Volleyball is the world’s most popular participation sport. The Federation Internationale de Volleyball (FIVB), volleyball’s international governing body, reports that over 800 million people worldwide play volleyball. Individuals of all ages and skill levels can enjoy the sport. Athletes in over 200 countries play volleyball and almost half of these countries compete at the international level.
According to USA Volleyball, the national governing body for the sport in the United States, there were 34.1 million players in the U.S. in 1998.
Volleyball players must combine vertical and horizontal motion. These athletes must utilize lateral, backward, forward and rotational motion complemented with jumps. The physical properties of the playing surface can further accentuate these demands. Given the growth of beach volleyball as well as court (indoor) volleyball, there are injuries that are distinct to each and common to both.
Given the popularity of the sport, the number of players and the potential rigors of the game, podiatrists can expect to see both acute and overuse injuries. Familiarity with injuries common to volleyball is necessary to facilitate appropriate diagnosis, treatment and rehabilitation as well as prevention.
Most volleyball injuries are related to blocking or spiking, both of which involve vertical jumps. The most common acute injuries in volleyball are ankle sprains. Common lower extremity overuse injuries include patellar, Achilles and peroneal tendonitis, patellofemoral syndrome and plantar fasciitis. Hyperextension and hyperflexion injuries of the toes also occur commonly.
Studies have shown that inversion or lateral ankle sprains account for 15 to 60 percent of recorded injuries in volleyball athletes. 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.
When this happens, the usual result is an inversion injury to the lateral collateral ligament complex of the blocker’s ankle. This injury occurs more often indoors because of the increased coefficient of friction between the floor and the athlete’s shoe. Furthermore, there are more players on the court with indoor volleyball (six players on each side) and they utilize side-to-side blocking techniques, which increase the risk of injury. In the beach player population, the combination of a more forgiving surface and the increased proprioception and tendon strength in a shoeless foot decreases the incidence of lateral ligamentous injury.
Grade 1 and 2 ankle injuries are more common than grade 3 injuries. One can treat the grade 1 and 2 injuries by emphasizing aggressive early weightbearing and range of motion, and progressing to strengthening and proprioceptive retraining exercises prior to a return to play.
As with all ankle sprains, the most important initial treatment is protection, rest, ice, compression and elevation. How long the athlete should use this regimen depends on the severity of the injury. Typically, the treatment lasts only a few days until edema subsides. The biomechanical ankle platform system (BAPS), tilt board or ankle discs can strengthen and restore balance. Functional exercises should begin with low-impact activities and advance to cutting and jumping activities. These athletes commonly use ankle braces, taping and high-topped shoes to provide stability to the ankle and prevent further injury.
The most common overuse injury reported in volleyball athletes is patellar tendinitis or “jumper’s knee.” Jumping to hit or block the ball requires a high rate of force development in extension and external tibial rotation, stressing the patellofemoral joint and tendon. Furthermore, eccentric loading of the quadriceps during landing can also compromise these tissues. Repetition of these mechanical stresses can cause microtears, irritation and inflammation, resulting in symptoms of pain and swelling localized to the lower pole of the patella, or less frequently, the upper pole of the patella or the tibial tuberosity.
Patellofemoral syndrome is also a common, overuse, knee-related injury in volleyball. Abnormal tracking of the patella within the femoral groove can cause irritation of the articular surface of the patella and inflammation of the femoral groove. Repeated, forced extension of the knees, as one may see in hitters and blockers, or the demands placed on the knees of defensive specialists can stress the patellofemoral joint. This is especially the case if the patella is not aligned properly within the femoral groove. The etiology of patellar malalignment is often an increased Q angle, which results in lateral tracking of the patella.
This situation is further complicated by anatomic variants such as genu valgum, genu recurvatum, patella alta, pronated feet, wide pelvis and external tibial torsion. Inflexibility of the iliotibial band or a weakness in the oblique portion of the vastus medialis can also result in lateral tracking of the patella. Give special attention to female athletes because they are more susceptible to these tracking abnormalities. Athletes who have patellofemoral symptoms experience pain with jumping and squatting. Stair climbing or sitting for long periods also increase knee pain. Crepitus and a patellar grind test are indicative of patellofemoral stress syndrome.
Managing these overuse injuries begins with ice and antiinflammatory medication. Paying close attention to patellar tracking is necessary to rule out any anatomic abnormalities, especially in the female athlete. Emphasizing exercise techniques to strengthen and improve recruitment of the vastus medialis can improve medial patellar stability. Using patellar mobilization techniques, iliotibial band stretching and foot orthoses to correct hyperpronation can also help re-establish lateral patellar mobility. Be sure to initiate hamstring and quadriceps flexibility and strengthening exercises. Taping, patellar stabilizing braces and patellar straps can also help to reduce pain.
To help prevent patellar tendinitis, identify players who are at increased risk. Those who generate the greatest power during jumping and have the highest vertical jumps have been found to be at the greatest risk. 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. Coaching these athletes in proper jumping technique may reduce the likelihood of these injuries.
Achilles tendinitis is another common overuse injury among volleyball athletes and occurs more frequently with indoor players. The repetitive eccentric loads of jumping, particularly on hard surfaces, can cause microtears within the tendon. Tight hamstrings, tibial varus, pes cavus and a tight gastrocnemius-soleus complex also predispose these athletes to tendinitis. Athletes will complain of pain while jumping or running that increases over time. Clinicians may detect tenderness, localized swelling, thickening, and crepitus upon palpation. Strength testing may reveal weakness in plantarflexion.
When it comes to treating these injuries, one should ask athletes to reduce their jumping activities, properly stretch the gastrocnemius-soleus complex and use taping to reduce dorsiflexion. Clinicians can add a 1/4- inch to 1/2-inch heel lift to each shoe to reduce stress on the tendon. As symptoms subside and flexibility increases, one can allow a slow progression back to jumping activities. Leave the heel lifts in the shoes for the first seven to 14 days of practice to offer some shock absorption and protection to the Achilles tendon.
The practitioner should always be aware of the possibility of a ruptured Achilles tendon. One would make this diagnosis with a positive Thompson test and/or a palpable tendon defect, and should confirm this with a MRI.
Peroneal tendinitis is often present in volleyball athletes with pes cavus feet. Frequent dorsiflexion and eversion movements while setting and playing defense are the usual causes. Tenderness, inflammation and crepitus may be palpable along the peroneal tendons and range-of-motion testing will reproduce symptoms of pain. Treatment includes ice, compression, elevation and antiinflammatory drugs for pain management. Initiate exercises to strengthen the peroneal musculature. One can use arch taping, foot orthoses and foot wedges to aid in correcting biomechanical abnormalities.
Plantar fasciitis is common in volleyball athletes because of the repetitive jumping required for the sport. The surface and type of shoe can also contribute to this condition. Athletes who practice on hard surfaces without adequate arch support are predisposed to plantar fasciitis. Other contributing factors include a tight gastrocnemius-soleus complex, a tight longitudinal arch and excessive subtalar joint pronation. With indoor athletes, one can treat this with an appropriate pad, heel wedge and/or foot orthoses. The only way to treat these injuries in beach volleyball, which is played barefoot, is to employ an appropriate supportive taping on the foot. Prevention begins with a stretching regimen, offseason conditioning, correct jumping technique and pronation control.
Hyperextension injuries of the great toe (turf toe) and lesser toes occur in both indoor and outdoor volleyball athletes. Employing taping techniques to prevent hyperextension can ameliorate this problem. Avoid ongoing hyperextension trauma since it can lead to hallux rigidus. When treating the indoor player, conservative treatment of hyperextension injuries includes the use of a stable, stiff-soled shoe and appropriate foot orthoses. Taping is the mainstay for beach volleyball players.
Hyperflexion injuries to the toes are rare indoors. It is common to have the toes fold plantarly when landing following a jump on uneven terrain (sand). Taping can prevent reexacerbation of this problem. Capsulitis and synovitis of the metatarsophalangeal joints may become chronic in addition to joint laxity. In chronic symptomatic cases that do not respond to conservative treatment, performing a synovectomy or surgical ligament or capsular repair may be indicated.
Dr. Caselli is a Staff Podiatrist at the VA Hudson Valley Health Care System in Montrose, N.Y. He is also an Adjunct Professor at the New York College of Podiatric Medicine and is a Fellow of the American College of Sports Medicine.
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