As both a physical therapist and a budding volleyball coach, I have become interested in the prevention and rehabilitation of the major types of volleyball injuries.  As coaches, parents or players, you probably have either a desire or a need to know some of the basics about volleyball injuries.  So, just A.S.K.!

     Ankle, shoulder, knee, that is.  Injuries occurring in the game of volleyball will most likely occur to these joints, in descending order of frequency.  Low back pain and finger injuries can also plague volleyball athletes, but I’ll save the former for another article and the latter for a good roll of tape.

     Let’s look at ankle injuries first.  The most common type of injury to the ankle joint is the inversion sprain, in which the lateral, or outside aspect of the ankle is suddenly stretched beyond its ligamentous limits when the foot is twisted toward the midline of the body.  This usually happens to players at the net in contact situations when they land on a fellow athlete’s foot but can also occur in non-contact situations in players with loose or lax joints.

     Pain and swelling can occur immediately, and depending on the severity of the sprain, may keep a player sidelined from several weeks to several months.  As for any joint sprain, the immediate treatment plan is “RICE”:  rest, ice, compression, and elevation.  This should be continued for at least the first 48 hours after the injury.  Non-weight-bearing range of motion exercises such as ankle pumps, ankle circles, and ankle alphabets should be initiated as soon as tolerated.  In the acute (first two weeks) and sub-acute stages of the injury, NO pain means lots of GAIN, so don’t push it.

     Players who experience a more severe ankle sprain that impedes the ability to walk normally for more than 10 to 14 days most likely need to seek medical attention.  A doctor may or may not prescribe physical therapy, but, if you specifically ask for it, you’ll get it in most cases.  A physical therapy evaluation and treatment plan will put you or your athlete on the right track for returning as quickly, and as safely, to the court as possible.  A review of research studies conducted between 1980 and 1998 summarized that balance training, which is a key component of ankle rehabilitation, reduces the incidence of ankle sprains in athletes with recurring ankle sprains to the same degree as in athletes with no history of ankle sprains¹.  So, get to a physical therapist and do your therapy!

     No discussion of volleyball ankle injuries is complete without the mention of bracing.  The same review mentioned above concluded that the use of either braces or athletic tape results in a decreased incidence of ankle sprains and in less severe injuries, but braces seem to be more effective.  However, it cannot be clearly concluded that all athletes—both previously injured and non-injured—benefit from these preventative measures.  Futhermore, a Fall 1999 article in “Volleyball USA” illustrated the dangers of over-use of ankle preventative bracing:  “(At) Disney's Wide World of Sports in Orlando, Florida, over 400 girls participated in a four-day tournament.  In that time frame, 17 volleyball players presented to medical staff for evaluation.  Of these, 15 had complaints of ankle injury.  All 15 had inversion sprains that occurred while at the net.  Contact was noted in almost every case that could be defined.  The unexpected item of interest was that 14 of 17 of the athletes were wearing braces on their injured ankle at the time of injury.  After discussions with the injured athletes, it was found that many of the teams considered the braces to be a part of their team's uniform.  At this point, the effectiveness of the braces comes into question.  Athletic trainers evaluated the athletes and several facts surfaced.  First, previous ankle injuries were noted in about half of the reported inversion sprains.  Second, a comprehensive rehabilitation program was not given to these athletes.  The third discovery was that four of the girls wore braces that did not fit them.  One of these girls had developed a sub-acute compartment syndrome directly from the lateral upright of the brace.”

     My personal feeling on this issue is that if you or your athlete has a history of ankle sprains, wearing a preventative brace and undergoing physical rehabilitation are imperative, especially for middle hitters/blockers.  If not, the decision becomes one of personal preference more than of physical need.

     Shoulder injuries in the game of volleyball typically evolve from the repetitive stress of overhead spiking and serving.  Studies have shown that the shoulder joint, which is inherently unstable due to its anatomy, rotates at angular velocities of over 4000 degrees per second during spiking.  There is more than 80 pounds of force exerted on the anterior or front of the shoulder by the head of the humerus during a spike.  The rapid deceleration of these forces required for performing the shortened follow-through motion of spiking also places tremendous stress on the biceps muscle at its proximal attachment in the front and top of the shoulder.

     Rotator cuff and/or bicipital tendonitis and shoulder impingement syndrome are the most common results of these repetitive motions.  These conditions tend to respond very well to a physical therapy protocol using modalities such as ultrasound, electrical stimulation, and ice, along with specific shoulder musculature strengthening activities.  More severe injuries such as traumatic dislocation, rotator cuff tears, or cartilage tears (known as “SLAP” lesions) are also seen.  SLAP lesions are becoming increasingly common in volleyball, most likely due to the ever-increasing force with which both men and women are able to attack the volleyball.  These latter conditions generally require surgical repair.

     One of the key factors involved in rehabilitating any shoulder injury, whether post-surgical or not, is strengthening of the stabilizer muscles of the posterior shoulder joint, the scapular muscles.  The rhomboids, middle and lower trapeziums, and latissimus dorsi muscles, as well as the rotator cuff muscles (infraspinatus, supraspinatus, subscapularis, and teres minor) are nearly always weaker on the injured side as opposed to the other side.  This often leads to a “sick scapula” condition in which the involved shoulder blade can be noted to tilt up and off the rib cage at an unusual angle.  The shoulder blade is the foundation for all movements occurring at shoulder joint.  If the shoulder blade is floating around on the rib cage uncontrollably due to muscle imbalance and weakness, increased strain is placed on the rotator cuff tendons and the shoulder joint ligaments.  Even the elbow can take the brunt of the altered forces caused by muscle imbalances around the shoulder blade. 

     This “sick scapula” can be detected in volleyball players quite easily using a pre-season screening format.  Proper training and conditioning of athletes with this problem can very likely prevent rotator cuff tendonitis and other conditions from benching a player.  If you as a parent or coach notice that the hitting shoulder blade of your player looks different from the other, especially in a painful shoulder, have a physical therapist or other sports medicine specialist evaluate your player for “sick scapula.”

     Lastly, let’s discuss the knee.  Sports medicine research conducted over the past 10 years has clearly documented the fact that the female adolescent athlete has a four to six times greater chance of knee injury than her male counterpart.  What is not so clear yet is the exact reason for this injury rate difference.  Theories have been developed around three main ideas:

At this point in time, more research is pointing to the neuromuscular differences between boys and girls as the primary contributing factor.

     Three common neuromuscular deficits have been identified in female soccer, lacrosse, basketball and volleyball players.  These deficits include ligament dominance, quadriceps dominance, and leg dominance.  The first, ligament dominance, defines the tendency of the female athlete to depend on knee ligament structures rather than the muscular system to absorb ground reaction forces during medial/lateral knee motion.  This is commonly seen in the “knock kneed” or valgus landing position of jumping athletes.  Quadriceps dominance is the tendency to activate the large muscle group in the front of the thigh rather than the hamstrings, located in the back of the thigh, to control knee stability during high torque movements.  Leg dominance refers to the side-to-side imbalance of strength and coordination with the deficit generally occurring in the non-dominant side hamstrings.  Observing incorrect jumping and landing strategies in the athlete can identify the latter two factors.  Landing “loudly,” flat-footed, straight-legged, or one-legged are all signs of potential deficits.

     This is the bad news.  Happily, there is good news.  Research conducted by sports physiologists such as Timothy Hewett at the Cincinnati Children’s’ Sports Medicine Biodynamics Center has shown that the effects of specific neuromuscular training can significantly lower serious knee ligament injury rates.  In fact, trained females were found to have a lower incidence of injury than of untrained males.  This important discovery is noteworthy for two reasons:  one, this means that female athletes can be taught proper techniques by coaches and trainers to help prevent knee ligament injuries; and, two, the lack of proper training can lead to serious injuries that can either temporarily or permanently interfere with the athlete’s ability to perform in her chosen sport.  This points to the important fact that volleyball coaches need to be aware of how their players are performing some basic skills of the game.

     What does this “specific neuromuscular training” involve?  Plyometric training in a physical therapy or sports conditioning clinic would certainly be indicated for athletes demonstrating one or more of the above neuromuscular imbalances.  But simple coaching techniques that are reinforced in every practice session can also make a difference.  The following four cues can be stressed to all players, but particularly to those who perform repetitive jumping:

• Jump from a low, crouched position with hips and knees bent
• Jump and land with hips, knees, and middle toes in vertical alignment (no knock-kneeing)
• Land softly, “like a feather,” with a toe to mid-foot rocking motion
• Jump up exploding like a spring and land like a shock absorber

      One last note:  All players can benefit from core conditioning focusing on optimizing the strength and control of the deep abdominal, back, buttock, and inner thigh muscles.  This is one type of exercise that can both prevent and rehabilitate all of the “A.S.K.” injury types.