Ep 197: SPORTS CORNER: Shouldering the handball load (plus bonus mini-masterclass!), with Dr Martin Asker

[00:00:06] [SPEAKER_00]: Insights, the podcast that aims to help you translate quality research to quality practice.

[00:00:12] [SPEAKER_00]: I'm Clara Dern, the Editor-in-Chief of the Journal of Orthopedic and Sports Physical Therapy.

[00:00:17] [SPEAKER_00]: It's great to have you listening today.

[00:00:23] [SPEAKER_02]: Today on JOSPT Insights, we are running another sports corner series, specifically

[00:00:28] [SPEAKER_02]: one focusing on the overhead athlete in relation to handball.

[00:00:31] [SPEAKER_02]: Joining us on this episode is none other than Dr Martin Asker, who has been working as a sports medicine therapist

[00:00:36] [SPEAKER_02]: for many elite sports clubs and athletes for over 20 years.

[00:00:39] [SPEAKER_02]: He holds a PhD in medicines, specifically sports medicine epidemiology, from Carolyn's K. Institute

[00:00:44] [SPEAKER_02]: in Stockholm, Sweden. Specializing in shoulder injury prevention rehabilitation,

[00:00:49] [SPEAKER_02]: Martin is a senior lecturer ahead of the handball research group at Sophia Hammett University,

[00:00:53] [SPEAKER_02]: where the research focuses on injury prevention, prognosis, and performance in handball.

[00:00:58] [SPEAKER_02]: He's been part of the medical team for several Swedish national handball teams, and has currently working with the Swedish women's team.

[00:01:04] [SPEAKER_02]: My name is Dan Chapman, owner of Summit Physical Therapy and Performance in Baltimore, Maryland.

[00:01:09] [SPEAKER_03]: And I'm Chelsea Cumin, a physical therapist and athletic trainer at Stanford University Athletics.

[00:01:14] [SPEAKER_03]: Martin, I am so grateful that you're here spending the, well, my morning, your evening at JOSPT Insights to give us the scoop on handball.

[00:01:23] [SPEAKER_01]: Thank you, thank you for having me. It's a pleasure.

[00:01:26] [SPEAKER_03]: Okay, so this is our sports corn episode. So we're going to hit the typical things we do to kind of learn just as much as we can about a sport in one podcast.

[00:01:35] [SPEAKER_03]: And this is a unique one because I think the American listeners are going to be maybe a little bit clueless.

[00:01:40] [SPEAKER_03]: We did just have the Olympic. So maybe we learned a little bit watching some of those teams and those games.

[00:01:47] [SPEAKER_03]: And then maybe some other listeners are going to know a little bit more.

[00:01:49] [SPEAKER_03]: So first, can you give us just like the rundown of the sport and the demands of that sport?

[00:01:57] [SPEAKER_01]: You play indoors a court is 40 meters by 20 meters. I don't know what that is in in the States.

[00:02:04] [SPEAKER_01]: Yes, yes.

[00:02:04] [SPEAKER_01]: Two thousand four nights or something like that.

[00:02:07] [SPEAKER_01]: And you play six Olympic players and one don't keep in each team.

[00:02:11] [SPEAKER_01]: And then it's the demand is pretty much it's the whole sports. It's you have to score more than the opponent. So that pretty much every other sport.

[00:02:21] [SPEAKER_01]: And the demands are pretty much it's quite a complex sport. So it's a lot of running, jumping, side cutting and not least throwing.

[00:02:30] [SPEAKER_01]: And in between that a lot of wrestling and tackling as well. So if you look at combination between rugby and baseball, breastling and then put a bit of chess in the game.

[00:02:43] [SPEAKER_01]: And then you play two half thirty minutes, most goals when.

[00:02:50] [SPEAKER_01]: And then it's just battle in between that. But it's still a very, very, very, very gentleman's sports. It's very quick and so to say. So it's hand shakes and then just bashing each other.

[00:03:03] [SPEAKER_01]: And then off the six to minute, it's hand shakes again and game is over. So it's a really nice force to play with. But it's a tough sport.

[00:03:12] [SPEAKER_01]: And as a clinician, it's like working with these athletes in types of injuries. It's a small sport of injuries.

[00:03:21] [SPEAKER_01]: If you like ACL injuries, you got it. If you like shoulder injuries, you got it concussion as well, spraying angles.

[00:03:26] [SPEAKER_01]: Pretty much every injury we read about in the book, you will find it in Hamburg.

[00:03:31] [SPEAKER_03]: So there's injuries for everyone. Can you go over other different like demands on, I mean, the goal might have a different demand than the people in the court.

[00:03:39] [SPEAKER_03]: Other differences in the demands of the people in the court besides like the running, jumping, cutting kind of a thing.

[00:03:43] [SPEAKER_03]: Or is that all pretty much the same between everybody?

[00:03:46] [SPEAKER_01]: Some of the men are pretty much the same. So running, side cutting moves, jumping those are pretty much the same.

[00:03:53] [SPEAKER_01]: But if you look at different demands where the wing players, they do more sprinting. So they do quick changes when you go from defense to attack and more jumping in from the wings for the side.

[00:04:07] [SPEAKER_01]: Not as much contact with opponents as the ones playing in the line player or the pivot.

[00:04:15] [SPEAKER_01]: This is the one in the middle, wrestling with everyone pretty much. And then when you play in an offensive attack, you have the nine meter place or the back court placed and they mainly do the throwing, especially in the left and the right position one while the middle one is pretty much a playmaker.

[00:04:31] [SPEAKER_01]: So it's a little bit demands, different, more throwing with the back court plays, more running and less order throws from the wing players and more wrestling.

[00:04:41] [SPEAKER_01]: And then you have players that more or less just only play defense and then they shift when the game changed.

[00:04:49] [SPEAKER_01]: And in that case it's more or less just playing defense trying to stop the other or the opponent to break through or score.

[00:04:55] [SPEAKER_01]: So it's a little bit different demands, but typically when we look at shoulder which my field, it's mainly the back court players doing most of the throwing and that's where we see high risk of shoulder ranges.

[00:05:08] [SPEAKER_03]: Okay, so I'm going to at this might be hard then because there's there's an injury for everyone in this sport, but what would you say are like the top?

[00:05:15] [SPEAKER_03]: I don't know, three to five like most common injuries that you see that come out of handball and I know that your shoulder experts are a little bit biased for the shoulders but you can have multiple those if you want to.

[00:05:26] [SPEAKER_01]: Yeah, we see a lot of finger and an ankle into this.

[00:05:29] [SPEAKER_01]: The spring ankles and fingers, spray as well often they're not that high burnness as a knee or severe shoulder injuries because you can mainly take them or or you could play with it with a.

[00:05:43] [SPEAKER_01]: More closely or something, but then we have of course an e-interest and the ligament injuries and the ACL being the worst one.

[00:05:51] [SPEAKER_01]: We have unfortunately a lot of ACL injuries in in Hamburg, especially in the female players in the gold players with a lot of elbow injuries with the extension.

[00:06:00] [SPEAKER_01]: And while this stretch when they're trying to save the balls, we get a lot of hard froze, but it block it with an extension in the elbows.

[00:06:10] [SPEAKER_01]: It's got its own terms, it's called go list elbow, so a lot of go list experienced that.

[00:06:16] [SPEAKER_01]: And then of course, we have a lot of shoulder problems, especially as I said in the back court place that doing a lot of throwing these are the main.

[00:06:24] [SPEAKER_01]: Thanks, so ankles, knees, shoulder fingers and elbows.

[00:06:28] [SPEAKER_01]: But if you ask the place pretty much often them have low back pain at some point, but we don't see as many like hamstring injuries or a doctor's strength that you see in like ice hockey or in football or soccer.

[00:06:41] [SPEAKER_01]: Probably because we don't do as long runs, so it just the court is 40 meters, so it's pretty much 30 meters runs.

[00:06:49] [SPEAKER_01]: We don't get into that overdrive, so to say, but we see the location about not as often as or as common as in soccer.

[00:06:57] [SPEAKER_03]: For shoulder specifically are you seeing more overuse like just like stuff from rowing a million times or is it more is it a lot of like falling on it and traumatic stuff?

[00:07:06] [SPEAKER_03]: What do you see mostly for the shoulder?

[00:07:09] [SPEAKER_01]: Mainly overuse were gradual onset problems with the shoulder and we see that from our data from our research as well.

[00:07:16] [SPEAKER_01]: So it's roughly 75 to 80% of the shoulder problems are classic overuse coming back from summer break, coming back from injury or at some point a coaches come up with the idea that now we're going to do a lot of throwing this practice and you're not really used to that.

[00:07:32] [SPEAKER_01]: And then you get typically a potato cough, 10 and up. So that's the absolutely most common problem. But then we have those who goes more into throwing related or overuse problem that is more the slap problem.

[00:07:47] [SPEAKER_01]: Not a traumatic slap injury but more slap that has been developed by a lot of lot of throwing so if you can keep on nagging or twisting on that shoulder in the insertion of the long head of the biceps and eventually it starts to get.

[00:08:02] [SPEAKER_01]: It's problematic and then we have some traumatic problem as well. But in hammered my experiences that that's normally occurs in non dominant shoulder which is really good so that's the one you fall on to try to do break throw with the ball in your hand and then you fall on the non dominant shoulders. That's where we mainly see the.

[00:08:22] [SPEAKER_01]: The traumatic instability and AC joint problems which is quite tricky when it comes through the habitation and going back to.

[00:08:29] [SPEAKER_01]: I've elocited throwing after instability.

[00:08:32] [SPEAKER_03]: So this is a throwing sport but it isn't little bit different than baseball and it's an overhead sport volleyball whatever because the ball is different or does that make that big of a difference.

[00:08:43] [SPEAKER_01]: Yeah, I think this if you're throwing a baseball it fit perfect in your hand.

[00:08:49] [SPEAKER_01]: And it can throw it really hard. It's hard to throw a handle as hard or with high velocity or speed as a baseball but we use less similar glue. So you grip the ball but you can't really grip it around your whole hand and then says it's size three.

[00:09:05] [SPEAKER_01]: So it's quite big all in soccer you have a size size five and that means that you have to grip it a little bit different compared to to baseball. So that will impact how are you throw and what you can actually do with the but you're throwing technique.

[00:09:21] [SPEAKER_03]: But it's still affecting the shoulder the same in the same way.

[00:09:24] [SPEAKER_01]: Yeah, absolutely. The different male and different that we see is in baseball you get bigger torsion on shoulder bigger rotation because more in external rotation than than.

[00:09:35] [SPEAKER_01]: And we're not having a lot of potential at least with what I kind of want to throw in.

[00:09:41] [SPEAKER_03]: If a handball athlete stumbles into our clinic and we're like okay now I know what these positions are and what the demands are and this guy's got an ankle injury I know that's really common.

[00:09:52] [SPEAKER_03]: What are some key takeaways that you can impart onto those of us who don't treat and live in brief handball to best treat these athletes.

[00:10:00] [SPEAKER_01]: I think that comes with every sport but you get to know your sport so what are the demands and then just backtrack look at what what the benchmark or right now at these athletes not just look at the ankle.

[00:10:13] [SPEAKER_01]: But also okay this is the aerobic capacity or the model of the sport so how is she or he doing on that.

[00:10:20] [SPEAKER_01]: And this is rotation demand in the shoulder or whatever part of the body is so if look at all these these metrics or all these values of factors whatever you call them and see okay how does that fit to the model of handle.

[00:10:36] [SPEAKER_01]: So could be like yes friend your angle good we need you to get back to that and do all that basic or rehabilitation for that specific injury but also take the time to look at what else or or missing because we have an opportunity now we have them in our clinic.

[00:10:51] [SPEAKER_01]: So we have an open window to see okay what else can we try to to fix or what else can we try to increase in terms of their capacity to meet that sports demands and that's not specific to to handle but as I said in hand will they have a lot of different demands is not just jumping high it's not just running fast it's a lot of it and it's a chaotic sport.

[00:11:13] [SPEAKER_01]: So try to figure out what can we do in terms of that spring and ankle when it comes to rehabilitation protocols so it's not perhaps not just jumping or box jumping or jumping up and down or running etc.

[00:11:27] [SPEAKER_01]: It's all these demands that we try to fit into a rehabilitation protocol it's get a little bit tricky to fit all that in when it's so many things to try to figure out what is this not just figure out but.

[00:11:41] [SPEAKER_01]: You have to keep in mind that what is the position of this player so going back to where we started is to play is that jumping a lot or is it more sprinting or is it just standing still on the line and trying to wrestle or keep push some out of certain zone.

[00:11:56] [SPEAKER_01]: That will also affect a little bit on where we're going in the rehabilitation especially in that find the faces.

[00:12:03] [SPEAKER_03]: So basically making sure that you're looking at the whole athlete not just to that injury yeah that makes sense.

[00:12:09] [SPEAKER_01]: It's easier it's very easy to say to you and yeah I have to look at this and listen this but you have to start there and then when when experience and that comes with ever sport you can go get in this case.

[00:12:19] [SPEAKER_01]: You would probably need to build this up or we need to increase that range of motion or that power or the speed in that certain area of view about.

[00:12:32] [SPEAKER_01]: I think that's a lot of it in the field of animals a lot of things that's coming out right now and a lot of big core studies in our city as well as I know it's finishing or wrapping up something is going to be really.

[00:12:49] [SPEAKER_01]: Interesting year to come we just finished our four year data collection after implementing.

[00:12:57] [SPEAKER_01]: Cholar control or injury prevention program for shoulder and knee and I would just have the all the data so in the next six months we probably hopefully have that published and we'll see how.

[00:13:07] [SPEAKER_01]: The injured trench goes from ten years ago and then after we implemented this in your prevention program so that's that's the main thing down for you.

[00:13:17] [SPEAKER_01]: Now I've looked a little bit behind curtains so I'm thrilled but hopefully we'll in six next half of here so we'll have something published on that.

[00:13:27] [SPEAKER_03]: Okay so that means that you're going to be on podcast again talk about how injured prevention for the shoulder and then need how you were so successful and that right.

[00:13:34] [SPEAKER_01]: How important have we come back.

[00:13:36] [SPEAKER_03]: That's awesome that's awesome okay well is there anything else I feel like I understand a little bit more now I definitely want to watch some more matches.

[00:13:43] [SPEAKER_03]: Is there anything else you want to make sure that you share with any the listeners about him.

[00:13:47] [SPEAKER_01]: If you want to share something and as I said shoulder is the thing that makes my brain tickle a little bit more so.

[00:13:58] [SPEAKER_01]: In my case that's where most athletes that I seen the clinic and and if we'll give the clinicians see in these athletes and perhaps not seeing them a daily basis it's often when it comes to shoulders and especially.

[00:14:13] [SPEAKER_01]: Those who have not just afroying them on but a lot of other things going on like humble place it could be seen as quite complex and you don't know where to start or how to to categorize them etc.

[00:14:26] [SPEAKER_01]: One thing that you could.

[00:14:29] [SPEAKER_01]: It's not a black and white but you could pretty much categorize it that the most common one that we talked about in the shoulder and frozen and.

[00:14:37] [SPEAKER_01]: Ambul is not an exception is the desoleration related problems so it's pretty much it's getting worse and worse nothing.

[00:14:46] [SPEAKER_01]: A cute nothing traumatic but they pretty much every time increased their growing low where to come back from some of break where to come brought from injury, they have a rapid increase when you've been digging into their history.

[00:14:59] [SPEAKER_01]: And it's most often only a retiree cuff 10-opoldy.

[00:15:05] [SPEAKER_01]: They often have a weak posterior shoulder, a retiree cuff,

[00:15:09] [SPEAKER_01]: and quite often they have lack of internal rotation in the shoulder.

[00:15:14] [SPEAKER_01]: And their focus for that athlete will be just unloading them a bit

[00:15:18] [SPEAKER_01]: and then just build up the posterior cuff strength,

[00:15:22] [SPEAKER_01]: and then just wind them back to flowing.

[00:15:25] [SPEAKER_01]: And that would pretty much give everyone will return to sport,

[00:15:28] [SPEAKER_01]: whether that is within a couple weeks,

[00:15:31] [SPEAKER_01]: or within month depending on how much they pushed through their 10-opoldy.

[00:15:36] [SPEAKER_01]: The other one we run into are the ones who have an acceleration-related problems.

[00:15:41] [SPEAKER_01]: So that's the one where they say when they will start flowing

[00:15:44] [SPEAKER_01]: and that would be called a parking face,

[00:15:47] [SPEAKER_01]: and that was hurt.

[00:15:48] [SPEAKER_01]: That would hurt in a tear-y-ported shoulder in my armpit.

[00:15:51] [SPEAKER_01]: Often they have a specific onset.

[00:15:54] [SPEAKER_01]: I did this throw, I did this, and it just oo, something snatch,

[00:15:58] [SPEAKER_01]: something happened in the shoulder.

[00:16:00] [SPEAKER_01]: And in that case, it's often a subscap or an autism's door,

[00:16:04] [SPEAKER_01]: so it's on a bigger internal rotator,

[00:16:06] [SPEAKER_01]: that you have a muscle injury,

[00:16:09] [SPEAKER_01]: often in the muscle tendon junction.

[00:16:11] [SPEAKER_01]: That will have a little bit different of a rehabilitation,

[00:16:13] [SPEAKER_01]: because that's not just something you push through as a ten-opoldy,

[00:16:17] [SPEAKER_01]: that you need healing, et cetera.

[00:16:19] [SPEAKER_01]: So more longer initial face,

[00:16:22] [SPEAKER_01]: often, and it's something that you will find on the MRI

[00:16:25] [SPEAKER_01]: or ultrasound if you refer into that.

[00:16:29] [SPEAKER_01]: And then we had the third one, which is what we call the inside impingement,

[00:16:33] [SPEAKER_01]: or the posterior impingement, or internal impingement.

[00:16:37] [SPEAKER_01]: And that's when it's a little bit more problematic on the top.

[00:16:40] [SPEAKER_01]: Back to the shoulders, still in the parking face,

[00:16:43] [SPEAKER_01]: often not a gradual onset,

[00:16:46] [SPEAKER_01]: and that's what we discussed a little bit earlier when

[00:16:49] [SPEAKER_01]: they had that slack problem,

[00:16:51] [SPEAKER_01]: or long-hand pices problem,

[00:16:53] [SPEAKER_01]: when they got a little bit unstable in the shoulder,

[00:16:56] [SPEAKER_01]: and they get often weak and lack external rotation,

[00:17:00] [SPEAKER_01]: instead, and they get weak internal rotation.

[00:17:04] [SPEAKER_01]: And in that case, the rehabilitation will be more

[00:17:06] [SPEAKER_01]: into that direction, gradually increase their external rotation,

[00:17:10] [SPEAKER_01]: gradually load the internal rotation in that parking face,

[00:17:14] [SPEAKER_01]: and building up the strength, and especially in the later face,

[00:17:19] [SPEAKER_01]: the force reaction into throwing.

[00:17:20] [SPEAKER_01]: So just easily or categorize them into different categories,

[00:17:25] [SPEAKER_01]: depending on their problems related to their sport,

[00:17:30] [SPEAKER_01]: and this time throwing, instead of trying to find a specific tissue

[00:17:34] [SPEAKER_01]: that ignores it, which is quite hard in these types of athletes,

[00:17:39] [SPEAKER_01]: and especially if just thrown them in the MRI,

[00:17:42] [SPEAKER_01]: you will find that pretty much 95% of them will have something

[00:17:45] [SPEAKER_01]: in the shoulders that are not related to their problems at all.

[00:17:48] [SPEAKER_01]: So we'll all be something that you can stick to knife,

[00:17:51] [SPEAKER_01]: and so just thinking more of a functional way

[00:17:55] [SPEAKER_01]: to diagnose these types of especially the gradual onset wound.

[00:17:58] [SPEAKER_01]: I think that will help a lot when it comes to shoulders,

[00:18:03] [SPEAKER_01]: and especially in the humble place,

[00:18:06] [SPEAKER_01]: because that complex demand not just throwing,

[00:18:08] [SPEAKER_01]: but also wrestling tackling landing on the shoulder, et cetera.

[00:18:11] [SPEAKER_03]: Hey, that is really great,

[00:18:14] [SPEAKER_03]: little clear synopsis of trying to break those three things down

[00:18:17] [SPEAKER_03]: and you're seeing your hand, boss. Thank you for that.

[00:18:19] [SPEAKER_03]: I know we'd get like a little bonus shoulder,

[00:18:21] [SPEAKER_03]: shoulder lesson today, I love it. Okay, well Martin,

[00:18:24] [SPEAKER_03]: thank you so much for spending your evening with us.

[00:18:26] [SPEAKER_03]: With me, I really appreciate it,

[00:18:28] [SPEAKER_03]: and I'm so excited for people to learn a little bit more about it,

[00:18:31] [SPEAKER_03]: and offer me a.

[00:18:32] [SPEAKER_01]: No, no problem at all, and if you're really interested in humble,

[00:18:35] [SPEAKER_01]: I have a website called humblemedicine.com,

[00:18:39] [SPEAKER_01]: where I hopefully clarify some of the stuff,

[00:18:42] [SPEAKER_01]: especially around the shoulder that I mentioned here,

[00:18:44] [SPEAKER_01]: that you can dig into deeper if you're interested in humble.

[00:18:46] [SPEAKER_01]: It was written nice to be on the podcast. Thank you for having.

[00:18:51] [SPEAKER_02]: So even though I couldn't make it to this recording,

[00:18:53] [SPEAKER_02]: I still just wanted to chime in and thank Dr. Asker

[00:18:55] [SPEAKER_02]: for coming on the show, sharing its time and experience with all of us,

[00:18:58] [SPEAKER_02]: and as always, we want to thank you for listening to JOSBT Insights.

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