Bony Anatomy, Soft-Tissue Adaptations and Neuromuscular Risk Factors of Shoulder Injury in Handball Players: A Narrative Review

Handball is a high-intensity contact sport that imposes significant mechanical stress on the shoulder joint through repetitive, high-velocity overhead throwing, predisposing athletes to a wide spectrum of shoulder injuries. This narrative review examines the factors associated with shoulder injuries in handball players, highlighting underlying structural, adaptive and functional mechanisms across male and female athletes. A literature search of PubMed/MEDLINE was conducted to synthesize current evidence on bony anatomy, soft tissue adaptations and neuromuscular characteristics in handball cohorts. Factors associated with shoulder injury or symptoms can be broadly categorized into three conceptual domains: (i) bony anatomy and structural features, (ii) soft tissue adaptations and (iii) dynamic functional and neuromuscular factors. Bony factors include reduced acromiohumeral distance, increased humeral retrotorsion as a sport-specific skeletal adaptation and variations in glenoid morphology that may influence glenohumeral stability. Soft tissue adaptations include posterior capsular tightness, anterior capsular laxity and alterations in shoulder range of motion, particularly glenohumeral internal rotation deficit (GIRD) accompanied by external rotation gain (ERG), which may influence glenohumeral kinematics and potentially contribute to shoulder symptoms or overuse conditions. Beyond these structural features, dynamic functional factors, including shoulder rotator muscle strength imbalances, impaired scapular control and training-load management, play a central role in injury development. Therefore, a comprehensive assessment encompassing anatomical correlates, soft tissue characteristics and functional/neuromuscular characteristics may support the development of targeted injury-prevention and rehabilitation strategies in handball players.