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EHF medical & scientific conference , Bukarest, Romania, 11-2015

Knee injuries in handball


Prof. Romain Seil, MD, PhD

Orthopaedic Centre Hospitalier


Surgery de Luxembourg

Sports Medicine Luxembourg


Research Laboratory Institute of Health
Personal motivation

Handball player Handball science Knee & sports surgeon

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Luxembourg:
0,5 mill.people
2.500 km²

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PubMed search 8.1.2015

700
617
600
500
400
300 234
200
103
100 49 30 29 22 20
0

Sports injuries = 36.628; Football = 6.387

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Epidemiology

 Jorgensen 1984
 Fagerli 1990
 Wedderkoop 1997
 Myklebust 1998
 Seil 1998
 Nielsen 1998
 Asembo 1998
 Petersen 2002
 Olsen 2006
 Langevoort 2007

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Injury locations

Knee = No. 1 injured joint

18 to 35 %
Myklebust G, 2010
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Injury mechanisms

Valgus collapse

 Valgus collapse

 Hyperextension

 Hyperflexion

 Contact / non-contact ?

 Velocity ?

Courtesy of Prof. L. Engebretsen, Oslo, Norway


 Rotation ?

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ACL
Understand the ACL injury mechanism
2 main injury mechanisms

Plant & cut

1-legged
jump shot
landing

Olsen OE, Am J Sports Med 2004


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ACL
Understand the injury mechanism
2 main injury mechanisms

Forceful valgus collapse


+
Knee close to extension
+
Internal/external rotation tibia

From: Bahr R, Maehlum S: A clinical guide to sports injuries, 2004

Olsen OE, Am J Sports Med 2004


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ACL
Understand the injury mechanism
Quantification of knee joint motion

 ACL # within 40 ms after landing


 Knee flexion angle
@ landing: 23° (11-30)
@ 40 ms: + 24° (19-29)
 Rotation
40 ms: 5°ER 8°IR
After 40 ms: 17 ° ER

3-D knee joint kinematics  GRF @ 40 ms: 3.2 x body weight


Model-based image matching technique

Koga H, Am J Sports Med 2010


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ACL
Understand the injury mechanism

Forceful valgus Quadriceps


ER femur pull Reflex
Reflexreposition
reposition
 ACL#
IR tibia  ACL# IR
IRfemur
femur
Koga H, Am J Sports Med 2010
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ACL
Understand the injury mechanism

Spheric
lateral
femoral
condyle

Convex
lateral Reflex reposition
Forceful valgus Quadriceps pull
tibial
IR tibia plateau
ACL# IR femur
Koga H, Am J Sports Med 2010
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ACL
Understand the injury mechanism

Spheric
lateral
femoral
condyle

Convex
lateral
tibial
plateau
ER femur Reflex reposition
 ACL# IR femur
Koga H, Am J Sports Med 2010
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ACL
Understand the injury mechanism

Seil R, Arthroscopie SFA 2015


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Hyperextension

Courtesy of Dr. B. Galaud, France

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Hyperextension
Tibia plateau fracture

P. Hens
Germany-Iceland
Olympic Games Beijing 2008

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Hyperextension

P. Hens, Germany-Iceland
Olympic Games Beijing 2008
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Hyperflexion

PCL injury

AL bundle

Courtesy of A. Amis, London


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Hyperflexion

Posterolateral instability

♂, 22 y.: LCWO in 2002; professional handball player


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Contact injury
Tibia plateau fracture

Attack Defense

Nührenbörger C, submitted
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Contact injury

Traumatic proximal tibiofibular joint instability

ER
(°)

ER: + 7°

♂, 19 y.

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Injury types

Structural / anatomic Appearance


 Ligaments  Acute
 Meniscus  Chronic
 Cartilage
 Tendons
 Bone

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Ligaments
ACL

EPIDEMIC !
Courtesy of Prof. L. Engebretsen, Oslo, Norway

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ACL
Understand the epidemiology
Up to 30%
retear rates

Frobell RB, Scand J Med Sci Sports 2007, Granan LP, Am J Sports Med 2009,
Renstrom P, Br J Sports Med 2012; Seil R, OTSR, accepted
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ACL
Understand the epidemiology

Seil R, Mouton C, OTSR, accepted for publication


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ACL
Understand the associated injuries
% of males 52-68 74
Injuries related to sport 72-88% 83%
Football 17-50% Football 43%
Norway
Most represented sports Basketball 17-20% Basketball 17%
Ski 13-14% Sweden
Ski 10%
Isolated ACL injuries 32-42% Denmark
30%
Menisci 35-65% Australia
60%
Medial menisci 19-40% Kaiser-Permanente
31%
Associated ACL
injuries Lateral menisci 9-44% MOON
40%
Cartilage 17-46% 21%
Revision 6-14% 10%

Csintalan et al. Permanente Journal 2008 Granan et al. AJSM 2008


Granan et al. Acta Orthopedica 2009 Granan et al. AJSM 2009
Lind et al. KSSTA 2009 Magnussen et al. KSSTA 2010
Maletis et al.JBJS 2011 Janssen et al. Scand J Med Sci Sports 2011

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ACL
Understand the associated injuries
11-2011

05-2012

09-2012
- cart lesion

+ cart lesion

Preop
+ OATS

Rotterud JH, KSSTA 2012


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ACL
Understand the associated injuries

Claes S, J Anat 2013


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ACL
Understand the associated injuries
Meniscosynovial lesions
Posterior compartment arthroscopy

Medial meniscus = secondary stabilizer


Diagnosis & repairs often insufficient
Sonnery-Cottet B, Seil R, AJSM 2014
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ACL
Understand the treatment

Seil R, Mouton C, unpublished data


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ACL
Understand the anatomy

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Understand surgery
Nonanatomic placement

The major reason for failure of


conventional ACL reconstruction is
still incorrect position of the femoral
tunnel !

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ACL
Risk factors
Extrinsic factors Intrinsic factors
Non-modifiable Non-modifiable
• Type of sport • Maturity level
• Weather • Previous injury
• Level of play • Age
• Time of season • Gender
• Sport context
• Playing position
Modifiable Modifiable
• Rules and regulations • Fitness level
• Coaching Female noncontact • Sport-specific
ACL injuries
education/training training/warm-up
• Playing time • Muscle strength
• Playing surface • Flexibility
• Equipment • Joint stability
• Biomechanical factors
• Balance
Artificial vs. wooden floors:
and OR 2.35
proprioception
• OE,
Olsen Psychosocial
Scand J Medfactors
Sci Sports 2003

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ACL
Risk factors
Extrinsic factors Intrinsic factors
Non-modifiable Non-modifiable
• Myklebust
Type ofG,sport
Clin J Sports Med 2003 • Maturity
Garrick JG, Requa R, Clin J Sports Med 2005
level
Holm I, Clin J Sports Med 2004
• Weather • Previous Myklebust
injury G, Instr Course Lect 2007
Olsen OE, BMJ 2005 Panics G, Br J Sports Med, 2008
• Level of play • Age
Petersen W, Arch Orthop Trauma Surg 2005 Zebis MK, Clin J Sports Med 2008
• Time of season • Gender
Odegaard TT, Risberg MA, Austr J Physiother 2005 Barendrecht M, J Strength Cond Res 2011
• Sport context • Laxity
• Playing position
Modifiable Modifiable
• Rules and regulations • Fitness level
• Coaching
Increasing evidence that • Sport-specific
education/training training/warm-up
neuromuscular
• Playing time • Muscle strength
training can
• Playing decrease
surface • Flexibility
• ACL
Equipment
injury rates • Joint stability
• Biomechanical factors
• Balance and proprioception
• Psychosocial factors

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Risk factors

Hyperlax patients at higher risk for severe knee injury

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Return to sport
Does return to sport in good physical condition prevent reinjury ?

Limb symmetry (%) 20%

10% 7% 6% 7%

0% 0% 0%
0%
Q Ham con. Ham exc. single-CMJ hop distance side hop
-5% -4%
-10%

-20%
-20%
-22%
-30%

-40%

-50% -47%

-60%
-61%

-70%

Proove
♂ 23 efficiency of secondary
y, bad rehab, safe return to sports prevention
♂ 17 y, perfect rehab, retear
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Return to sport
RTS group

Goals:
 Get athletes safely back to the field
 Restore function of injured limb
 Minimize risk of re-injury
 Teach injury prevention

Inclusion criteria:
 6 months after ACLR
 Sufficient functional scores for strength
and stability
 Medical clearance
 Signature of participation agreement

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Injury types
Overuse injuries

• Repetitive micro-trauma
• Gradual onset Bahr R, 2009
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Injury types
Overuse injuries

23 % 20 % 36 %

16 %

22 % 16 %

Oct 2010 – March 2011 Clarsen B, Bahr, R, 2014


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Understand the athlete

« End of career » athlete

Weight: 103  93
Knee ROM: + 20°
Performance: sporadic  60’
Career: + 2 years
Iker Romero
Füchse Berlin

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Youth sports: specificities

• Susceptibility of growth plate


• Direct mechanical stress
• Repetitive physical strain

• Growth spurt during puberty


• Mechanical (over-)loading

• Variation of biological maturity at same


age

• Skeletal development precedes muscle


& tendon growth
• Permanent changes of lever arms,
imbalances of muscle chains

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Understand knee growth & joint maturation

Growth of upper & lower segment not proportional

Growth velocity

♀ 13 y.
Height
♂ 15 y.
Upper segment
Juvenile peak
Lower extremity

Difference
Trunk / lower extremity

Skeletal age

Gicquel P, Rev Chir Orthop 2007


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Youth sports: specificities

The injured knee in the young athlete

• Incidence of severe knee injuries


8200 / 100.000 young athletes
Malisoux L, 2012
• Incidence of ACL injuries (n=8) Frisch A, 2012
Theisen D, 2013
830 / 100.000 young athletes Seil R, unpublished data

• Incidence of ACL injuries in general population


81-85 / 100.000 citizens
Frobell RB, Scand J Med Sci Sports 2007
Sports injury surveillance in youthGranan
sportsLP, Am J Sports Med 2009
should become mandatoryRenstrom! P, Br J Sports Med 2012

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Traction apophysitis

Sinding - Larsen

Osgood-Schlatter

Sever

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Injuries of extensor mechanism

Watson-Jones fracture Patellar dislocations

♂, 16 y.

Ryu RKN, CORR; 1985


Inoue G, Br J Sports Med, 1991 From: Bahr R, Maehlum S
Watson-Jones R, CORR, 1974 Clinical guide to sports injuries (2003)

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Juvenile osteochondritis dissecans
Stable
4-2010 11-2011

Nonoperative
treatment

♀, 13 y. ♀, 15 y.

Unstable

( Surgery )

Bruns J, 1997
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Summary

 Need for more research in handball medicine


 Injury type & mechanisms
 ACL problem (injury mechanism, risk factors,
prevention and treatment)
 Specific gender & age differences
 Multidisciplinary approach

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17th
ESSKA Congress

ESSKA President Congress President Scientific Chairman Organiser & Contact


Matteo Denti (Italy) Joan C. Monllau (Spain) Roland Becker (Germany) Intercongress GmbH
Gino M. Kerkhoffs (Netherlands) esska@intercongress.de
Pablo E. Gelber (Spain)

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