Managing Acute and Overuse Disorders
William W. Briner, Jr, MD; Holly J. Benjamin, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 3 - MARCH 1999
In Brief: Most volleyball injuries are related to blocking or spiking, both of which involve vertical jumps. The most common acute injuries include ankle and thumb sprains, and common overuse injuries include patellar and shoulder tendinitis, suprascapular neuropathy, and low-back injury. Symptoms will usually resolve with conservative treatment, which may include activity modification, such as reduced jump training or jumping on a sand surface, and technical instruction. Players who have significant symptoms from suprascapular neuropathy may require diagnostic electromyography and MRI before surgical decompression.
Volleyball has been popular since its invention in 1895 in Massachusetts. The Fédération Internationale de Volleyball, volleyball's international governing body, currently reports that over 800 million people in about 130 countries play volleyball, making it one of the world's most popular participation sports. Players include males and females of all ages and skill levels who play year-round on indoor and outdoor courts. The 1996 Olympic Summer Games in Atlanta for the first time featured six-player teams competing on hard-surface indoor courts and two-player contests on outdoor sand courts.
Given the number of players and the potential rigors of the game, acute and overuse injuries are to be expected. Fortunately, most can be managed by primary care physicians. Familiarity with injuries common to volleyball can facilitate diagnosis, treatment, and rehabilitation and promote prevention.
Volleyball players perform a variety of maneuvers that are unique to the sport, and each poses a risk of injury. Play begins with an underhand or overhead serve, delivered jumping or standing. The opposing team usually starts offensive play with a standard bump-set-spike pattern. With arms extended and the hands held together below the waist, a player will bump or pass the serve by playing the ball off both forearms. The ball is then "set" by a teammate who, with both hands overhead, directs it toward the net, where another teammate jumps and attacks or spikes the ball, using an overhead arm swing. The goal of spiking is to generate a powerful hit into the opponent's court.
The defensive players typically try to block a spike by jumping with their hands overhead above the net to force the ball back to the hitter's side. If the block fails, another defensive player attempts to bump the ball and initiate the bump-set-spike sequence. This type of bump is referred to as "playing defense," which may include quick movements near the playing surface and even dives to play the ball.
Injury rates in volleyball are difficult to determine with precision because researchers' definitions of injury vary. Nonetheless, some trends are clear.
The highest rate of volleyball injury is associated with blocking, followed by spiking (1-3), both of which require a jump. A 1987 review of outpatient rehabilitation records of 106 patients treated for volleyball injuries found that 63% of the injuries were related to jumping (4). Defense is associated with a smaller number of injuries, and serving, passing, and setting with even fewer (1-4). In general, each player uses all of these maneuvers during a game, so all players are exposed about equally to the risk of injury.
Some data on volleyball-related injuries are available from reports of competitions. At the 1987 US National Amateur Volleyball tournament, injuries occurred at a rate of about 1 in every 50 player-hours of play (1). During the 1995 US Olympic Festival, the rate was 1 per 25 player-hours of competition and training (3). In both surveys, an injury was "any condition causing the athlete to present to the medical staff."
Frequent play may entail a significant risk of minor injury. An analysis of 86 Scottish National League male players demonstrated that 53% were injured during a year. However, few suffered season-ending injuries, and most missed fewer than 4 days of play (2). In this study, injury was "any condition resulting in 2 or more consecutive days missed from play."
Not surprisingly, injury incidence is related to the court surface. For example, patellar tendinitis—the most common injury overall in volleyball players—is more common in those who play on concrete or linoleum than in those who play on softer wood courts (5). Elite collegiate players reported five times as many injuries per hour when they played on indoor hard courts as when they played on sand courts (3).
Overuse injuries are more common than acute injuries in volleyball, constituting about 50% to 80% of the total (1-4). The approximate distribution of injuries by type is shown in table 1.
Ankle sprains. Ankle sprains account for 10% to 30% of all sports-related acute injuries and 15% to 60% of acute injuries reported in volleyball (1-3). Most players injure their ankles when they land after blocking or spiking in the front court. The most common mechanism of injury is forced supination that occurs when the blocking player's foot lands on an opposing spiker's foot that has come underneath the net and is in the "conflict zone." (A player's foot may intrude into the opponent's side of the court as long the foot remains in contact with the line that runs directly beneath the net.) When this happens, the usual result is an inversion injury to the lateral collateral ligament complex of the blocker's ankle.
The standard regimen of rest, ice, compression, and elevation is always appropriate in the treatment of acute ankle sprains. Nonsteroidal anti-inflammatory drugs may also be useful (see "Ankle Sprains: Expedient Assessment and Management," October 1998, page 29). This regimen should continue, even during weight-bearing activity, until edema abates.
To help minimize the risk of recurrence, a rehabilitation program is essential for all ankle sprains and should include proprioceptive exercises such as single-leg balancing with eyes open and closed and balance-board exercises (5). The use of an ankle orthosis is often recommended while a patient is doing active rehabilitation, since it also probably decreases the risk of reinjury (6).
A significant number of ankle sprains may be prevented through a training program (5) that teaches players to avoid the center line during practice and that identifies "problem attackers"—players who jump forward when spiking the ball. These players are taught to take longer final steps in approaching their jump and then to jump straight up rather than forward. This program was combined with an ankle proprioception program and evaluated in Norway. After training, players noted more success in spiking, and the study found a 50% decrease in ankle sprains.
Hand injuries. Volleyball players can sustain some unusual hand and wrist injuries, such as pisiform fractures and antebrachial-palmar hammer syndrome (7). (See "Hand Ischemia in Active Patients: Detecting and Treating Hypothenar Hammer Syndrome," January 1998, page 57.) More often, however, they suffer minor hand injuries that rarely result in time missed from play or practice.
Most finger sprains and closed fractures can be managed by splinting or taping (see related article, page 89). Buddy taping is recommended for collateral ligament injuries and is particularly effective in protecting an injured finger by creating a functional mobile splint with the healthy adjoining finger.
Sprain of the radial collateral ligament of the thumb metacarpophalangeal joint is the most frequent volleyball-related hand injury (8). It often occurs in blocking and may require splinting or taping. Unfortunately, the thumb does not lend itself well to buddy taping. Thumb spica taping (figure 1) often gives players enough support to allow them to return to play.
Knee injuries. Acute knee injuries in volleyball are less common than overuse injuries (see below). Severe ligamentous injuries requiring surgery are rare. In one large series of these, more anterior cruciate ligament injuries occurred among female players than males (9).
Overuse injuries are the most frequent complaint that sends volleyball players to their athletic trainers (1,3). Patellar tendinitis is the most common overuse injury, followed by tendinitis of the supraspinatus or biceps tendons, or both (table 1). Injury of the suprascapular nerve and low back also occur quite frequently.
Patellar tendinitis. Patellar tendinitis (jumper's knee) is by far the most frequently reported overuse injury in volleyball injury surveys (1-4), probably because jumping is so integral to the sport. Furthermore, elite volleyball players spend much of their practice time doing jump training, which includes plyometrics to increase vertical jump height. However, supervised, properly executed plyometric training has not been associated with this condition in these players (7).
According to one study (10), patellar tendinitis is more common in those who play more than four times weekly and peaks in players who are 20 to 25 years old and in those who have played 3 to 5 years. Most players with this condition have pain at the lower pole of the patella, and inflammation has been localized histologically to the bone-tendon junction.
Patellar tendinitis can usually be managed with 1 to 2 months of conservative treatment that includes ice, anti-inflammatory medication, and alterations in training. Stretching of the hamstrings and quadriceps may also be helpful.
To help prevent patellar tendinitis, players who are at increased risk should be identified. Those who generate the greatest power during jumping and have the highest vertical jumps have been found to be at greater risk (11). Decreasing their jump training may help prevent patellar tendinitis. Players who have increased external tibial torsion and deeper knee flexion at takeoff may also be at greater risk (12), so coaching them in proper jumping technique may reduce the likelihood of injury.
Shoulder tendinitis. Shoulder injuries, which account for 8% to 20% of volleyball injuries, are usually rotator cuff and/or biceps tendinitis caused by overuse (1-3). The shoulder is susceptible to these injuries because volleyball, like swimming and other sports that involve overhead arm movement, subjects the shoulder to repetitive abduction and external rotation followed by extension and internal rotation. In addition, contact with the ball when spiking occurs at the point of maximal arm abduction, which may increase the impingement forces.
Players who have shoulder tendinitis may present with generalized shoulder pain or weakness or both. The physical exam should include an evaluation of the symmetry of scapulothoracic motion and of glenohumeral stability, using impingement maneuvers, Speed's test, and Jobe's test.
Treatment includes relative rest, daily application of ice packs, and anti-inflammatory medications. In addition, a shoulder rehabilitation program must be prescribed. An athlete who has scapulothoracic instability should initially do scapular stabilization exercises (figure 2), followed by rotator cuff exercises aimed at glenohumeral rehabilitation (figure 3). Symptomatic players may also have an altered arc of rotation with increased external and decreased internal rotation. Players with this imbalance should follow a stretching program (figure 4).
Suprascapular neuropathy. Suprascapular neuropathy is an unusual condition, involving suprascapular nerve compression, that may be present in up to 32% of elite volleyball players (13) and may require specific rehabilitation or surgical decompression. Several factors may contribute to this condition, but in volleyball players, the nerve is usually compressed at the spinoglenoid notch (figure 5: not shown), where the terminal branch, an entirely motor nerve, passes to the infraspinatus muscle.
This injury may be the result of the "floater" serve that is commonly used in indoor volleyball to impart as little spin as possible to the ball, making it difficult to pass. This serve requires the player to stop the overhand follow-through immediately after striking the ball. The result is a forceful eccentric contraction of the infraspinatus muscle to decelerate the arm. This contraction is believed to result in traction from the myoneural junction to the spinoglenoid notch and compression of the nerve.
Players may not know that they have this condition (13) but may present with isolated weakness of external rotation on a preparticipation physical exam. Unlike shoulder tendinitis, which is painful, suprascapular neuropathy is often painless, so most players are asymptomatic (10) and probably do not require further evaluation or treatment. Findings of isolated external rotation weakness (figure 6) and infraspinatus atrophy should be noted on preparticipation exam for future reference, in case the player develops shoulder pain.
In those who have significant symptoms, such as shoulder pain, surgery may be indicated. However, magnetic resonance imaging should be seriously considered prior to surgical decompression, since up to 67% of affected individuals may have a ganglion cyst compressing the nerve (14). Electromyography usually confirms isolated involvement of the infraspinatus muscle. If denervation is not complete, rehabilitation should be directed toward strengthening the external rotators (figure 3d). Indications for surgery include shoulder pain and notably decreased performance, especially in elite players.
Low back. Low-back injuries account for up to 14% of volleyball injuries (1,3) but do not often eliminate players from participating. Again, jumping may be related to low-back injury because landing increases the forces on the spine, which may result in mechanical low-back pain. Fortunately, disk herniations of the lumbar spine are rare in volleyball players.
An appropriate treatment regimen may include decreased jumping activity, playing on softer surfaces such as sand, and a functional low-back exercise program that includes flexion and extension exercises.
Playing for Prevention
The maneuvers and movements of volleyball make certain areas of the body vulnerable to acute and overuse injuries. Repetitive jumping can stress the ankles, knees, and back; overhead serving and spiking can injure the shoulder; and blocking may jam the fingers. Preventive measures such as modifying playing time and surfaces and improving technique can help minimize players' risk of injury. If injury does occur, prompt diagnosis, treatment, and rehabilitation can allow most volleyball enthusiasts to continue playing.
Dr Briner is medical director of Lutheran General Sports Medicine Center in Park Ridge, Illinois, and an assistant clinical professor in the department of family practice at the University of Illinois in Chicago. He holds a certificate of added qualifications in sports medicine and is a fellow of the American College of Sports Medicine. Dr Benjamin is an assistant professor of pediatrics and surgery in the section of orthopaedic surgery and rehabilitation medicine at the University of Chicago. When the article was written, she was a primary care sports medicine fellow with Dr Briner. Send correspondence to William W. Briner, MD, Dept of Family Practice, 6 South, Lutheran General Hospital, 1775 Dempster St, Park Ridge, IL 60068; e-mail to [email protected].
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