Sehr geehrte Damen und Herren,
am 25. August 2019 beginnen die 33. Judo-Weltmeisterschaften in Tokio/Japan. Bis zum 01. September messen sich die besten Judoka aller Altersklassen rund um den Globus.
Immer mehr junge Athleten begeistern sich für diese Sportart. Und so wird Judo in Vereinen bereits schon für 3Jährige angeboten. Der spielerische Übergang zu judospezifischen Formen ist dabei fließend. Die Sportart erlaubt es durch Ihre reichhaltigen Facetten Judo aktiv bis ins sehr hohe Alter zu praktizieren. Judoka mit über 80 Jahren sind keine Seltenheit mehr. In über 150 Ländern wird dieser Sport ausgeübt und ist damit die am weitesten verbreitete Kampfsportart der Welt. Judo (jap. 柔道 jūdō ) – das heißt wörtlich „sanfter/flexibler Weg“. Das Motto ist hier „Siegen durch Nachgeben“ und „maximale Wirkung bei einem Minimum an Aufwand“. Das heutige Judo ist von den Wettkampftechniken der letzten Jahre dominiert und wird entsprechend vom Techniktraining geprägt. Sehr häufig gibt es dabei Schulterverletzungen. Unser Autor Dr. Paul Brinkmeier, Orthopäde, Mannschaftsarzt und Spezialist für die Judoka berichtet über Verletzungsmuster bei Kindern und Erwachsenen, über chronische Schäden und die Prävention im Judo-Sport.
Herzlichst,
Ihre Kathrin Reisinger, GOTS-Pressesprecherin (presse@gots.org)
Die Wurfschulter beim Judoka
© BrinkmeierJudo (jap.: „sanfter Weg“) entstammt der alten japanischen Kampfkunst. Ursprünglich entwickelt als Weg zur Leibesertüchtigung und Philosophie zur Persönlichkeitsentwicklung mit den Leitmotiven „Gegenseitiges Helfen und Verstehen zum beiderseitigen Fortschritt und Wohlergehen“ und „Bestmöglicher Einsatz von Körper und Geist“, hat sich Judo heute zu einem stark wettkampforientierten und weltweit betriebenen Kampfsport entwickelt. Prof. Jigoro Kano (1860–1938) ist dabei als Vater des modernen Judo anzusehen. Judo war bei den Olympischen Spielen 1964 in Tokio erstmals olympische Sportart. Die Rückkehr nach Tokio in diesem Jahr (Weltmeisterschaft) und im kommenden Jahr (Olympische Spiele 2020) stellen sicher Highlights der Sportart Judo dar.
Durch Nutzung von Wurf- und Grifftechniken wird im Stand und Boden gekämpft. Im Boden kommen Halte-, Würge- und auch Ellenbogenhebeltechniken zum Einsatz. Neben dem Einsatz von Kraft und Schnelligkeit geht es beim Judo v.a. um die Nutzung biomechanischer Momente, um das Gleichgewicht des Gegners brechen und diesen auf den Rücken werfen zu können. Da es sich bei Judotechniken vorwiegend um Wurftechniken handelt, ist gerade die Schulter hier besonderen Belastungen ausgesetzt. Daher sollen im Folgenden speziell die Schulterverletzungen im Judo genauer beleuchtet werden.
Grundlagen der Sportart
Gekämpft wird barfuß im traditionellen Judogi (Kampfanzug). Dieser besteht aus einer Hose und Jacke, die durch einen Gürtel zusammengehalten werden. Hose und Jacke bestehen aus einem schweren Baumwollstoff. Auf höheren Wettkampfebenen trägt gewöhnlich ein Kämpfer einen weißen und der andere einen blauen Judogi. Die Gürtelfarbe signalisiert den Ausbildungsstand eines Judoka. Differenziert wird nach Schülergraden (Kyu-Grade, beginnend mit Weiß über Weiß-Gelb, Gelb, Gelb-Orange, Orange, Orange-Grün, Grün, Blau bis Braun) und Meistergraden (Dan-Grade, 1.–5. Dan Schwarz, 6.–8. Dan Rot-Weiß sowie 9.–10. Dan Rot).
Im Training unterscheidet man die beiden Partner in Tori („Greifender/Handelnder“) und Uke („Erleidender/Verteidiger“). Uke ist demnach derjenige Partner, bei dem die Techniken angewendet werden.
Gekämpft wird auf einer quadratischen Matte (Tatami). Es existieren verschiedene Alters- und Gewichtsklassen, in denen gekämpft wird. Im Erwachsenenbereich bestehen bei den Männern die Gewichtsklassen: –60, –66, –73, –81, –90, –100 und +100 kg. Bei den Frauen: –48, –52, –57, –63, –70, –78 und +78 kg.
Die Kampfzeit beträgt für Männer und Frauen 4 Min.. Für die ausgeführten Aktionen können drei unterschiedliche Wertungen, Ippon, Waza-ari und Yuko oder Bestrafungen (leichter Regelverstoß =
Shido, schwerer Regelverstoß = Hansoku-make) vergeben werden. Ein Ippon bedeutet einen vollen Punkt und Sieg über den Kontrahenten. Ein Ippon kann erreicht werden, indem ein Wettkämpfer den Kontrahenten mit Kraft, Kontrolle und Schnelligkeit überwiegend auf den Rücken wirft, 20 Sekunden lang in einem Haltegriff hält, durch Aufgabe des Kontrahenten (signalisiert durch Abklopfen) oder durch Kampfunfähigkeit des Kontrahenten als Resultat einer Würge- oder Armhebeltechnik. Ein schwerer Regelverstoß bedingt stets die Niederlage und mit wenigen Ausnahmen die Disqualifikation mit direktem Ausschluss vom weiteren Turnier.
Neben dem eigentlichen Wettkampf (Shiai), nimmt beim Judo v.a. der Übungskampf (Randori), ähnlich dem Sparring beim Boxen, einen wichtigen Teil des Trainings ein. Eine weitere Säule des Judosports ist der Formenlauf (Kata).
Der Deutsche Judo-Bund (DJB) ist der Dachverband der Judo-Landesverbände in Deutschland. Gut 150.000 Mitglieder in über 2700 Vereinen waren im Jahr 2017 im DJB gemeldet.
Altersgruppen
© Pixabay (2)
Im DJB existieren verschiedene Altersklassen, in denen weibliche und männliche Athleten bei Turnieren gegeneinander antreten: U12, U15, U18, U21, Frauen/Männer (ab 17 Jahren). Für Jugendpokalturniere existieren darüber hinaus die Altersklassen U14 und U16. Die Teilnahme in der Judo-Bundesliga ist ab einem Alter von 16 Jahren gestattet. Innerhalb der verschiedenen Altersklassen existieren unterschiedliche Gewichtsklassen, sowie Limitationen der Kampfzeit. In den Altersklassen U12 und U15 ist die Anwendung von Würgetechniken im Boden nicht gestattet, in der U12 darüber hinaus auch die Anwendung von Hebeltechniken. Auch im Standkampf gibt es Verbote für die jüngeren Altersklassen So sind bei der U12 Kontertechniken nach hinten verboten. Bei der U12 und U15 sind ebenfalls Techniken, die auf einem oder beiden Knien angesetzt werden, Abtauchtechniken oder der Griff in und um den Nacken bzw. der Gri über die Schulter verboten.
Verletzungsmuster
85% aller Verletzungen im Judo entstehen während des Standkampfes. Die Opferrolle beim Werfen ist dabei die häufigste Ursache für deren Entstehung (70%).
Unter den Verletzungen sind Schulterverletzungen häufig im Judo und machen etwa 22% aller Verletzungen aus. Sie sind nach Knieverletzungen diejenigen, die mit dem längsten Trainingsausfall einhergehen. Harmlose Verletzungen wie Verstauchungen, Prellungen und Zerrungen machen mit großem Abstand die Mehrheit der Verletzungen aus. Diese führen meist nur für wenige Tage zu einem Trainingsausfall, wohingegen ernstere Verletzungen mit Ausfallzeiten von 3 Wochen und länger einhergehen.
Schulterverletzungen bei Kindern
Im Kindesalter treten im Gegensatz zu Erwachsenen häufiger Frakturen am Schultergürtel auf. Dies hat v.a. mit der noch bestehenden Knochenunreife zu tun. Interessanterweise sind Jungen hier signifikant häufiger als Mädchen von betroffen.
Unterschiedliche Untersuchungen fanden in bis zu 30% der kindlichen Verletzungen Frakturen. An der Schulter werden sogar in bis zu 2/3 der Fälle Frakturen beobachtet. Im Vordergrund stehen dabei Claviculafrakturen (46%) und proximale Humerusfrakturen (18%).
Die Gefahr kindlicher Oberarm- und Schulterverletzungen liegt dabei in Vergleichsuntersuchungen auch höher als z.B. im Karate oder Taekwondo.
12 Jahre alter weiblicher Judoka mit verkürzter und dislozierter Claviculafraktur im mittleren Drittel. In diesem Fall erfolgte eine Stabilisierung mittels ESIN.
Meist lassen sich Claviculafrakturen im Kindesalter konservativ mittels Rucksackverband behandeln. Bei Kindern reicht in der Regel eine zweiwöchige, bei Jugendlichen eine vierwöchige Behandlung. Im Falle einer deutlichen Verkürzung und Dislokation > Schaftbreite, sowie Kontraindikationen für eine konservative Therapie kann eine operative Versorgung notwendig werden. Favorisiertes Verfahren bei Kindern ist hierbei meist eine elastisch stabile intramedulläre Nagelung (ESIN) z.B. mittels Nancy-Nagel.
Hauptursache für diese Verletzungen ist bei Kindern die Opferrolle beim Werfen. Dabei können die Verletzungen zumeist auf eine unsaubere Wurftechnik des Werfenden oder eine unzureichende Falltechnik des Fallenden zurückgeführt werden. Grade bei Kindern ergibt sich daraus die Notwendigkeit von Anfang an korrekte Falltechniken zu erlernen bzw. neue oder komplexe Techniken nur unter Aufsicht des Trainers und mit entsprechender Vorbereitung zu erlernen.
Schulterverletzungen bei Erwachsenen
Bei Erwachsenen stehen an der Schulter Kapsel-Band-Verletzungen im Vordergrund. Schulterwurftechniken (Seoi-Nage) sind mit die beliebtesten Wettkampftechniken und gelten gleichzeitig als Hochrisikotechniken für Verletzungen. Während der Werfende hier eher Knieverletzungen erleidet, treten gerade beim Geworfenen häufig Schulterverletzungen auf.
Tiefer Ippon-Seoi-NageDie Schultereckgelenksprengung gilt als häufigste, akute Schulterverletzung beim Judo. Sie tritt überwiegend in Folge eines Sturzes auf den Schultergürtel auf, wenn sich der Geworfene nicht mehr rechtzeitig auf den Bauch drehen kann um einen Ippon abzuwenden oder sich beim Fallen überdreht und statt auf dem Rücken mit dem Schultergürtel aufkommt. Die Schwere der Akromioklavikulargelenksluxationen wird n. Rockwood in die Schweregrade I-VI unterteilt (Abb. 3). Da es bei der Versorgung von Grad III-Verletzungen immer wieder zu Kontroversen kam, schlug die ISAKOS 2014 eine weitere Unterteilung der Grad III-Verletzung in IIIA (stabil) und IIIB (instabil) vor. Grundsätzlich sollte ab Vorliegen einer Grad IIIB-Verletzung für sportlich aktive Judoka die Empfehlung zur operativen Versorgung gestellt werden. Die Versorgungsoptionen der Schultereckgelenkverletzung wurden ausführlich im GOTS-Newsletter 11/2017 dargelegt.
Rockwood-Klassifikation der Schultereckgelenkssprengung
Bankart-Läsion nach traumatischer vorderer Schulterluxation ©BrinkmeierDie zweithäufigsten, akuten Schulterverletzungen beim Judo sind glenohumerale Schulterluxationen. Der Sturz auf den angehobenen Arm oder eine äußere Krafteinwirkung auf den abgespreizten, außenrotierten Arm sind typische Verletzungsmechanismen.
Klassische Situationen für solche Verletzungen im Judo sind für Uke z.B. der Versuch einen Sturz auf den Rücken mit dem gestreckten Arm abzuwehren bzw. für Tori eine unkontrollierte Wurfausführungen nach vorne mit konsekutivem Abstützen auf den Arm. 95% der Schulterluxationen sind unidirektional nach anteroinferior gerichtet.
Eine traumatische Schulterluxation stellt einen Notfall dar und sollte alsbald möglich reponiert werden. Hierbei ist jedoch v.a. darauf zu achten, dass vorab eine Röntgendiagnostik sowie Dokumentation der peripheren Durchblutung, Motorik und Sensibilität erfolgt, da Begleitverletzungen des N. axillaris oder Plexus brachialis in bis zu 6% d. Fälle vorkommen.
Es sollten ausschließlich schonende Repositionstechniken am entspannten, schmerzarmen Patienten durchgeführt werden. Eine „brüske“ Reposition noch auf der Judomatte ist nicht zu empfehlen. Besser ist eine Immobilisation der Schulter in einer Schlinge (z.B. mittels Judogürtel) und anschließend zeitnahe Reposition in einer chirurgischen Notaufnahme.
In über 80% der Fälle kommt es bedingt durch die traumatische vordere Schulterluxationen zu Kapsel-Labrumverletzungen (V.a. Bankart-Läsionen).
Ebenfalls häufige Begleitverletzungen sind SLAP-Läsionen oder knöcherne Begleitverletzungen am Humeruskopf (Hill-Sachs Läsion) sowie am Glenoid. Angelehnt an den ISIS-Score n. Balg und Boileau ergibt sich bei solchen Verletzungen für den Judoathleten meist die Empfehlung für eine arthroskopische Schulterstabilisierung mit Labrumrefixation +/- Adressierung der langen Bizepssehne.
Chronische Schulterbeschwerden
Nicht immer muss eine stattgehabte vordere Schulterluxation ausschlaggebend für eine vordere Schulterinstabilität beim Judoka sein. Häufig leiden Judoka durch die besonderen Belastungen beim Werfen oder Fallen im Sinne repetitiver Mikrotraumata der Schulter an einer chronischen Schulterinstabilität. Die Athleten klagen meist über anhaltende Schulterschmerzen während der Ausübung des Sports, ohne dass ein Akutereignis erinnerlich wäre. Solche Beschwerde sollten im Rahmen einer gründlichen sportorthopädischen Untersuchung abgeklärt werden. Die klinische
Untersuchung der Schulter steht dabei im Vordergrund. Es sollte viel Wert auf die Detektion etwaiger Instabilitäten gelegt werden. Neben vorderen Schulterinstabilitäten muss dabei auch an die Möglichkeit des Vorliegens einer posterioren oder multidirektionalen Instabilität gedacht werden.
Ergänzend kommen bildgebende diagnostische Verfahren wie Sonografie, Röntgen und MRT zum Einsatz. Gezielt muss dabei auch nach Begleitverletzungen der langen Bizepssehne bzw. von Pulley und/oder SLAP-Komplex (Abb.5) sowie der Rotatorenmanschette gesucht werden. Je nach Schweregrad und Vorliegen struktureller Schäden stehen dabei verschiedene Möglichkeiten der operativen oder konservativen Therapie zur Verfügung. Während im deutschsprachigen Raum für die operative Versorgung überwiegend arthroskopische Techniken zur Anwendung kommen, werden in Japan speziell für Judoka auch offene OP-Techniken wie z.B. der offene inferiore Kapselshift (MICS) beschrieben. Bei Schwergewichtsjudoka, gerade im Hochleistungssport, kommen dort sogar bei uns eher obsolete Verfahren wie z.B. der Verschluss der Rotatorenintervalls zur Anwendung, um eine ausreichende Stabilität zur Fortsetzung von Judo im Spitzensport zu gewährleisten.
Einer japanischen Erhebung nach scheint es so, als wären die operativen Ergebnisse nach Schulterstabilisierung bei Judoka besser, wenn die nicht-dominante Schulter (Zugfunktion) statt der dominanten Schulter (Hebefunktion) des Kämpfers betroffen war.
Isolierte SLAP 2-Läsion eines 26-jährigen männlichen Judoka in der MR-Arthrografie in Folge einer repetitiven Traumatisierung ohne erinnerliches Akutereignis. ©Brinkmeier
Im Falle anhaltender Schulterschmerzen sowohl bei Breiten- als auch Leistungssport-Judoka sollte bei auffälliger klinischer Untersuchung immer eine bildgebende Diagnostik zum Ausschluss eines strukturellen Schulterbinnenschadens erfolgen. Sind diese ausgeschlossen oder nicht im Einklang mit
klinischen Befunden, sollte primär eine intensive physiotherapeutische Behandlung der dann a.e. funktionellen Probleme erfolgen. Dabei stehen Kräftigungsübungen der Rotatorenmanschette und Skapula-stabilisierenden Muskulatur, wie auch Übungen zur Skapulakontrolle und Haltungsschulung im Vordergrund.
Prävention
Der behandelnde Arzt sollte genaue Kenntnisse über die Besonderheiten des Judosportes besitzen. Gerade bei Schulterverletzungen spielt auch die Kenntnis des Verletzungsmechanismus oder evt. die Kenntnis der (Wurf-)Technik, die zur Verletzung geführt hat, eine große Rolle, da dadurch bereits erste Verdachtsdiagnosen gestellt werden können.
Zur Prävention von Schulterverletzungen gehört vor allem im Jugendbereich und/oder Breitensport das korrekte Erlernen von Falltechniken und Wurftechniken. Hier hat der Trainer eine besondere Rolle, der seine Athleten schrittweise an komplexe Techniken heranführen muss. Gerade im Breitensport ist der Trainer sicher die wichtigste Instanz zur Prävention von Verletzungen. Neben dem Techniktraining hat er auf korrekte Aufwärm-, Kräftigungs- und Dehnübungen zu achten.
Zur Prävention von Schulterverletzungen sollte beim Krafttraining auf eine gut ausgeprägte Rumpfmuskulatur (Core stability) geachtet werden. Ein möglicher Test zur Evaluation der Core stability ist der Functional Movement Screen (FMS), der auch zur Beurteilung von Fortschritten bei der Therapie eingesetzt werden kann.
Allgemein beinhaltet das Konditionstraining beim Judo sowohl Ausdauer-, als auch Kraft- und Beweglichkeitstraining. Hierzu liegen judosportartspezifische Empfehlungen vor, welche auch im Trainer-Fortbildungsprogram des DJB hinterlegt sind.
Natürlich dient im Leistungssport auch eine regelmäßige sportärztliche und sportphysiotherapeutische Untersuchung dazu, um etwaige muskuläre Dysbalancen oder Überlastungsschäden aufzudecken. Eine interdisziplinäre Zusammenarbeit von Ärzten, Physiotherapeuten und Trainern ist hier enorm wichtig.
Da Judo in Gewichtsklassen praktiziert wird, besteht wie in anderen Kampfsportarten mit Gewichtsklassen, das Phänomen des „Abkochens“ oder „Gewichtmachens“ vor dem Wettkampf. Da die Zuteilung zu einer höheren Gewichtsklasse ggf. mit geringeren Erfolgsaussichten auf eine Platzierung einhergehen kann, versuchen Athleten kurz vor dem Wettkampf oft noch einige Kilo Körpergewicht zu verlieren. Dies wird meist durch Nahrungsrestriktion und Wasserverlust erreicht. Zu intensive Gewichtsreduktion schadet den Athleten dabei. Gewichtmachen um mehr als 3% der Körpermasse sollte unbedingt vermieden werden, da andernfalls das Verletzungs- und Unfallrisiko bedingt durch psychische und physische Leistungseinschränkungen steigt.
Fazit
Verletzungen der Schulter im Judosport sind häufig. Bei den ernsten, akut traumatischen Verletzungen dominieren im Erwachsenenalter Schultereckgelenksverletzungen, gefolgt von glenohumeralen Luxationen. Bei den chronischen Verletzungen stehen bedingt durch repetitive Traumatisierungen Verletzung des Kapsel-Labrum-Komplexes, der langen Bizepssehne und der Rotatorenmanschette im Vordergrund. Bei Kindern kommt es wesentlich häufiger zu Frakturen, wobei Claviculafrakturen fast 50% der ernsten Verletzungen ausmachen. Zur Erkennung und Behandlung der Verletzungen ist eine genaue Kenntnis der Sportart und ihrer Besonderheiten von
Vorteil. Bei der Prävention von Verletzungen kommt dem exakten Erlernen von Falltechniken eine besondere Bedeutung zu, da die Opferrolle beim Werfen die häufigste Ursache für (Schulter-)Verletzungen darstellt. Neben dem Techniktraining und Randori müssen Ausdauer-, Kraft- und Beweglichkeitstraining in den Trainingsalltag eines Judoka integriert werden. Das Erarbeiten einer guten core stability ist dabei besonders wichtig.
Der Autor
Dr. med. Paul Brinkmeier ist Assistenzarzt an der Klinik für Orthopädie, Unfall- und Handchirurgie des Klinikums Osnabrück unter der Leitung von Prof. Dr. Martin Engelhardt. Ein Schwerpunkt der Klinik ist die operative und konservative Versorgung von Spitzensportlern und leistungsorientierten Freizeitsportlern. Dr. Brinkmeier war über 20 Jahre selbst aktiver Judoka und ist Träger des 2. Dan. Er besitzt viele Jahre Wettkampferfahrung und hat in verschiedenen Judo-Mannschaften u.a. bis auf 2. Bundesliga-Ebene gekämpft. Im Rahmen seiner klinischen Tätigkeit beschäftigt er sich intensiv mit Verletzungen der Schulter und betreut Judoka aus Vereinen in Münster, Osnabrück und Dortmund.
GOTS-Aktivitäten
13. GOTS-Schweiz-Sommerkongress 2019
Zum 13. Mal startet in der Schweiz der GOTS Sommertreff – dieses Mal zum Thema
„Unlock the limits“. In der heutigen Zeit der schnell fortschreitenden Entwicklungen in der Medizin, sollen die Möglichkeiten der Leistungssteigerung kritisch beleuchtet werden.
Das wissenschaftliche Programm beinhaltet das technische und medizinische Doping genauso wie den Sinn und Unsinn von Leistungssteigerung im Alter aus chirurgischer, internistischer und physiotherapeutischer Sicht. Im Bereich der Sportorthopädie werden ausgewiesene Experten
anhand exemplarischer Fälle aufzeigen, was heute möglich ist und auch Sinn macht. Im Anschluss gibt’s in der Paneldiskussion Gelegenheit mit den kompetenten Referenten über die Fälle zu
diskutieren. Als besonderes Highlight konnten Marc Gisin, Skirennfahrer und Lukas Christen, Goldmedaillien Gewinner der Paralympischen Spiele gewonnen werden, die einen Blick hinter die Kulissen des Profisportes gewähren werden.
Leitung: Dr. med. Lukas Weisskopf, Dr. med. Christian Egloff,PD Dr. med. Carlo Camathias,Dr. med. Pascal Molteni / Anmeldung unter gots.ch
GOTS-Kongress-Nachlese
Preisträger 2019
Sporlastic Posterpreis
Platz 1: Thilo Hotfiel, Clinical Practice meets Science: Wie beeinflusst eine PRICE-Therapie die intramuskuläre Gewebedurchblutung?
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Platz 2: nicht vergeben
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Preis für den besten Vortrag
Volker Schöffl – „Radiologische Anpassungserscheinungen von jugendlichen Freizeit- versus Leistungskletterern – Eine prospektive 11 Jahresanalyse der Deutschen Jugendnationalmannschaft und einer Gruppe Freizeitkletterer“
Platz 1: Gokeler, Alli; Benjaminse, Anne; Seil, Romain; Kerkhoffs, Gino; Verhagen, Evert, Using principles of motor learning to enhance ACL injury prevention programs
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ESSKA Master Arthroscopist
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GOTS-Aufruf
Waren Sie als betreuender Arzt auf namhaften Sportveranstaltungen, haben Sie Neues von Ihren Symposien, Workshops, Veranstaltungen, aus Ihren Kommissionen oder gibt es neue bedeutende Publikationen von Ihnen? Dann freuen wir uns auf Zusendung von Texten und Fotos oder einfach nur Stichpunkten / Links dazu, um alles multimedial vermarkten zu können.
Die Adresse: presse@gots.org
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