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Spiking injuries out of volleyball: A review of injury counter measures

Monash University Accident Research Centre - Report #181 - 2001

Author: Erin Cassell

Abstract:

The Australian Bureau of Statistics (ABS) estimates that in 1999-2000 approximately 150,000 Australians aged 18 years and older (including 46,000 Victorians) participated in organised and unorganised volleyball. Volleyball was ranked 26th in the table of most-played sports and physical activities by adults in Australia (22nd in the table for Victoria).

There is no one comprehensive source of data on injury in volleyball in Victoria or elsewhere. Injury data were extracted from a range of sources for this review including the ABS, Victorian hospital admissions and emergency department databases and Australian and overseas published studies. The weight of evidence indicates that volleyball has a lower risk of injury than all football codes, basketball and some high-risk recreation activities, for example horse riding and skiing. Studies uniformly report that sprains and strains (predominantly ankle sprains) account for approximately two-thirds or more of volleyball injuries. The ankle, hand/finger, knee and shoulder are the most common sites of volleyball injuries.

The overall aim of this report is to critically review the formal research literature and informal sources that describe measures to prevent volleyball injury and to assess the quality of evidence supporting claims of effectiveness. There are few formal evaluations of countermeasures to injury in volleyball so our review was extended to include countermeasures in other team ball sports that may be applicable to volleyball.

Recommendations in this report include: extension of pre-participation evaluation; improvements to education and training for players and coaches, particularly at the wider community level; promotion of modified games for children; consideration of conditioning and exercise programs to prevent ankle and knee injuries (ankle disc and plyometric training); training in specific skills and techniques; use of ankle and finger taping and bracing; provision of appropriate and prompt first aid by trained personnel; improvements to injury data collections; and further epidemiological, biomechanical and laboratory research into the causes of volleyball injuries and measures to prevent them.

Volleyball requires a variety of physical attributes (speed, power, flexibility, strength and balance) and specific playing skills. Therefore, participants need to train and prepare to meet at least a minimum set of physical, physiological and psychological requirements to cope with the demands of play and reduce the risk of injury.

Executive Summary

Volleyball is a very popular international sport. The International Volleyball Federation (Federation Internatonale de Volley-Ball - FIVB) claims 800 million participants world-wide who play at least once a week. If this number is accurate then volleyball ranks as the world's most popular participation sport (Briner & Kacmar 1997).

The Australian Bureau of Statistics (ABS) estimates that in 1999-2000 approximately 150,000 Australians aged 18 years and older (including 46,000 Victorians) participated in organised and unorganised volleyball. Volleyball ranked 26th in the table of most-played sports and physical activities by adults in Australia (22nd in the table for Victoria).

The weight of available evidence indicates that volleyball has a lower risk of injury than all football codes, basketball and some high-risk recreation activities, for example horse riding and skiing. Studies uniformly report that sprains and strains (predominantly ankle sprains) account for approximately two-thirds or more volleyball injuries. The ankle, hand/finger, knee and shoulder are the most common sites of volleyball injuries.

The countermeasures that are considered in this report include:

extension of pre-participation evaluation;
education and training for players and coaches, particularly at the wider community level;
modified games for children;
conditioning and exercise programs to prevent ankle and knee injuries (ankle disc and plyometric training);
training in specific skills and techniques of the game;
personal protective equipment, particularly the relative effectiveness of taping and bracing to prevent ankle, knee and finger injuries;
first aid and rehabilitation;

Data and research needs are also articulated.

Summary of Recommendations

RECOMMENDATIONS FOR PLAYER SAFETY: GENERAL

Screening, conditioning and fitness programs

Pre-participation evaluation

Extend pre-participation evaluation (and associated individually tailored conditioning and training programs) to a wider group of higher-level senior and junior players and evaluate the protective effects of these programs.

Training and conditioning

Simple pre-season fitness testing should be conducted on players participating in competitive volleyball at the inter-club level, four to six weeks prior to the start of the season.
All competitive and recreational volleyball players are advised to undergo a graduated skills development and training program (which includes cross training) guided by results of an initial fitness test.
Players should consult an accredited coach on their individual training requirements.
Coaches should vary training routines and concentrate on developing players' technical skills in training sessions.
Initiatives to increase the awareness of players and coaches of the injury consequences of training errors (including over-training) should be continuously developed, and refined as new knowledge becomes available.

Warm-up and cool down

All players should routinely warm-up and cool down before and after every game and training session. On the basis of current research, the inclusion of stretching exercises in warm-up does not reduce the risk of injury.
The specific needs of the players recovering from injury should be considered when warm-up and cool down regimes are developed.

Environmental safety measures

Extreme heat policy and rules need to be developed at the association level for both beach and indoor games.
All beach volleyball clubs and outdoor events managers should provide umbrellas or shaded areas and ice-chests on court, and ensure that water and 'sports' drinks (with 4%-8% carbohydrate content) are available.
Beach and indoor players, particularly when participating in tournaments, should monitor their fluid intake during games by weighing themselves or by noting any reduction in the amount and concentration of urine output in relation to fluid intake (oliguria). Players should replace fluid and electrolyte loss by consuming 400-600 mls of fluid (2-3 standard glasses) at least 30 minutes before play, 200-300 mls (1-2 glasses) every 15 minutes during play (at change of ends) and more than they are thirsty for after activity (at least 500 mls).
Education and signage about measures to prevent heat illness should be provided at the club level.
Players playing outdoors should use a broad-spectrum sunscreen and hat, even on cloudy days.
Clubs, in association with venue owners and managers, should develop, implement and monitor risk management/sports safety plans. These should include measures to eliminate or ameliorate environmental and other injury hazards. Guidelines and support for the development of these plans should be available from sports associations.
The playing surface should be checked for cracks, holes and debris prior to play and defects remedied.

Training and education of coaches and officials

Accredited coaches and sports trainers should be available at every club to advise and monitor the skills development of players at all levels of play (competitive and recreational).
All coaches and sports trainers should undergo training and re-accreditation through Volleyball Australia and state divisions.

Modified games for children

Volleyball Victoria should continue to promote the adoption of modified rules volleyball games for children in schools, recreation venues and junior volleyball clubs.

First aid, treatment and rehabilitation

All players should be taught the RICER, NO HARM regime, through schools and volleyball associations and clubs.
Players should seek prompt attention for injuries from a sports medicine practitioner and allow enough time for adequate rehabilitation before returning to their pre-injury level of activity.
Event organisers and clubs should ensure that there are qualified first aid personnel/sports trainers at all training sessions, competition match days and events.
Clubs should have a well-stocked first aid kit and a supply of ice-packs.
Players with serious acute and chronic injuries should seek advice from a medical practitioner trained in sports medicine on appropriate treatment and taping or bracing if recommended and rehabilitation regime.

RECOMMENDATIONS FOR PLAYER SAFETY: SPECIFIC TO ANKLE, KNEE, SHOULDER AND HAND/FINGER INJURIES

Preventing ankle injuries

Associations should consider the introduction of a stricter netline violation rule to reduce foot conflict under the net.
Players with ankle sprains should complete supervised rehabilitation before returning to competition.
Players who have suffered a moderate or severe sprain should wear an appropriate orthosis (brace) for at least 6 months and, preferably, twelve months.
Players with unstable ankles should consider prophylactic bracing and taping for training sessions and matches. There is evidence to suggest that bracing is more effective, cost effective and convenient than taping, and does not interfere with performance.
Specialist blockers, particularly the middle blocker, should consider prophylactic ankle bracing (or taping).
Coaches should introduce drills which train players in the following techniques:
- taking a quick and long last step when trying to reach a 'tight' set rather than trying to 'outjump' the ball (which carries a higher risk of foot conflict under the net with opposing players); and
- reducing side-to-side movement and using proper take-off technique when setting one-man and two-man blocks.
Ankle disc (balance board) training should be trialed and evaluated by volleyball clubs.
Playing shoes should be in good condition.
Training should be conducted on sand, wood or synthetic 'forgiving' surfaces, not concrete or linoleum.
Playing surfaces should be diligently maintained and regularly checked for hazards such as hollows, cracks and wear.

Preventing knee injuries

Indoor volleyball should be played on wooden floors (or synthetic floors with similar elastic properties). Playing on hard surfaces (for example concrete or lino) should be avoided.
Serious competitors should use cross training to limit the amount of training involving repetitive stresses on the knees.
Knee pads should be worn in training and match play to prevent acute knee injuries and the acute exacerbation of overuse injuries.
All players, especially female players, should be trained to 'land softly' on the balls of their feet with knees and hips flexed.
Coaches should consider introducing balance board training, particularly for female players and players with knee instability.
A plyometric (jump training), stretching and strength training program should be considered for all players to decrease peak landing forces, and particularly for female players to correct imbalances between hamstring and quadriceps muscle strength. Plyometric training should be under the supervision of a trained coach and programs should be carefully evaluated.
Players who are already proficient jumpers, middle blockers and players with knee pain are advised to decrease their jump training time and pay close attention to technique.

Preventing shoulder injuries

All players, especially attackers and beach volleyball players, should include specific exercises to strengthen the shoulder in external rotation and increase the flexibility of internal rotation of the rotator cuff.
Beach volleyball players should include spike co-ordination training drills with the shoulder joint held in different rotations.

Preventing hand/finger injuries

All schoolchildren and new players should be introduced to the game progressively with the proper techniques for each of the basic volleyball skills taught and practiced in a controlled environment prior to full participation. Junior players should progress to regular volleyball through the modified "Volleystars" and mini-volleyball programs.
Players should not wear rings or other jewellery. Coaches and match officials should strictly enforce this ban.
Hand/finger injuries should be immediately treated with ice and assessed by a medical practitioner within 24 hours.
Coaches and trainers should be alert to the potential long-term adverse effects of hand/finger injuries and advise players against 'playing on' with hand/finger injuries.
Buddy taping or, preferably, a finger brace should be worn in both practice and games (if permitted within the rules) until symptoms resolve, which may be several months.

RECOMMENDATIONS FOR FURTHER RESEARCH AND COUNTERMEASURE DEVELOPMENT

General injury data, risk factor identification and risk management research needs

Volleyball associations should establish an injury reporting system for the documentation of volleyball injuries. All data collections should conform to national guidelines for sports injury surveillance (the Australian Sports Injury Data Dictionary).
Action needs to be taken to improve the quality and specificity of data on sports injuries collected through the Victorian hospital system.
Further epidemiological research is needed to determine the risk factors for volleyball injury and to evaluate the effectiveness of countermeasures.
Current work by volleyball associations on guidelines for minimum safety requirements for organised volleyball should be expedited.
A cost of sports injury study is required to determine the overall cost of sports injury and the relative cost of injuries for different sports.

Research needs associated with general injury prevention measures

Pre-participation evaluation

Continue to research assessment measures that are volleyball-specific to improve pre-participation evaluation instruments.
Systematically evaluate the injury prevention efficacy of the current pre-participation evaluation program for elite players.

Training and conditioning

Controlled evaluation studies should be conducted to determine 'best practice' conditioning and training programs that develop the skills and fitness necessary for competitive volleyball and protect players from injury.

Warm-up and cool down

The protective effects of warm-up, stretching and cool-down require further evaluation in controlled trials in specific sports populations.

Environmental safety measures

Research should continue on player diet and hydration issues.
The injury prevention effect of the implementation of club and association sports safety plans should be evaluated.

Training and education of coaches and officials

Continuous systematic evaluation of the effectiveness of coach and sports trainers' education/training programs should be maintained.

Modified games for children

Research to determine the appropriate age/stage of physical and skills development for children to graduate from modified to full participation in volleyball.
The pattern of child injury in volleyball needs to be better reported and monitored to enable the development and evaluation of current skills development and modified rules programs.

First aid, treatment and rehabilitation

Further research and evaluation of first aid and rehabilitation programs are required, to develop optimal regime for recovery and return to play.

RESEARCH NEEDS SPECIFIC TO THE PREVENTION OF ANKLE, KNEE, SHOULDER AND HAND/FINGER INJURIES

Ankle injuries

Further studies, preferably using a randomised controlled design, should be undertaken to better establish the clinical effects of braces, ankle disc training and training drills in ankle sprain injury reduction.
Further laboratory and controlled field research is needed to determine the optimal safety performance values for volleyball shoes and playing surfaces.

Knee injuries

Population-based studies to determine gender-specific risk factors for non-contact ACL injuries.
Further epidemiological, biomechanical and laboratory studies to clarify the role of intrinsic risk factors in non-contact ACL injuries and establish countermeasures to ACL injury.
Research to better identify high-risk player positions and player manoeuvres for ACL injury and to develop protective neuromuscular responses when high-risk situations are encountered.
Research to better understand the influence of playing surface and shoe-surface interaction on knee injury.
A randomised controlled trial (in a population with no foot pain) to test the advantage of placing the foot in a supinated or neutral position rather than a pronated position when playing sport. Such a trial would have the capacity to establish the significance of pronation in overuse injury and the clinical value of an orthosis.
Evaluation studies, preferably controlled trials, to determine the effectiveness of strategies and countermeasures to knee injuries in volleyball.

Shoulder injuries

In-depth research on the incidence, patterns, mechanisms and consequences of shoulder injuries in volleyball at all levels of play with a view to developing specific countermeasures
Controlled investigations on the optimal preventive and rehabilitative exercise programs to prevent shoulder overuse injuries.

Hand/finger injuries

In-depth research on the incidence, patterns, mechanisms and consequences of hand/finger injuries in volleyball at all levels of play with a view to developing specific countermeasures, for example protective gloves for new players and other players at higher risk of injury.
Controlled investigations on the optimal treatment and rehabilitation regimes for different types of hand/finger injury including the amount of rest from play that is advisable.
Controlled trial of the most effective type of protective support for the hand/finger (tape or brace) to prevent re-injury on return to play.

Sponsoring Organisation: Sport and Recreation, Victoria

Spiking injuries out of volleyball: A review of injury counter measures

Abstract:

Executive Summary

Summary of Recommendations

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