than a week (Biener and Perka, 1980; Lindblad, Jensen, Terkelsen, Helleland & Terkelsen, 1993; Lindblad, Hoy, Terkelsen, Helleland & Terkelsen, 1992; Nielsen and Yde, 1988). Asembo and Wekesa (1998), suggest that injuries in handball are inevitable. They also suggest that for these specific injuries measures of prevention, treatment and rehabilitation should be taken. Adamczewski (1999), also suggests that for the reduction in frequency of such injuries, preventative actions are recommended. The Wolf et al. (1974), report that the main actions of prevention are determined by the observation of injury factors.

If we consider that almost 50% of handball players sustain at least one injury throughout a year (Hoeberigs et al, 1986), that a percentage of the injured athletes are hospitalized and that the majority of these athletes are absent from training sessions for more than a week and finally that a percentage of these athletes abandon the sport because they could not recover from the injury (Lindblad et al, 1993), we understand that injuries in handball constitute an important issue concerning this particular sport. The cause of injuries in each sport can differ between different subgroups of the athletes’ population. Different subgroups of the athletes' population in each sport, also need different prevention programs, so that the highest frequency and severity reduction of particular injuries is achieved. Therefore, scientific research should be specialised, so that the groups at high risk are ascertained and independent variables for forecasting injuries are defined for each subgroup separately. The results of such studies can provide effective precautionary measures and prevention programs. It is desirable that such research include similar subgroups for the determination of injuries and should be based on epidemiologic and methodological principles (Inklaar, 1994).

Deductively, it is obvious that while the interest for the sport of handball is steadily increasing, there is absence of research via which we would generate precious information and reliable data on factors that determine the reduction of injuries in national team level. Via research, prevention measures will be upgraded. Moreover there is lack of research data about injuries of handball players of national teams that evolve after a long-lasting period of participation. Lack of data and research that concerns this particular subject gave birth to the present study. Thus, the aim of this study was the recording of injuries that occurred in Greek national teams' handball players aged 19 years or more, with the final objective to become a useful tool in finding those measures of prevention that will contribute to future injury reduction.

MATERIALS AND METHODS

Sample

The total sample of the study consisted of 32 handball players who were in Greek national teams of juniors and men. All athletes were regular participants of the teams. Junior athletes participated in preliminary European championship and men participated in the pre Olympic preparation.

Research tools

All athletes were given a self-reported questionnaire developed specifically for this research. The questionnaire was related to the injuries the players had suffered during their involvement with the sport within the period of the last 24 months. An injury was defined as an accident sustained during practice or competition, which led to a medical problem (e.g., pain, disability) and prevented participation in training sessions or games for at least one day beyond the date of occurrence (Gibbs, 1993; Hodgson, Standen and Batt, 1998). More specifically, at the beginning of the questionnaire each player was required to give information and data on personal characteristics such as age, weight, height and his history of athletic activity and participation. In addition, each player gave further information about warm up exercises, prophylactic equipment, stretching exercises and technical training. In the main part of the questionnaire, information was required on injuries which the players had sustained during the last two years. For instance, the incidence, severity (injuries were graded into four categories of severity): mild (absence from practice less than 1 week), moderate (1-2 weeks absence), serious (2-4 weeks absence), and severe (more than 4 weeks absence) (Seil, Rupp, Tempelhof and Kohn, 1998), the percentage of players who had to be hospitalized, localization, type and mechanism of injury, time (that is, during training or at a match), type of treatment, and relapse of the injury. Finally, information was asked about various environmental factors, such as the surface of the field, the soles of the player’s shoes as well as the place where the injuries occurred.

Procedure

The questionnaires were suitably formed and were completed by each player separately during the visit made by the researchers at one of each national team training sessions. The completion of the questionnaires was done during Junior's European Championship and Men’s Balkan Championship. Participation in the study was voluntary. If an injury was listed, more questions had to be answered regarding the severity, localization, time (that is, during training or at a match) and relapse. The researchers were present to answer any questions posed by the athletes. There was a 100% response from the questionnaire. In total, 32 questionnaires were completed. All injuries reported concerned sport injuries and not those related to overuse syndromes. Nicholas and Hershman (1990), state that sport injury is an acute myoskeletic injury, related to an accident which happened in scheduled matches or training sessions and which results in the absence of a player from at least one match or training session.

In the present study handball players were asked to complete a self-reported questionnaire. Therefore an issue can be raised regarding its reliability. It should be underlined that none of the scientific articles that were used as a reference for the research confirmed the reliability of the administered questionnaire. It is possible that the contradictory results which are frequently found in the literature, regarding sport injuries, stems from tools of low reliability. Future studies should attempt to clarify this issue. The results of the present study should be viewed while taking into account the above considerations.

Statistical Analysis

The mean, the standard deviation, the frequency of the values of each variable and their percentage were considered in the descriptive statistical analysis of the data. In the deductive statistic analysis Kruscal Wallis' and Mann Whitneys' scale was used to define the interaction between frequency and severity of injuries and all other variables.

RESULTS

Descriptive statistics

From the statistical analysis of the results concerning the players’ personal characteristics the average age was 23.1±3.9 years. The average weight was estimated at 84.4±16.87 kg and height at 188±7.19 cm. The average training age was 10.9±3.54 years, with 6.3±1.4 average training sessions per week. All the players executed warm-up exercises. The use of prophylactic equipment was 43.8% for the total number of players. This prophylactic equipment was used exclusively for the protection of the joints and not for rehabilitation or treatment reasons. Moreover, all players were physically fit and were not involved in rehabilitation or treatment, which meant they were ready to participate in a game. Stretching exercises were executed in two ways: at the warm-up period and after training or games. At the warm-up period the percentage was 90.9%. After training or games the percentage was 72.7%. The majority of players (81.3%) reported the use of technical training, which helps to avoid injuries due to poor technique.

Our findings also revealed a high incidence of injuries for the total number of team handball players. Fifteen out of all players (46.8%) had treatment for at least one injury during the previous two years. Specifically these athletes had a frequency of injury of 0.7 per 1000 hours of reported athletic activity. From the athletes with injuries, 11 (73.3%) had suffered an injury, 3 (20%) had suffered two injuries and 1(6.7%) had suffered above two injuries in a 2 years period. Moreover, the most injuries presented the line players (Table 1).

Table1. Number of injuries and field position.

FIELD POSITION	NUMBER OF ATHLETES	ATHLETES WITH INJURY	%
GOALKEEPERS	7	2	6.25
WING	9	4	12.5
CENTRAL BACKCOURT	3	2	6.25
BACKCOURT	7	3	9.3
PIVOT	6	4	12.5
TOTAL	32	15	46.8

Regarding the severity of injuries, these were 9.1% of soft form (absence from trainings for at least one week), 36.4% of moderate form (1-2 weeks absence), 40.9% of serious form (2-4 weeks absence) and 13.6% of severe form (more than 4 weeks absence). See Figure 1.
Further, the percentage of players who had to be hospitalized was 17.4%. The localization of injuries was 78.3% in the lower limbs, 13% to the torso and 8.7% in the upper limbs. The most frequent injury was ligament injuries (31.8%) and fractures (18.2%). The main cause of injuries was the violent conflict with opponent player (57.1%) and without any contact (33.3%). Most injuries were reported to have occurred during training (69.6%), while the remaining 30.4% occurred during matches. Most players followed conservative treatment (68.2%) while the rest (31.8%) followed operative treatment. A percentage of 13% from these team handball players had a relapse of the injury referred to. Further still, our findings revealed that most injuries occurred on a wooden surface (54.5%) versus 31.8% on a synthetic surface. Moreover, the majority of the soles of the player’s shoes when injuries occurred were appropriate (shoes especially for handball) (86.4%). Furthermore, the playfield characteristics, where injuries occurred, were indoors and of official dimensions (59.1%).

Inductive statistical

Frequency of injuries:
 
As for the frequency of injuries, the results pointed out that the athletes who suffered a single injury in the past, came back sooner to the prior state of athletic activity, in contrast to those who had suffered two or above injuries. Mann Whitney U=2.00, p=.027.

Severity of injuries:

As for the severity of an injury, it appeared that those that had not followed the preseason program presented higher severity of injuries. H=10, p=.019. It appeared also that in the training sessions we had more serious injuries in contrast to games. H=7.55, p=.05. The athletes that had more serious form of injuries followed a surgical treatment. H=10.47, p=.01. Finally, it appeared that the athletes that had more serious form of injuries needed more days for their comeback to athletic activity. H=13.29, p=.00.

DISCUSSION

A percentage of athletes 56.2% did not use protective equipment. This result correlates with that of Tsigilis and Hatzimanouil (2005), in only that the 41.7% of all handball players of the Greek first league made use of protective equipment. In handball intensive precautionary measures should be applied not only during games, but also during training sessions (Wolf et al, 1974). As it appears from the research of Dirx, Bouter and Geus (1992), protective measures are of high significance for the reduction of injuries. Biener and Fasler (1978), recommend to the high risk group of athletes particularly those that had a history of injuries in the ankle joint and in the lower limbs, to consider as a standard procedure protective taping or other protective measures in the above-mentioned joints. The same researchers recommend the use of kneecaps and elbow caps. Biener and Perka (1980), report as a protective measure taping before training session, but also the use of other protective equipment that will minimize the risk of injuries. Adamczewski (1999), supports that taping has a lot of advantages.

The majority of athletes used stretching exercises in the warm-up and also after the end of the training session or the game. As Aronen (1995 & 1991) reports, stretching exercises before and after the training session, is a measure of high significance for the prevention and reduction of injuries. Of course, Bradford (2000) reports that the stretching exercises should be continued after an injury as a measure to prevent relapse.

Moreover, most athletes followed a program of technique exercises in order to avoid injuries as a consequence of bad technique application. As Aronen supports (1995), errors in technique is a cause of injuries. Ehrich and Gebel (1992) propose that the technique exercises should be of special stress, in order to correspond to the requirements of a game. The most common case of erroneous technique is that of the reception of the ball, which causes injuries (disarticulation) in fingers (Aronen, 1991; Biener and Fasler, 1978 Taillandier, Quignard and Pilardeau, 1990).

According to the results it appears that 15 out of 32 players (46.8%) had suffered at least an injury during the past 2 years and this points to a high incidence of injuries in this particular group of athletes. These results correlate with those of Tsigilis and Hatzimanouil (2005) who examined handball players of the Greek first league. These particular athletes presented a frequency of injuries of 0.96 per 1000 hours of reported (games and trainings) athletic activity. The results that concern the incidence of athletes that suffered two or more injuries, correlate with those of Hatzimanouil et al. (2005), who examined Greek handball players of different game level and found that the majority of athletes suffered a serious injury in the past two years.

The results of the present study concerning field position and occurence of injury correlates with those of Tsigilis and Hatzimanouil (2005) as well as Olsen, Myklebust, Engebretsen, and Bahr (2006), who found that players playing the field position of pivot and those playing the field position of wing had the most injuries. This is logical because line attack players have more frequent contact with opponent players who try to protect the line. Moreover pivot always takes part in handgrips with the opposing players when he catches the ball while the wings are the first players who take part in (individual or team) fast break thus very fast movements are necessary.

The results of the present study concerning the severity of injuries, differ from those of Junge et al. (2006), and Langevoort, Myklebust, Dvorak and Junge (2006), who examined injuries during the 2004 Olympic Games in Greece and World cups and found that most injuries resulted in abstinence from 0 days to a week. The above-mentioned researchers examined and took into consideration the injuries for the actual championships and did not examine these athletes for a long-lasting period. Moreover in the present study, an important percentage needed hospitalization. This declares that some injuries require immediate hospital care. Furthermore the rate of hospitalization correlates with the results of Hatzimanouil et al. (2005), who analyzed injuries of handball players in teams of different game level.

With regard to the localisation and the type of injuries, the results of this study correlate with those of Benito (1999), who examined handball players of the national team of men of Spain and found that the majority of injuries were located in lower limbs and concerned ligaments and articulars injuries. The same conclusions were made by Junge et al. (2006), and also Langevoort et al. (2006), who examined handball players of national teams in various championships and found that most injuries were located in the lower limbs. The same researchers report that ligament injuries were of high frequency. The cause of the majority of injuries was contact with an opponent. These results correlate with those of Langevoort (2003), Schulz, Henke and Heck (2005), the Junge et al. (2006) and Langevoort et al. (2006) who report that the majority of injuries is due to contact.

The 69.6% of injuries in the last two years were sustained during training sessions. These results do not correlate with those of Schulz et al. (2005), Andren-Sandberg (1994), Myclebust, Maehlum, Holm and Bahr (1998), Myclebust, Maehlum, Engebretsen, Strand and Solheim (1997), Nielsen and Yde, (1988), Retting, 1998, Seil et al. (1998), Seil, et al. (1997) and Tyrdal and Bahr (1996), who however examined athletes of national championships and not international handball players. Probably this happens because of the small participation of the athletes in official games during the last two years. The majority of the athletes followed conservative treatment and only certain cases of injuries needed surgical treatment. This correlates to Benito's (1999) results.

Moreover, the results of the study that concern the relapse of injuries that were reported by the athletes, correlate with those of Nielsen and Yde (1988), who however examined handball players in teams of associations. Although most injuries were sustained on a wooden floor, according to Olsen, Myklebust, Engebretsen, Holme and Bahr (2003), the type of floor is not related to the increase of the number of injuries to men handball players, while on the contrary it is related with the occurrence of injuries in women handball players. Moreover, the results showed that the majority of players were wearing suitable footwear. Seil et al. (1998), support that the combination of flexible floor and soles of the shoes, possibly is the responsible factor for frequent complications at lower limbs. Jorgensen (1984), suggests that for handball players a shoe with 'high cut' should be preferred and that the soles of the shoes should correspond in the different floors that an athlete can meet. This footwear should protect the ankle and its sole should have a moderate friction with the floor. This is proposed for the reason that footwear with 'low cut', while they give bigger acceleration, leave the ankle exposed. Missteps also are due to very small or very large friction, while suitable footwear constitute an important measure to prevent injuries (Andren-Sandberg, 1994; Biener & Perka, 1980; Quinn, Parker, de Bie, Rowe & Handoll, 2000; Tittel et al., 1974).

CONCLUSIONS

Deductively, handball players of national teams of men and juniors do not use protective equipment for joints, and they present a high frequency of severe injuries. The players playing the field position of pivot and wing present most injuries, which are located in lower limbs and they mainly concern joints. They are caused after contact with the opponent during training session, they heal after conservative therapy, while some relapse in a small percentage. The flooring, the footwear of athletes as well as the characteristics of playfields at the time of injuries were found to be appropriate. The frequency of past injuries relates to the time that is required in order for the athlete to return to prior athletic activity, while the severity of the injuries relates to the attendance of season and preseason training schedule.

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