Concussions in Handball

Concussions in handball represent one of the sport’s most serious yet frequently overlooked injuries. When I work with goalkeepers and coaches around the world, I consistently encounter the same troubling pattern: a strong shot to the head is treated as just another save, something to shake off and move past. The expectation, often instilled from youth training, is that a brave goalkeeper simply continues playing.

I understand this mindset because I lived it. During my active goalkeeping career, I sustained multiple concussions without understanding the severity of what was happening to my brain. In 2000, at 17 years old, I took a direct shot to the head from the 6-meter line. The force sent me flat on my back. I couldn’t see or hear anything for several seconds. When my teammates reached me, the only thing I asked was whether I had saved the shot. Ten minutes later, despite feeling “funny” and seeing everything “smooshed,” I returned to the goal because the team needed me.

That decision, and many similar ones throughout my career, taught me a crucial lesson that I now share with every goalkeeper and coach I work with: courage in goal must be paired with knowledge about protecting your brain.

Key Takeaways

• Concussions in handball account for 22-28% of all reported injuries in the sport, making them one of the most common serious injuries, yet they remain widely underestimated and underreported.
• Never return to play on the same day after a suspected concussion. Research shows half of youth handball players continue playing immediately after a head impact, often without proper medical evaluation.
• The 2023 Amsterdam Consensus Statement introduced updated guidelines, including the SCAT6 assessment tool and a revised return-to-play protocol emphasizing light activity within the first 48 hours rather than complete rest.
• Convergence insufficiency affects 1 in 2 people who experience a concussion, making vision problems one of the most common and often overlooked consequences of head injuries.
• Neck strength training may reduce concussion risk. Research suggests that for every pound of neck strength an athlete gains, their odds of concussion decrease by approximately 5%.

Why Concussions in Handball Deserve More Attention

The numbers tell a sobering story. Research from Swedish injury surveillance data shows that concussions in handball represent 22-28% of all reported injuries in the sport. A German cross-sectional study including approximately 3,000 athletes found that 24% of handball players had previously experienced a concussion. These rates place handball among the higher-risk team ball sports for head injuries, alongside soccer and basketball.

What makes these statistics even more concerning is the likelihood of underreporting. A 2025 Danish study tracking nearly 950 youth handball players found that half of those who experienced a head impact continued playing immediately afterward. Most made this decision independently, without consulting medical staff or coaches. One in four missed school or training afterward, suggesting the impacts were significant enough to affect daily functioning.

For goalkeepers, the risk profile is unique. Unlike field players whose head impacts often come from collisions with opponents or falls, goalkeepers face direct ball impacts to the head as a regular part of play. The combination of high ball velocities, close shooting distances (particularly from the 6-meter line), and the expectation to save shots using the head and face creates a specific vulnerability that the handball community has been slow to address.

This video is for the educational purpose only and the original video is a property of ehftv.com .

What Actually Happens During a Concussion

A concussion is a traumatic brain injury caused by biomechanical forces transmitted to the brain. The 2023 Amsterdam Consensus Statement, the most current international guidance on sport-related concussion, defines it as an injury that occurs when direct or indirect force to the head causes the brain to move within the skull.

Understanding the mechanism helps explain why concussions are so serious. When you receive a strong impact to the head, your brain doesn’t stay stationary. The brain, which has a consistency similar to gelatin, shifts and twists inside the skull. The head moves in one direction, the brain lags behind, then the brain catches up and impacts the interior of the skull. It may then rebound and strike the opposite side.

This movement stretches the axons, which are the long nerve fibers that carry information throughout the brain. Axons can tolerate slow stretching, but sudden, rapid stretching from an impact damages these delicate structures. The degree of axonal damage predicts how severe your symptoms will be and how long recovery will take.

The damage from concussions in handball doesn’t occur on the outer surface of the brain where imaging might detect it. Instead, the injury happens deep toward the center of the brain, which is why CT scans and MRIs typically appear normal even when someone has sustained a significant concussion. This invisible nature of the injury contributes to both underdiagnosis and the tendency to minimize its importance.

Recent research has identified that the direction of head movement matters. While forward and backward movement is common in handball (especially when a ball strikes a goalkeeper’s face directly), rotation of the head to the left or right appears to be more dangerous for causing concussions.

Recognizing Concussion Symptoms

The signs and symptoms of concussions in handball vary significantly between individuals. Some symptoms appear immediately, while others may develop hours or even days after the initial impact. What makes recognition challenging is that you don’t need to lose consciousness to have a concussion. In fact, most concussions occur without any loss of consciousness.

Immediate signs to watch for include:

Headache or a feeling of pressure in the head that may worsen over time. Blurred or double vision. Slurred speech or difficulty finding words. Confusion or feeling like you’re in a fog. Nausea and in some cases, vomiting. Dizziness or the sensation of “seeing stars.” Ringing in the ears. Decreased coordination and balance problems. Amnesia, particularly around the events of the injury. Delayed responses to questions. Sensitivity to light and noise.

Symptoms that may develop later include:

Concentration and memory difficulties. Sleep disturbances, either sleeping more than usual or having trouble falling asleep. Irritability and personality changes. Depression and anxiety. Fatigue and low energy that persists despite rest.

The system that seems to be affected more consistently than others following concussions in handball is the visual system. Research indicates that convergence insufficiency is present in approximately half of all people who sustain a concussion. This means the eyes struggle to work together when focusing on close objects, leading to reading difficulties, headaches, double vision, and problems tracking moving objects. For a handball goalkeeper who relies heavily on visual processing to track high-speed balls, this consequence of concussion can be particularly debilitating.

The Danger of Returning Too Soon

Second Impact Syndrome (SIS) represents one of the most severe potential consequences of returning to play before a concussion has fully healed. This rare but potentially fatal condition occurs when someone sustains a second head impact while still recovering from an initial concussion. The brain, already in a vulnerable state from the first injury, reacts with rapid and severe swelling that can be catastrophic.

The first 10 days following a concussion appear to be the period of greatest risk for sustaining another concussion. Research shows that athletes who have sustained one concussion are at significantly higher risk for being diagnosed with another one, and a second concussion during this vulnerable window can double the damage and dramatically prolong recovery.

Young athletes face particular vulnerability. Children and adolescents are more susceptible to the effects of concussion because their brains are still developing. Their symptoms and neurocognitive performance take longer to improve compared to adults, and they require more careful return-to-play monitoring.

The culture in many handball environments works against proper recovery. Players feel pressure to return quickly. Coaches may need their athletes for important matches. The athlete themselves may feel they’re letting their team down by sitting out. But the brain doesn’t respond to willpower or team loyalty. It heals on its own timeline, and rushing that process risks permanent consequences.

What Current Research Says About Recovery and Treatment

The landscape of concussion management has shifted significantly based on the latest evidence. The 2023 Amsterdam Consensus Statement, which emerged from the 6th International Conference on Concussion in Sport, introduced several important updates to how we think about treatment.

The shift away from complete rest. Previous guidance recommended strict physical and cognitive rest until all symptoms resolved. Current evidence shows this approach is not beneficial and may actually delay recovery. The Amsterdam statement recommends encouraging early return to light-intensity physical activity, such as walking and daily activities, within the first 48 hours after injury. This represents a meaningful change in approach, though activity should only continue if symptoms don’t worsen.

Active rehabilitation matters. For adolescents with dizziness, neck pain, or headaches lasting more than 10 days, cervicovestibular rehabilitation is now specifically recommended. This type of therapy addresses the vestibular (balance) and cervical (neck) systems that are often affected by concussion.

Most people recover, but timelines vary. While previous estimates suggested recovery within 7-10 days, this was probably overly optimistic. Current understanding acknowledges that 20-30% of youth and adults may experience symptoms lasting longer than four weeks. Having had previous concussions increases the likelihood of prolonged recovery.

Assessment tools have improved. The Sport Concussion Assessment Tool (SCAT) has been updated to version 6 (SCAT6), and a new office-based assessment tool (SCOAT6) was developed for evaluating athletes beyond the immediate post-injury period. These tools incorporate symptom scales, balance measures, cognitive assessment, and oculomotor and vestibular evaluation.

As neuro-optometrist Dr. Charles Shidlofsky often says: “When you’ve seen one brain injury, you’ve seen only one brain injury.” The individual nature of concussion recovery means that what works for one athlete may not work for another, and careful monitoring throughout the process is essential.

The Updated Return-to-Play Protocol

The stepped return-to-play progression, now based on the 2023 International Consensus guidelines, provides a framework for safely returning to handball after a concussion. The principle is straightforward: progress through each stage only if symptoms don’t return or worsen.

Stage 1: Symptom-Limited Activity Daily activities that don’t provoke symptoms. Gradual return to work or school activities. This stage is about achieving baseline daily functioning before considering sport-specific activities.

Stage 2: Light Aerobic Exercise Walking, swimming, or stationary cycling at slow to medium pace. The goal is increasing heart rate without head movement or resistance training. Duration of 10-15 minutes. No weight lifting.

Stage 3: Sport-Specific Exercise Running drills and other sport-specific activities for 20-30 minutes. For handball, this means basic movement patterns without any contact or ball work that could result in head impact. No heading practice for goalkeepers.

Stage 4: Non-Contact Training Drills More complex drills including coordination work, passing, and movement patterns. Exercise intensity increases but all activities remain non-contact. For goalkeepers, this means no shooting practice yet, as there’s still risk of head impact.

Stage 5: Full Contact Practice (Medical Clearance Required) Return to normal training only after receiving clearance from a healthcare professional experienced in concussion management. This is when goalkeepers can resume saving shots.

Stage 6: Return to Competition Full participation in games and matches. The earliest appropriate return is typically one week from the initial injury, though many athletes require longer.

Critical rules for progression:

Each stage requires a minimum of 24 hours, though it may take multiple days to progress through a single stage. If symptoms return during any stage, stop immediately and return to rest for at least 24 hours. After symptoms resolve, restart from the previous stage. Never skip stages. Young athletes often require more time at each stage than adults.

Long-Term Consequences: CTE and Chronic Effects

Growing attention has focused on the potential long-term consequences of repeated head impacts, including the development of Chronic Traumatic Encephalopathy (CTE). This progressive brain disease has been found in the brains of some former contact sport athletes who experienced repeated head trauma throughout their careers.

CTE is characterized by a buildup of abnormal tau protein in the brain that causes progressive damage to brain tissue. The symptoms associated with CTE include problems with thinking and memory, depression, anxiety, impulse control issues, and aggression. These symptoms typically develop years or decades after the period of head trauma exposure.

What’s important to understand is that CTE appears to be associated with cumulative exposure to repeated head impacts over time, not necessarily with the number of diagnosed concussions. This means that even subconcussive hits, the kind that don’t produce obvious symptoms, may contribute to risk when accumulated over years of play.

Currently, CTE can only be definitively diagnosed through brain examination after death. However, research continues to advance methods for detecting signs of the disease during life. The CDC notes that while CTE has been found in some former contact sport athletes, it remains relatively rare in the general population, and many questions remain about who develops the condition and why.

For handball players and goalkeepers, the takeaway isn’t to live in fear but to take head impacts seriously, ensure proper recovery from concussions, and recognize that protecting the brain is a long-term investment in your health beyond your playing career.

Prevention Strategies for Concussions in Handball

While not all concussions in handball can be prevented, evidence supports several strategies for reducing risk.

Neck Strength Training

Research has established an inverse relationship between neck strength and concussion risk. A study of high school athletes found that for every pound increase in overall neck strength, the odds of concussion decreased by approximately 5%. Stronger neck muscles help stabilize the head during impact, reducing the acceleration and rotational forces transmitted to the brain.

The mechanism is straightforward: when neck muscles can generate tension quickly in response to an impact, they better control head movement and reduce the “whiplash” effect. This is particularly relevant for anticipated impacts, such as when a goalkeeper sees a shot coming and can brace for contact.

Effective neck strengthening doesn’t require expensive equipment. Isometric exercises (pressing the head against resistance without movement), resistance band work, and partner exercises can all build neck strength. The key is consistency and progression over time. For younger athletes especially, building neck strength before they reach higher competition levels provides protective benefits.

Vision training also plays a role in concussion prevention. Athletes with better visual and sensory skills experience lower head impact forces because they can anticipate and prepare for contact. Improving peripheral awareness and reaction time allows players to see threats coming and position their bodies more safely.

Rule Implementation and Awareness

The International Handball Federation has implemented rules to protect players from head-shooting, including suspensions for shooting at a goalkeeper’s head in certain situations. However, rule changes only work when consistently enforced and when all participants understand their purpose.

Research from a 2024 workshop with handball experts identified several prevention strategies: better information about high-risk situations for concussion, stricter enforcement of rules against careless play, and teaching safe playing strategies for goalkeepers, defensive players, and attacking players. Core and neck strength training was recommended for all players as part of standard conditioning.

Recognition and Immediate Response

Perhaps the most important prevention strategy is simply taking concussions seriously. Recognizing symptoms early, removing players from play when concussion is suspected, and ensuring proper evaluation before return can prevent the most dangerous outcomes, particularly second impact syndrome.

Coaches, parents, and players themselves need education about concussion symptoms and the importance of reporting them. The culture of “playing through” head injuries must change, and that change starts with information.

My Research and Ongoing Commitment

At the end of 2023, I was honored to contribute two research papers to the 7th European Handball Federation Scientific Conference in Portugal as an EHF Expert. One my research paper, “Unveiling the Hidden Dangers of Concussions: The Invisible and Underrated Risk in Handball Goalkeeping“, examined why concussions in handball goalkeeping remain underrecognized and underreported. My second research paper, “Consequences and Frequency of Convergence Insufficiency in Handball Goalkeepers“, explored the visual system impacts that affect so many athletes following head injuries.

This research represents my commitment to bringing scientific attention to goalkeeper health and safety in our sport. The intersection of neuroscience, vision, and athletic performance has become central to how I approach goalkeeper training and coach education.

Resources for Learning More

If you want to deepen your understanding of concussions:

The film “Concussion” (2015) starring Will Smith tells the story of Dr. Bennet Omalu’s discovery of CTE in American football players. While focused on American football, it provides important context for understanding traumatic brain injury in contact sports.

The documentary “Head Games” examines the concussion crisis across American sports and features interviews with researchers, athletes, and families affected by brain injuries.

The CDC’s HEADS UP program offers free resources for coaches, parents, and athletes about concussion recognition and management.

For scientific guidance, the Amsterdam Consensus Statement on Concussion in Sport published in the British Journal of Sports Medicine provides the most current international recommendations.

Moving Forward

The point of this article isn’t to make goalkeepers fear the ball or avoid saves. Courage remains essential for our position. But courage without knowledge is simply reckless.

A brave goalkeeper must be familiar with the possible consequences of head impacts. They should know the symptoms that indicate something is wrong. They should understand why returning to play too soon creates serious risks. And they should have the confidence to speak up when they need to rest and recover.

If you are a coach, parent, goalkeeper, or player, take the time to learn about concussion symptoms, treatment approaches, and proper return-to-play protocols. Share this knowledge with your teammates and clubs. Push for proper concussion protocols at every level of the game.

By knowing more, we can all act more appropriately when dealing with concussions in handball. Our brains are irreplaceable. They deserve our protection.

References:

1. Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport. British Journal of Sports Medicine 2023;57:695-711.
2. Sturesson V, Marforio P, Reuter A, et al. Youth handball concussion prevention strategies: a workshop-based study with experts and end users. BMJ Open Sport & Exercise Medicine 2024;10:e001877.
3. Health And Performance Promotion in Youth Sport (HAPPY): Concussion Incidence Rates in Danish Youth Handball Players. Journal of Orthopaedic & Sports Physical Therapy 2025;55(12):779-787.
4. Davis GA, et al. Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023. Pediatrics 2024;153(1):e2023063489.
5. Collins CL, et al. Neck strength: a protective factor reducing risk for concussion in high school sports. Journal of Primary Prevention 2014;35(5):309-319.

Talk by David Camarillo

To learn more about why helmets don’t prevent concussions, check this talk by David Camarillo:

Katherine’s concussion story

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