Table 5 Characteristics of the included studies

Edouard et al. [37]

Prospective Cohort Study

Season 2009–2010

16 F elite handball players and

14 healthy F non-athletes (Control group)

Age (18 years, SD 1)

Height (174 ± 6 cm)

Weight (70 ± 9 kg)

BMI (23 ± 2 kg.m)

Right-handed (n = 11)

Workload: Mean 10 h—per week and

28 matches per year

Goalkeepers (n = 2),

Wingers (n = 5)

Backcourts (n = 5)

Centres (n = 3)

Pivot (n = 1)

NR

Rotator muscle strength imbalances (Isokinetic dynamometer). Muscular imbalance if ≥ 2 of the following criteria existed: dominant side deficit of ≥ 10% in concentric (at 60, 120, or 240°/s) and/or in eccentric (at 60°/s); ER/IR ratio below 0.63 at 60°/s; ER/IR ratio below 0.64 at 120°/s; ER/IR ratio below 0.69 at 240°/s; ERecc/IRcon ratio below 0.67; and IRecc/ERcon ratio above 1.61 at 240°/s

All new shoulder injuries were recorded by the national team physician and/or by monthly physician's medical interview. Injury was defined as the player being unable to participate fully in training or match at least one day past the day of injury

A significant association was found between muscle imbalance (ERcon/IRcon at 240°/s and IRecc/ERcon at 60°/s) and shoulder injury (RR 2.57, 95% CI: 1.60–3.54; P < 0.05)

Clarsen et al. [16]

Prospective Cohort Study

Season 2011–2012 (September 2011 to May 2012)

206 M elite handball players

Age (24 years, SD 4)

Height (189 cm)

Weight (89 kg)

Handball experience (14 years and 4 years in elite series)

Right-handed (73%)

Back players (42%)

Wing players (23%)

Line players (15%), Goalkeepers (14%) Combination of positions (6%)

N = 42 (inadequate response to questionnaire excluded from the analysis)

1) TROM (digital inclinometer)

2) Isometric ER, IR, and abduction strength (digital handheld dynamometer)

3) Scapular control (during 5 repetitive flexion and abduction movements with 5 kg). Rating: normal control, slight dyskinesis, obvious dyskinesis

OSTRC Overuse Injury Questionnaire (email every 2 weeks)

Obvious dyskinesis (OR 8.41, 95% CI 1.47 to 48.1, p < 0.05), total rotational ROM (OR 0.77 per 5° change, 95% CI 0.56 to 0.995, p < 0.05) and ER strength (OR 0.71 per 10 Nm change, 95% CI 0.44 to 0.99, p < 0.05) were significant risk factors

Achenbach et al. [36]

Prospective Cohort Study

Season 2017–2018 (7 months)

138 (70 M and 68 F)

elite youth handball players

Age (14.1 years, SD 0.8)

Height (175.2 ± 8.2 cm)

Weight (64.0 ± 9.6 kg)

BMI (21.1 ± 2.0)

Team handball experience (8.2 ± 2.2 years)

NR

1) GIRD, TROM, ER gain (manual goniometer)

2) ER strength, IR isometric and eccentric strength, ERecc/IRecc, and ER isometric/IR isometric (hand-held dynamometer)

3) Scapular movement (overhead movements while holding a 2-kg dumbbell. Rating as present or absent and absent, moderate or

severe scapular dyskinesis

4) Maximum throwing velocity (stationary radar gun)

Data were collected at 5 time points using the same questionnaire: after baseline screening, before beginning of the season, after the preseason, during mid-season, and at the end of the season

Decreased absolute, isometric ER strength and normalised isometric and eccentric ER strength, as well as the ER:IR strength ratio were significant risk factors for overuse injury. ER gain of > 7.5° and GIRD of > 7.5° were also significant risk factors for an overuse injury in girls. Scapular dyskinesis and maximum throwing velocity were not different among players with or without overuse injury

Giroto et al. [35]

Prospective Cohort Study

One season

339 elite handball athletes (156 M

and 183 F)

Age (23.4 years, SD 4.6)

Weight (76.7 kg)

Height (1.77 m)

BMI (24.2 kg/m²)

Right-handed (84.9%)

Left-handed (15.1%)

Previous injuries last 6 months (46.6%)

N = 27 (the reason is not reported)

1) Sex

2) Age

3) BMI

4) Previous injuries

5) Exposure (hrs/week) to strength training

6) Number of matches/week

Weekly exposure questionnaire was filled out by one person (in each team) responsible to provide data

History of injury (OR: 2.42,

95% CI: 1.51–3.89), and an extra match per

week (OR: 1.31, 95% CI: 1.05–1.62) were risk factors for overuse injuries. Female athletes (OR: 1.56, 95% CI: 1.08–2.25), and an extra hour of training per week (OR: 1.09, 95% CI: 1.02–1.15) were risk factors for traumatic injuries. Age and BMI were not significant

Asker et al. [17]

Prospective Cohort Study

One season (2014–2015 or 2015–2016 season

471 elite adolescent handball players (215 M and 256 F)

Age (16.4 years, SD 0.85)

Height (176.8 cm)

Weight (74.15 kg)

BMI (23.8)

Year of playing handball (9.1 years)

Goalkeepers (n = 72)

Wing players (n = 90)

Line players (n = 63)

Backcourt players (n = 241)

National level (n = 119)

Regional level (n = 352)

N = 26 (Quit handball, long-standing injury not in the shoulder, unable to continue, unknown reason)

1)Sex

2)Player’s position

3)School Grade

4)Playing level

The Swedish version of the OSTRC overuse

injury questionnaire (every week)

Higher prevalence in female (PR 1.46, 95% 1.04–2.06) and backcourt players (PR 1.58, 95% CI 1.08–2.32). School grade (PR 1.21 95% CI 0.88–1.67) or playing level (PR 1.09 95% CI 0.76–1.56) were not significant risk factors

Moller et al. [38]

Prospective Cohort Study

One season (2013- 2014)

679 elite youth handball players (304 F and 375 M)

Age (16 years, SD 2)

Back players (n = 303)

Wing players (n = 168)

Line players (n = 102)

Goalkeepers (n = 97)

History of shoulder injury (n = 43)

N = 8 (excluded from analysis as they did not report any handball participation)

1) Handball load changes: (a) < 20% increase or decrease, (b) 20% to 60% increase or decrease (c) > 60% increase

2) Scapular control (normal or obvious scapular dyskinesia)

3) Rotational isometric strength (ER:IR ratio dominant arm at 0 and 30 degrees of rotation) and abduction strength (hand-held dynamometer)

4) Glenohumeral ROM side to side differences in TROM, IR, and ER

Injury and participation

information were collected weekly by SMS and a telephone interview, and a physical examination by medical personnel within 1–2 weeks following an injury

Significantly higher injury rate with a > 60% increase in load (HR 1.91; 95% CI 1.00 to 3.70). This was more pronounced when reduced ER strength co-existed (HR 4.2; 95% CI 1.4 to 12.8). If handball load increased between 20 and 60% rate of injury was higher only when players had reduced external rotational strength (HR 4.0; 95% CI 1.1 to 15.2) or scapular dyskinesis (HR 4.8; 95% CI 1.3 to 18.3)

Andersson et al. [39]

Prospective Cohort Study

One season (2014–2015)

329 elite handball players (168 M and 161 F)

Age (14 years, SD 5)

Right-handed (78%)

Backs (41%)

Wings (25%)

Line players (15%)

Goalkeepers (13%)

Multiple positions (6%)

N = 39 (withdrawn, retired from handball, pregnant, acute injury rest of season)

1) Glenohumeral IR and ER ROM (digital inclinometer)

2) Isometric IR and ER rotation strength (handheld dynamometer)

3) Scapular dyskinesis (5 reps of flexion and abduction with extra weight). Rating: normal control, slight dyskinesis or obvious dyskinesis

OSTRC Overuse Injury Questionnaire (six time points in the whole season)

No significant associations between total rotational ROM, external rotation strength, or obvious scapular dyskinesis and overuse shoulder injury. Greater internal rotation was associated with overuse injuries (OR 1.16 per 5° change, 95% CI 1.00 to 1.34)

Asker et al. [40]

Prospective Cohort Study

One or two seasons (2014–2015 and/or 2015–2016)

344 students handball players (180 F and 164 M)

Age (16.55 years, SD 0.85)

Height (176.6 cm)

Weight (74.7 kg)

Handball experience (9.35 years)

Goalkeepers (17%)

Wing players (20.5%)

Line players (15.5%)

Back players (47%)

1^st grade (47.5%)

2^nd grade (35%)

3^rd grade (17.5%)

History of shoulder pain (31.5%)

Regional playing level (76%)

National playing level (24%)

N = 127 (Absent during baseline test days, unable to perform shoulder tests, reported an OSTRC score of ≥ 40 the past 2 months, no response to any of the weekly questionnaires)

1) Shoulder strength (isometric ER, IR, abduction) and eccentric ER (handheld dynamometer)

2) Shoulder ROM (digital inclinometer)

3) Shoulder joint position sense (supine position with target angle at 75% of the maximum ER)

4) Scapular dyskinesis (Each player

performed two repetitions of maximum shoulder abduction and maximum shoulder flexion in random order with weights (1kgr for female and 2kgr for male). Videos were reviewed by one tester for presence or absence of scapular dyskinesia separately for abduction and flexion)

A modified version of OSTRC overuse injury questionnaire (every week)

Isometric external rotation strength in female players (HR = 2.37, 95% CI 1.03- 5.44) but not in male palyers (HR = 1.02, 95% CI 0.44–2.36) was found significant. Same results for isometric internal rotation strength (Female HR = 2.44, 95% CI 1.06–5.61 and male HR = 0.74, 95% CI 0.31–1.75). There was no association between ROM and shoulder injuries for both sexes. Scapular dyskinesia during abduction was significant only in male players (female HR = 1.53, 95% CI 0.36–6.52, male HR = 3.43, 95% CI 1.49–7.92. Scapular dyskinesia in flexion and joint position sense were not significant factor for shoulder injuries in both sexes