Mavropoulou Aggeliki, Hatzimanouil Dimitrios, Lazaridis Savvas, Iconomou Charalabos and Sikaras Euaggelos

Abstract

Flexibility in handball is a basic element of motor skill for all players especially for goalkeepers. “Handball goalie's elbow” is a specific elbow injury in handball goalkeepers. Strengthening exercises are used simultaneously for the management of this injury. The aim of the study was the evaluation of flexibility of elbow joint before and after a muscular strength training program of the upper limbs in sixteen goalkeepers divided in two groups (study-control). Parameters were the maximal perimeter of arm and forearm, range of motion (ROM) of elbow joint (flexion-extension, pronation-supination) and wrist joint (flexion-extension). The results showed significant differences in perimeter. More specifically there were significant differences in three of four measurement positions only for the experimental group. The difference between initial and last measurement of right and left arm was 0.63 cm and 0.75 cm respectively. Small growth was possible because of the specific training method. The results showed that there were no significant differences in range of motion (ROM) between groups. In conclusion the specific strength training program with this specific training method can be applied by goalkeepers with beneficial results without limitations in flexibility and performance. Further research is needed in similar programs with the same method but with longer duration and more participants.

Key words: elbow syndrome; handball; goalkeepers; range of motion

Introduction

Handball is a dynamic team sport that is distinguished by a highly developed force level, agility and flexibility (Khosla, 1983). Flexibility is considered a basic motor skill for players because it enables the implementation of a larger width of joints’ movements and is crucial for their success (Anderson, 1989). On the other hand, poor flexibility is typically thought to limit athletic performance by limiting the range of motion, and can result in torn muscle or connective tissue. Muscle tightness predisposes to strains, while flexibility is considered to be an important factor in reducing the potential for injury. According to scientific research, stretching exercises significantly improves flexibility, but dynamic movement during training conditions tends to decrease rang of motion (ROM) in the activated joints (Zakas et al., 2003).

Many researchers evaluated a significant number of elbow injuries, specifically among goalkeepers (Tyrdal & Finnanger, 1999; Tyrdal & Pettersen, 1998). A specific elbow injury in handball goalkeepers is referred as “handball goalie's elbow” (Tyrdal & Bahr, 1996; Tyrdal & Finnanger, 1999; Tyrdal & Pettersen, 1998). Several studies claimed that the mechanism underlying the problem of “handball goalie's elbow” is increased load in hyperextension (Popovic & Lemaire, 2002; Tyrdal & Bahr, 1996; Tyrdal & Finnanger, 1999; Tyrdal & Pettersen, 1998). Injury appears as a result of the main function of the goalkeeper to save or block shots, usually using fully extended arms. More specifically 50% of the goalkeepers who suffer from “handball goalie's elbow” present thickening of the medial collateral ligament MCL.

Conditioning and strengthening exercises of musculature situated synergistically with the MCL could potentially augment medial elbow stability and either help to prevent or facilitate rehabilitation of this commonly injured entity (Popovic & Lemaire, 2002). Thus, the management of this injury may be achieved with muscular strengthening, as it is more effective from other therapeutic methods, like taping, use of special splint and bracing (Tyrdal & Bahr, 1996).

Strength training protocols which last more than four till eight weeks can alter the size of muscle fibers which lead consequently to hypertrophy (Fleck, 2000 ). Thus, the possibility that strength training alone might inhibit flexibility gains should be considered when prescribing exercise programs. Strength training may actually decrease range of motion and the supplemental stretching exercises during training merely offset this decline (Girouard & Hurley, 1995). If muscle hypertrophy is extreme, increase in muscle size can partially restrict range of motion. Thus, specific flexibility training should be included in the overall training regimen to maintain adequate range of motion (Nobrega, Paula, & Carvalho, 2005).

On the contrary, strength training will improve flexibility as long as stretching exercises are included in the program (Girouard & Hurley, 1995). A higher volume of flexibility training need to be employed in the case of deleterious effects of resistance training on flexibility (Nobrega, Paula, & Carvalho, 2005). Another investigation reported increased flexibility when flexibility training was incorporated into a training regimen (Guy & Micheli, 2001). On the other hand, no specific flexibility training would be necessary if resistance training itself could improve flexibility (Nobrega, Paula, & Carvalho, 2005).

Therefore, the aim of the current study was the evaluation of flexibility of elbow joint before and after a muscular strength training program (without specific flexibility exercises) of the upper limbs for the management of “handball goalie's elbow” injury.

Materials and methods

Participants

Participants of the current study were 16 handball players, playing as goalkeepers. They were players of senior categories (A1, A2 leagues) of Greece National Championship. Individuals were selected by random sampling. In the last two years, the players had constantly and actively participation in their teams and they took part in championship matches as well. All 16 individuals had faced, in the past, problems at / in the elbow area. Problem in /at the elbow area was considered the feeling of pain at the joint in the past, during training and official matches (Tyrdal & Bahr, 1996).

Goalkeepers were 23.6 ± 5.3 years old with 1.86 ±.4.8 height and 86.9 ± 10.8 weights. Their training age was 11.2 ± 4.20 years and their training participation was 5.20 ± 1.48 times per week. Moreover their time participation in official games was 30.6 ± 15.26 minutes per game. They all reported they use the right hand for the pass and when they shoot. From 16 goalkeepers 15 reported they use the right hand for daily activities and only one the left hand. Before testing, participants read and signed a written informed consent statement. This study met the ethical standards suggested by Aristotle University of Thessaloniki, Greece.

Equipment description.

During this study the instruments which enrolled were the following:

1. Accurate tape measure which was used for calculation of perimeter of arm and forearm.

2. Goniometer (universal) which was used for calculation of ROM of inversion and eversion of the forearm joint and flexion and extension of wrist.

3. Dumbbells which were used during the intervention performed by the handball players. Dumbbells were consisting by adapting knuckheads that varied from 0,5 to 10 kilograms.

Test description

a) The measurement of maximum arm and forearm perimeter was carried out in specific spot. The marking of specific spot was carried out during experiment session. Each time the tape measure was placed on the spot of maximum perimeter of arm and forearm (Tyrdal & Pettersen, 1998). Until find out the spot of maximum perimeter of arm and forearm the tape was placed on many times. During the perimeter measurement, muscles were in contraction status. During measurement of maximal perimeter of arm, the upper limb was in touch with upper body and the elbow in extension and in 90˚ of flexion when we measured maximum perimeter of forearm.

b) Elbow range of motion was measured while the individual lied in supine position with the upper limb in touch with the torso and the forearm in eversion. During the movement of intension and extension of elbow, the arm remained immobile. The center of the goniometer was placed on the lateral epicondyle process of forearm. The fixed part of the goniometer was placed in side middle line of arm, considering as guiding anatomic part, while the mobile part was placed parallel to lengthwise axis of the radius considering as guiding anatomic part the styloid apophysis of the radius.

Range of motion of pronation and supination was carried out while the individual was in sitting position, with 90⁰ of elbow flexion and the forearm in zero position. The wrist and fingers were in zero starting position. During supination and pronation of the forearm, the arm remained steady, to avoid any elbow motion. The center of the goniometer was placed on the top of the middle finger; the fixed steady part of the goniometer was placed parallel to the frontal line of humerus while the motive part was placed parallel to the line that connects the tops of the fingers. ROM was carried out while the athlete was in sitting position with his shoulder in 90⁰ of abduction, elbow was in 90⁰ of flexion and forearm with wrist in neutral (nilpotent) position. The forearm was lying on the table and remained steady, in order to avoid supination and pronation. The centre of the goniometer was placed on the external side of wrist. The fixed part of the goniometer was placed parallel to the longitudinal axis of ulna and the moving part parallel to the longitudinal axis of the 5^th metacarpial bone (Κoutras, 1996).

Measurement process

In the onset of 2003-2004 championship league, each goalkeeper was submitted to the process of recording and calculation on upper’s limbs arm and forearm perimeter. Moreover, measurements of elbow’s ROM, pronation and supination of forearm and flexion and extension of wrist were carried out. The experimental group followed the intervention protocol of maximal strength development through the method of maximal contraction of short duration. Muscular strengthening program lasted three months. The program started in the beginning of the athletic season and included strength exercises for elbow and wrist in flexion and extension and forearm in supination and pronation. The exercises were performed 3 times a week, in 3 bouts of 3-4 repeats each (Κellis, 2002). The intensity was 90% of maximum repeat and every month was defined the maximum effort of each athlete, so to readjust the weight of each muscular group that participated in the program. The calculation of the intensity of the maximum effort of each athlete was executed with strength test 1 RM. Each athlete started with sub maximum efforts until to achieve one maximum (100%) repetition (1 RM). With this way there was the calculation of 90% of maximum performance. The calculation of 90% of maximum performance was done according to the next up or down half kilo.

All initial measurements were repeated after 3 months in middle of the athletic season.

Training intervention

Before and after every training session there was a warm up using mostly upper limb exercises and muscle stretching. The exercises were divided into six parts. The first part included elbow extension of the right limb. Subjects used the top of an inclined board to perform standing preacher curls supporting right upper arm on the board. After, they gripped a dumb-bell with their palm facing upwards bending the elbow rapidly, drawing the dumb-bell to the shoulder with the help of the other hand. Then, the second repetition was performed. After four repetitions, elbow extension of the left limb was similarly done. The second part involved forearm pronation of the right limb. While kneeling over an exercise bench, holding an one –armed dumb-bell with the weight at the top of the hand with their palm up and the forearm rotated outwards. The dumb-bell was raised as quickly and high as possible. Returning the dumb-bell to the starting position with the help of the other hand the second repetition was attempted. After four repetitions, athletes performed forearm pronation of the left limb. The third part of exercises was wrist extension of the right limb. Kneeling over an exercise bench holding the dumb-bell in their hand with their palm down subjects was asked to raise the dumb-bell as quickly and high as possible. The dumb-bell was then returned to the starting position with the help of the other hand and a second repetition was attempted. After four repetitions wrist extension of the left limb was performed. The fourth part included elbow flexion exercise of the right limb using the same mode. After four repetitions elbow flexion exercise of the left limb was similarly done. The fifth part included forearm supination of the right limb with the forearm rotated inwards. After four repetitions the left limb was done with the same mode. The last part was wrist flexion of the right limb having their palm up. After four repetitions the left limb followed the same procedure.

Research design

The sample was randomly assigned into two groups: Group A (experimental) and group B (control). After the initial measurement group A performed a muscle strengthening program that lasted exactly 3 months. The program aimed to develop the maximum power output through maximum contractions with short duration method. Group B, wasn’t submitted to the intervention program.

Statistic analysis

Statistical analysis was performed with SPSS 15.0 program package for Windows. Means and standard deviations were calculated for the selected dependent variables. Repeated measures analysis of variance (Popovic et al.) 2x2 (training stage x group) was employed in order to determine possible statistically significant differences between initial and final measurement for each group. Post-hoc test were used for intended conclusions. Significance was set at p< .05

Results

Means, SD and level of significance of perimeter of arm and forearm before and after the complementation of the program for both groups are displayed in table 1.

	Experimental group		Control group
Perimeter		1st		2nd	P	ES	1st	2nd	p	ES
Right humerus		31.43±1.45		32.06±1.61	.002	.78	33.25±5.21	32.56±4.26	.24	.19
Left humerus		31.18±2.03		31.93±2.22	.02	.56	33.25±4.92	32.62±4.55	.14	.28
Right forearm		28.87±1.35		29.18±1.22	.049	.45	29.85±2.17	30.18±3.33	.31	.15
Left forearm		28.37±1.41		28.68±1.22	.09	.35	29.18±2.07	29.18±2.22	.99	.001

Table 2. Measurement of joint angle (ROM) for both groups

Variables		Experimental group				Control group
		1st	2nd	P	ES	1st	2nd	p	ES
Right elbow		-1±1.60 147.12±4.82 (148.12±5.94)	-1.12±1.73 146.50±5.07 (147.62±5.90)	.80 .35 .64	.01 .12 .03	1.38±4.72 146.25±3.53 (144.87±5.98)	1.13±4.61 147.00±3.85 (145.87±5.22)	.45 .22 .12	.08 .20 .31
Left elbow		-1.62±2.13 148.37±5.73 (150.00±7.07)	-1.62±1.99 148.50±5.88 (150.12±7.33)	.99 .83 .87	.001 .007 .004	1.65±4.56 147.00±4.17 (145.37±5.37)	1.88±4.25 148.00±3.96 (146.12±4.61)	.35 .07 .14	.12 .40 .28
Pronation of right forearm		85.37±6.86	85.00±6.46	.44	.09	92.62±11.74	93.00±11.45	.28	.16
Supination of right forearm		85.00±9.48	85.00±9.92	.99	.001	86.50±5.32	87.12±6.01	.28	.16
Pronation of left forearm		86.00±6.82	86.00±6.78	.99	.001	92.25±10.29	92.25±10.27	.99	.001
Supination of left forearm		86.12±7.60	86.62±7.83	.03	.50	86.75±4.33	86.87±3.60	.84	.007
Extension right wrist		61.50±13.64	61.75±13.75	.45	.08	65.12±11.45	65.12±10.72	.99	.001
Flexion right wrist		68.62±12.89	69.12±12.34	.27	.17	71.25±6.92	70.37±7.07	.09	.36
Extension left wrist		63.87±14.42	63.87±14.01	.99	.001	65.75±10.95	65.75±10.55	.99	.001
Flexion left wrist		69.87±12.00	69.87±12.82	.99	.001	74.62±8.55	74.12±7.88	.32	.14

Discussion

Results regarding arms and forearms perimeter of both experimental and control group showed that there were statistically significant differences in the experimental group between the initial and final of measurements in three out of four positions. On the contrary, there were no statistically significant differences on the control group. This was probably due to the program of muscular strengthening that was performed by the experimental group. In particular the difference between the initial and final measurement of the right and left arm perimeter was 0.63 and 0.75 respectively. According to Tyrdal (Tyrdal & Olsen, 1998; Tyrdal & Pettersen, 1998), changes in arm perimeter were 2,54cm. probably due to the different training method. Resistance training can modify muscular and tendinous physical characteristics as well as neuromuscular functional properties (Nobrega, Paula, & Carvalho, 2005). Thus, the method of repeated sub maximum tensions, increase the diameter of the muscle. The specific force training and especially explosive actions of muscle in a short period, increases the contribution of the neural system and synchronism of a motor unit which is activated without large increases in hypertrophy (Bompa, 1999)

In the present study there has been indicated difference 0,31cm. of right forearm perimeter between the initial and final measurement. Previous researchers (Tyrdal & Pettersen, 1998) found an increase of 1.12 cm. of the right forearm. The method that has been followed by them and specifically the tension of strength (80 %) has been proved extremely effective regarding muscular mass augmentation in athletes. On the contrary in our study, metabolism was not activated in such a degree, as to begin the process of significant promotion of muscle growth. The specific training enables athlete to increase maximal force, by using large number of motor units. Therefore, maximum power is increased without significant increase of muscular mass and body weight. Summarizing, it has been established that due to the specific training method, there were no significant differences in perimeter on the positions of measurement.

The joint capsule, muscles and tendons are the most important tissues for the limitation of flexibility (Hahn et al., 1999). In the present study there were not noticed statistically significant differences at the range of motion of right and left elbow, both in control and experimental groups between initial and final measurement. The particular values were between the normal limits referred at previous studies (Ellenbecker, 1997; Loudon, 1998; Κoutras, 1996). Similarly (Tyrdal & Bahr, 1996), reported a statistically significant decrease of flexion of 2.7± 1,0 degrees in both upper limbs between initial and final measurement at goalkeepers and volley ball players in particular. This decrease is possibly due to muscle hypertrophy, caused by the training program.

Pronation on right and left forearm of study group was normal in both initial and final measurement. Normal pronation range vacillates between 0º - 85º (Ellenbecker, 1997). In control group despite the fact that there were not any statistically significant differences between initial and final measurement, values were slightly increased compared to prices of experimental group. Experimental group had statistically significant differences between initial and final measurement of left forearm supination. These values were between the normal limits (Κoutras, 1996). These were the only statistically significant differences between initial and final measurement in both groups, in all range of motion measurements that were performed in both upper limbs. To sum up, all values appeared to be normal except those of pronation of right and left forearm in control group (Loudon, 1998; Κoutras, 1996).

Lastly, there were no significant differences in flexion and extension of wrist bilateral, in both control and experimental group.

Conclusion

In summary, values of measurements in the current study were between normal limits. No deviation was noticed in both control and experimental group, therefore it was established that the program followed by the experimental group did not affect flexibility of the joint under research. The specific strengthening program might not increased flexibility of the joint of forearm, probably because flexibility training was not incorporated into a training regimen (Guy & Micheli, 2001). In athletes, normal flexibility enables the biomechanical accuracy of competitive movements by improving the muscle function. It is generally recognized as a crucial factor in skilled movement and can also play a significant role in determining the final outcome of various performances or competitive situations (Zakas et al., 2003). Thus, flexibility of forearm’s joint maintained in normal levels by using the specific muscles strengthening method, without affecting negatively the syndrome treatment and by extension handball player’s performance.

Regarding range of motion between initial and final measurement that took place on upper limbs, there were no statistical significant differences in ROM between measurements of both groups, except forearm supination.

Practical application

The particular program can be practiced by goalkeepers with beneficial results without decrease of flexibility. However, further research is required in same programs of similar method in a large sample of athletes.

Acknowledgments

The authors would like to thank participants for their dedication throughout the course of this study.

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^ Corresponding author:

Lazaridis Savvas, Post Doc

¹Laboratory of Coaching and Sport Performance, Department of Physical Education and Sports Sciences, Aristotle University of Thessaloniki

Tel: ++30 6932587801, Fax: ++30 2310 720843

E-mail: sav200m@gmail.com

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