Treating and understanding volleyball related injuries

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

Treating and understanding volleyball related injuries

In this article, we will discuss chronic injuries that result in time away from training and match and how non-surgical treatments can help the volleyball player get back to the game. The beginning of this article is going to lay out the evidence of why you keep getting injured and why the preventative measures you are taking to avoid injury are not helping you.

Preventative injury programs do help a lot of athletes. Because you are reading this article, they may not have helped you and you are looking for answers.

Despite advanced preventative measures, elite volleyball players still get injured at a high rate

In February 2019, doctors asked elite volleyball players in Spain about the injuries they sustained during the season for the purpose of assessing advanced injury preventative measures. The results of their findings were published in the Journal of Sport Rehabilitation.(1)

• Questions included:
  • A description of the types of injury the player sustained.
  • If the athlete had participated in prevention strategies.
  • The length of time injuries caused the athlete to sit out.
  • A description of the treatments received.

In total, 490 players provided answers.

• The injury prevalence was 66.9% (More than 2/3rds of elite volleyball players in Spain sustained injury)
• Most Spanish elite volleyball players participated in prevention programs during the season (90.3%) and played volleyball with low-top shoes (83.6%), but these factors were not associated with the prevalence of injuries
• The most injuries were the ankle, knee, and shoulder; the most common types of injury were sprains, tendinopathies, and strains, usually occurring during blocking and attack actions during the in-season period.

CONCLUSION: Despite most elite volleyball players participating in prevention programs, the results reveal a high injury prevalence. Further prospective research on the effectiveness of prevention strategies in elite volleyball is needed.

“Currently, there is no overview of the incidence and (volleyball-specific) risk factors of musculoskeletal injuries among volleyball players, nor any insight into the effect of preventive measures on the incidence of injuries in volleyball.”

In July 2017, Dutch researchers writing in the European Journal of Sport Science (2) wrote:

• “Currently, there is no overview of the incidence and (volleyball-specific) risk factors of musculoskeletal injuries among volleyball players, nor any insight into the effect of preventive measures on the incidence of injuries in volleyball.”
• “Our systematic review showed that musculoskeletal injuries are common among volleyball players, while effective preventive measures remain scarce. Further epidemiological studies should focus on other specific injuries besides knee and ankle injuries, and should also report their prevalence and not only the incidence.”

What is being suggested is that research preventing volleyball related injuries focus on the ankle and knee, very few other studies focus on other injuries.

Focus on the other volleyball injuries and how it impacts men and women differently

Writing in the medical journal Sports Health,(3) researchers from Harvard, Vanderbilt University School of Medicine and the University of North Carolina reported on injuries sustained by college level volleyball players. Their focus, the difference in injury in men and women.

• What was expected to be found was the high incidence of ankle and knee injury. What was surprising was the high level of concussion.

The researchers looked at medical records from injured volleyball players from the 2013-2014 through 2014-2015 academic years. They were looking for among other things, injuries that caused Time-Loss (Unable to participate injuries) and Non-Time-Loss injuries (Able to participate)

Injury rates:

Ankle injuries

• The ankle was the most commonly injured body part that resulted in Time-Loss from practice/matches:
  • men, 25.8%; women, 24.3%
    • Please see our related articles on treatment options chronic ankle sprain treatments, surgical and non-surgical options, and our article on ankle impingement syndrome.

Knee injuries

• the knee was the most commonly injured body part among No-Time-Loss injuries
  • men, 25.5%; women, 16.3%
    • We discuss various knee problems related to athletes and non-surgical treatments in these articles:
      • The degenerative process in overuse or active patients Chronic Knee Pain, Knee Instability, and Degenerative Knee Disease 
      • Jumper’s Knee – Non-surgical solutions to the problem of chronic and recurrent Patellar Tendinopathy

Other injuries including a concussion from ball contact

• Among injuries causing Time-Loss from game:
  • Sprains men, 25.8%; women, 31.2%
  • concussions, men, 19.4%; women, 14.8%.
  • Most Time-Loss from game concussions were due to ball contact
    • Men, 83.3%; women, 53.6%.

The researchers concluded that there are differences in injury patterns and rates between male and female intercollegiate volleyball players. Although a limited-contact sport, a notable number of concussions were sustained, mostly from ball contact.

Please see these articles as they relate to concussion and post-concussion syndromes:

• Post-concussion syndrome – In this article, Ross Hauser, MD., discusses Prolotherapy injection treatments to the neck to help patients suffering from post-concussion syndrome.
• Could Neck Injury Be the Culprit in Post-Concussion Symptoms and the Development of Chronic Traumatic Encephalopathy?

The degenerative state of the knees of volleyball players

German researchers give a very detailed analysis of knee derangements in adolescent and adult volleyball players in the Journal of Experimental Orthopaedics. (4) Brief highlights of their research are presented here.

• Men had a higher risk of bone spurs at the tibiofemoral joint (the joint space between the femur (upper leg bone) and the tibia (the larger of the two shin bones.) A reason female players are less likely to have bone spurs lies with the greater knee valgus  (Q angle) that decreases stress on the tibiofemoral joint.

Previous knee surgeries cause accelerated knee degeneration in volleyball players

• Cartilage lesions were present in 56% of the adult volleyball athletes at baseline and follow-up. This was considered high.
  • One reason? “One reason for this may be that 44% of the adults in our study had undergone prior knee surgery, which increased their risk of cartilage lesions. However, they were still able to participate in a high level of volleyball.”
    • Please see our article Knee articular cartilage surgery and non-surgical repair for a discussion of post-surgical knee degeneration.

Early stages of knee osteoarthritis found in adolescent players

• The beginnings of knee osteoarthritis were found in osteophytes found in 39% at baseline and 56% at follow up in adolescents.
  • Several of the volleyball athletes demonstrated subarticular bone marrow lesions, which consist of focal signals of abnormality in the subchondral bone marrow and are believed to be caused by capillary leakage caused by trauma, lesions, or increased intravascular pressure due to either increased blood flow to or decreased the venous clearance of the marrow space. This is in simple words is knee joint degeneration reaching deep levels.
    • Previous studies have found subarticular bone marrow lesions in asymptomatic athletes.
  • Subarticular cysts were found in 11% of adolescent and 28% of adult volleyball players at both baseline and follow up.
    • Previous studies have found subarticular bone marrow lesions in asymptomatic athletes.
  • Meniscal lesions were found in 28% of the adolescents at baseline and follow up, and in 56 and 61% of the adults at baseline and follow up, respectively.
    • The high prevalence found in the adult cohort is largely attributable to the fact that 5 adults (28%) had prior meniscectomies.
      • Please see our articles Knee Surgery for Meniscus Tears | Complications and Outcomes and Stem cell injections after meniscectomy for discussions on repairing and regrowing meniscus tissue after surgery.

Problems of the shoulder

Doctors from the Office of Research Integrity and Protections, Marshfield Clinic Research Foundation writing in the PM & R: the journal of injury, function, and rehabilitation (5) examined competitors at the 2006 National Intramural & Recreational Sports Association Collegiate Club Volleyball Championship. A total of 422 athletes returned questionnaires, of whom 276 also underwent a structured physical

• Study participants provided information on any history of volleyball-related shoulder pain or dysfunction.
• Approximately 60% of the participants reported a history of shoulder problems.
  • Attackers and “jump” servers were more likely to have shoulder problems than setters, defensive specialists, and “float” servers.
• Nearly half of the athletes who reported shoulder problems perceived some associated functional limitation, with female athletes reporting greater problems than male counterparts.
• Athletes reporting shoulder pain and dysfunction were more likely to have higher SICK scapula scores. Participants who demonstrated core instability also had greater SICK scapula scores and were more likely to report a history of shoulder problems.
  • Please see our article Snapping Scapula Syndrome for non-surgical options. Snapping Scapula Syndrome, also known as “Washboard syndrome,” Scapulocostal Syndrome or Scapulothoracic Syndrome, is characterized by a grating, grinding, popping or snapping sensation of the scapula onto the back side of the ribs or thoracic area of the spine.
  • Shoulder impingement syndrome – Surgeons tell patients to say no to surgery – What are your options?
  • Chronic Shoulder Dislocation Treatments – The non-surgical approach to dislocation and subluxation

Women’s collegiate volleyball athletes swing more during practices than in matches and it causes more shoulder injury

In February 2019, Athletic trainers at Lincoln University and the University of Kentucky examined the workload of a volleyball athlete in a season and the relationship between that workload and shoulder injury. They wrote of their findings in the February 2019 edition of the International Journal of Sports Physical Therapy.(6)

The research team examined:

• The hypothesis that significantly more swings will occur in practices compared to matches.
• The secondary hypothesis was that greater swing volume and greater musculoskeletal injury frequency will occur in the pre-season than during the season.

From the study: “Researchers observed practice and match videos and counted overhead serves and attacks of 19 women’s collegiate volleyball players for two seasons. Serves, overhead hits, and total swings (serves + hits) were the dependent variables; event (matches and practice) along with position (defensive specialists, setter, outside hitter, and middle blocker) were the independent variables. Musculoskeletal injury frequency and swing volume workload were compared across pre-season and competitive season time periods.”

Findings:

• Across all positions except outside hitters twice as many total swings occurred in practices compared to matches resulting in an average of 19 more swings in practice than in matches.
• The average number of total swings during the pre-season 47.1 was significantly greater than average swings per session during the competitive season 37.7.
• Conclusion: “These findings support the primary hypothesis that women’s collegiate volleyball athletes swing more during practices than in matches. The higher average number of serves in the pre-season and the greater frequency of musculoskeletal injuries requiring participation restriction or removal from participation suggest that a concordant relationship may exist between workload and injury variables.”

Prolotherapy for shoulder injuries

An unstable shoulder joint can strip an athlete’s swing or stroke of its power, and produce excruciating pain. This pain is a signal that the body needs repair to the shoulder region. Often this involves damage to the glenoid labrum, the supraspinatus tendon, or the rotator cuff tendon, among other shoulder structures. As these structures degenerate further with every practice or game, the pain typically worsens over time. With Prolotherapy, the goal is to stop and reverse the degeneration. The Prolotherapy injections stimulate repair of the painful shoulder joint, and its numerous attachments. As it heals, a person can continue to be active, making it an ideal option for shoulder pain in athletes.

Common diagnoses for which an athlete with shoulder pain would seek Prolotherapy include:

• Bursitis
• Frozen shoulder
• Glenoid labral tear
• Impingement syndrome
• Rotator cuff tear
• Shoulder instability
• Supraspinatus tear

Do you have questions about your volleyball related chronic injury? Get help and information from our Caring Medical staff.

1 Cuñado-González Á, Martín-Pintado-Zugasti A, Rodríguez-Fernández ÁL. Prevalence and Factors Associated With Injuries in Elite Spanish Volleyball. Journal of sport rehabilitation. 2018:1-27. [Google Scholar]
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4 Boeth H, MacMahon A, Eckstein F, Diederichs G, Schlausch A, Wirth W, Duda GN. MRI findings of knee abnormalities in adolescent and adult volleyball players. Journal of experimental orthopaedics. 2017 Feb 21;4(1):6. [Google Scholar]
5 Reeser JC, Joy EA, Porucznik CA, Berg RL, Colliver EB, Willick SE. Risk factors for volleyball-related shoulder pain and dysfunction. Pm&r. 2010 Jan 31;2(1):27-36. [Google Scholar]
6 Wolfe H, Poole K, Tezanos AG, English R, Uhl TL. VOLLEYBALL OVERHEAD SWING VOLUME AND INJURY FREQUENCY OVER THE COURSE OF A SEASON. International Journal of Sports Physical Therapy. 2019 Feb;14(1):88. [Google Scholar]

2028

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.