Rotator cuff injuries are the Achilles heel in volleyball. Not only difficult to heal, they require lots of rehab and can force you into early retirement. As with many medical conditions, most have heard of this but few know what it is. The rotator cuff is a series of four smaller muscles originating on the top and back of the shoulder, which wrap over the front. These muscles all end in tendons, which attach to the anterior surface of the shoulder in the same area, resembling a cuff. Although small in size, they are in charge of fine movements of the shoulder, primarily of rotation - hence their name. Irritation of these tendons creates inflammation, yielding tendonitis, or worse, the dreaded tear.

The shoulder is more apt for injury by the nature of its design. It is a typical ball and socket joint, but the socket is much shallower then similar joints, causing the muscles, tendons and ligaments increased wear and tear - a tradeoff for more flexibility and movement. Diagram #1 shows the rotator cuff muscles, originating from the shoulder blade and ending on the humorous. The muscles found behind the shoulder act to rotate the shoulder backwards. When you are engaged in a high velocity swing after hitting a ball, these muscles get stretched as the arm decelerates, and may tear. The most common problem by far is the supraspinatus muscle, found on top of the scapula. It sits in a gully on top of the scapula and feeds through a tunnel underneath the coracoacromial ligament (diagram #2). This muscle initiates the action of pulling the arm up, until stronger muscles can take over. The problem arises when the arm gets to 90 degrees or higher. The tendon of this muscle gets pinched under this ligament, causing friction and impingement (diagram #3). Normally there is enough room when the arm is under 90 degrees, but in volleyball, the arm is raised not only when attacking the ball, but also with blocking and serving. This could account for hundreds of times of potential irritation in a single night of playing. Volleyball is not the only culprit; our sport shares the same pathology with competitive swimmers and pitchers. Luckily for us, the tendons and muscles are pretty durable, and can tolerate a fairly good amount of abuse. It is the overuse of an irritated tendon with constant playing that leads to further degeneration, and ultimately to a tear. Additionally, a sudden fall on an outstretched hand or collision involving the shoulder could be the cause of rotator cuff pathology.

There are many pain locations and conditions in the shoulder that are directly related to trauma associated with volleyball, hence self-diagnosis is difficult. It is always best get an evaluation by a Doctor with a good sports injury background. Generally, the pain with rotator cuff injury presents as a sharp, stabbing pain initiated with movement. It may later progress to a dull achiness deep within the joint. The mechanism that produces pain in the tendon starts with localized trauma or friction, which leads to intermittent swelling. As the frequency of swelling continues, the blood supply to the tendon gets squeezed off due to compression. This condition now is considered tendonitis, or inflammation of the tendon. This continual disruption of blood flow and chronic irritation leads to a fragmentation and rearrangement of fibers within the tendon, thus weakening it. Ultimately, this leads to a partial or total tear of the tendon. If the rotator cuff is completely torn, there is no choice - you need surgery. Partial tears, irritation, inflammation or impingement syndrome should all start with conservative care. And this always begins with rest.

REST No condition will get better if you are constantly irritating it. Inevitably, everyone learns that the only way to fully heal is to pull back from playing and let Mother Nature take over. This is the hardest concept for younger players to learn, because they are used to their body always getting better no matter what they do to it. This condition will not go away unless proper steps are taken. One initially does not need to completely retire from playing, instead, cut down to once per week and see if you can get any response while following the rest of this program. If all else fails, you need to stop playing altogether for a few months.

SAVING THE SHOULDER Closely associated with the concept of rest is taking it easy on the shoulder if you are still playing. Start with a thorough warm up. This includes stretching, throwing the ball a dozen times, and range of motion arm swings before play. Next, you need to train your other arm to hit the ball whenever possible. Some great players have been made by putting this concept to use. Third, swing only at good sets. Shoulders are ruined by power swings at poorly placed sets. Roll or dink the ball instead. Lastly, incorporate a shoulder saving serve, such as a floater, Asian serve or an underhanded skyball. Jump serves look pretty, but they tear up injured tendons with frequent use.

REDUCE INFLAMMATION This of course starts with rest, but is best accomplished with ice. Ice calms down swelling and is a great painkiller. You must ice the shoulder after every time you play, with two ten - minute applications of ice separated by half an hour. Shoulders don’t really respond well to heat, so ice is consistently used. The reusable blue gel ice packs are great, and every player should have a few of these tucked in the freezer. When at a tournament, a zip lock baggy filled with ice cubes or the commercial ice bag with harness (i.e. Body Glove) is the best. Non steroidal anti- inflammatory drugs (NSAIDS) such as Ibuprofen, Aspirin or Naproxen are quite valuable, and should be used in the early phases to calm the inflammation, but not for extended use as many players do. Along the same lines are proteolytic enzymes as a nutritional supplement from health food stores. These work much like NSAIDS, but are the latest product out and are totally natural. Lastly, a good Calcium/magnesium supplement should be considered, as these are the main component of tendons and will speed up the healing process.

STRETCHING PROGRAM The idea behind stretching is to increase the length of an injured muscle. All muscles undergo shortening once they are injured, as is evidenced by a decrease in the range of motion as compared to the normal shoulder. The following stretching program should be done daily, initially twice per day:

1. Place your hand on the opposite shoulder. With your free hand, pull the elbow to further stretch the posterior shoulder. Hold 1 min.

2. With both arms extended over your head (as in blocking), slowly stretch each hand higher to its maximum length. 20 apiece.

3. Arm behind your back, following up your spine as much as it can go. Rotator cuff injuries will not be able to move as high as the healthy arm. To further aid this stretch, hold a towel with the good hand over your head, grab the other end with your bad hand (shoulder) and pull up with the good hand slowly, to increase movement.

4. Place your arm over your head, resting your forearm on your head. Bend to the opposite side until you feel a stretch in the shoulder. Hold for 20 seconds, repeat.

EXERCISES Exercising works by putting a controlled load on the damaged muscle or tendon, forcing the body to accelerate repair of that area. There is however, a fine line between therapeutic exercise and overdoing it, which recreates tissue damage. The series of exercises illustrated help to strengthen and repair the rotator cuff. These exercises can be done with hand weights, or with surgical tubing, which is basically a strong rubber band that offers resistance. You should do these exercises until the point of pain, and stop if they create anything beyond minimal pain. The best program is run 3-4 times per week, and must continue for several months. Once healing occurs, you should continue this program indefinitely. Rick Bahr (Medical Director of the Bud Light Tour) elaborated on a program used for the pro beach athletes as well as our national team. Along with their drills and volleyball workouts, they are all encouraged to hit the gym several days a week, as an attempt to protect valuable body parts. For rotator cuff, his advice is to use gym machines that force you to pull towards you. Pushing away (i.e. bench press) should be avoided. Pat Powers, the famed veteran of an Olympic gold medal and former AVP player, is also a veteran of shoulder surgery. His advice on keeping healthy: “Work extra hard at keeping the shoulder strong through the year, and you should never have to worry about surgery.”

ANKLE SPRAIN

Bryan Collier, D.C., C.C.S.P.

A sprained ankle is every player’s nightmare. Just the thought of landing wrong on the ankle and the pain that follows is sure to bring a shutter to those who have experienced it. And if you haven’t experienced it, law of averages says you will within five years, considering frequent play. I recall talking with a fellow player a few years back about injuries, and was amazed to hear that while playing 4-5 times per week, he had never sprained an ankle in his 5 years of volleyball. Two weeks later, he developed one of the worst ankle sprains I have seen to date.

Without question, this is the most common injury in Volleyball. In the course of a game, the ankle is carrying the full body weight and is forced repeatedly to cut and pivot. Due to the weakness of its anatomical design, these motions often times push the joint beyond the normal range of motion, thus creating injury. The ankle joint is intended to move only up and down and tilt slightly inward and outward. Rolling the foot outward jams the top of the ankle into the end of the fibula. Because the fibula is longer than the tibia, it is easier to roll the foot inward than outward. This is the mechanism of injury to the ankle. When excessive inward rolling occurs, the anklebone is forced or pried out of the ankle joint. What normally restrains the ankle from allowing this to occur is the ligaments. It is the ligaments on the outside of the ankle that get the brunt of the injury. Depending on the severity of the rolling, the ligaments either get stretched or torn. The rolling or turning of the ankle most commonly occurs by either stepping into a pothole on grass or by coming down a player’s foot while blocking or hitting. The symptoms take place immediately. Because the ligaments and surface of the bone are laden with nerves, pain occurs spontaneously. Usually you can walk off the pain in the next five to ten minutes. Your ankle then goes into a period of pain-free ”shock” for approximately 30 minutes, where swelling, spasm and pain are minimal. This gives most players a false feeling of security, and continuing into play often times exaggerates the injury. What follows next is severe pain and swelling, usually located over the outside end of the fibula. Muscle spasm develops as a defensive mechanism to protect the joint from further injury.

There are three grades of ligamentous injury. Grade One is a stretching of the ligament, which has minimal swelling and tenderness. You usually can walk home with this one. Grade Two has more swelling and tenderness and you will have trouble walking and moving your ankle up and down. Grade Three requires crutches and has more swelling, tenderness and bleeding (black and blue). Sometimes this results in a total tearing of the ligaments, whereby surgery is required to stabilize the joint. Often times a bad injury will give pain on the outside and the inside of the ankle. This is an injury to both sets of ligaments, damaging both sides of the joint. If you have trouble walking after an ankle injury, you should see a doctor for proper evaluation and x-rays. Although ligaments do not show up on x-rays, fractures do, as well as dislocated or slightly displaced bones.

Treatment starts immediately with ice and immobilization. Healing is accelerated following the PRICE method. P is protection from further injury. R is rest. I = ice. C is compression, such as an ace bandage. E is elevation of the foot to reduce swelling, best accomplished by sleeping with two pillows under your foot. Protection and compression are often accomplished with the same thing. The simplest defense is the ace bandage wrapped in a figure 8 around the ankle. Much better than this is the air cast or gel cast, which is strapped to the ankle and squeezes the swelling from the joint while only allowing up and down motion of the ankle. This is the first protection most Doctors recommend after an injury because it allows you to walk on the ankle much sooner. You can wear this while playing and get great protection although it is not as comfortable as a canvas brace, which is worn over your sock and extends above your shoe to protect the ankle. These are probably the best therapy for older injuries, are easy to put on and are available from surgical supply houses, drug stores or doctors. Equally effective is a strap-on hinged brace produced by Active Ankle, which completely secures the joint in place. If you have seen any recent photos of the men’s or women’s national team, you would have noticed all players wearing the active ankle brace bilaterally. According to Rick Bahr, Assistant Athletic Trainer to both teams, mandatory use of the brace has reduced ankle sprains from an average of 15 per year down to 3. Taping also does a great job of protecting the ankle and perhaps is the most effective protection of all when applied properly.

Most ankle injuries take 4-6 weeks to heal on the average. This can be accelerated with proper therapy administered at a doctor’s office. I have seen ankle injuries heal in one quarter of the time with the proper program. Advil or other over the counter anti-inflammatory medications are critical to reducing swelling. Chiropractors, physical therapists and athletic trainers have access to machines, which can reduce the swelling and inflammation and accelerate healing. Also, realignment of the ankle joint by manipulation after an injury decreases healing time and prevents future reinjury by establishing normal joint motion.

Rehabilitation of all ankle injuries is extremely important. Many times after an old, untreated injury the pain comes and goes with exercise and can continue for years to follow. Additionally, untreated injuries often times leave the joint weaker, which can lead to the same sprain again. Each time the injury occurs, the ligaments get stretched. If rehabilitation is not performed on these ligaments, the joint gets looser and looser which leads to chronically weak ankles.

The first stage of rehabilitation is ice. The recommended regime is 10 minutes on, 15 minutes off. This cycle can be repeated throughout the day until the swelling has stopped. Ice naturally reduces swelling and inflammation. The ice is best applied with cold packs or ice in a bag, which is separated from the skin with a thin cloth like a tee shirt to prevent burns. During this time period when swelling is present, light exercise is encouraged such as the “gas pedal “ routine where you flex and extend the ankle up and down. You can also attempt to “write the alphabet” with your toes in mid air to encourage the joint to work properly and to decrease spasm. Obviously, if walking is painful at this time, crutches are a necessity. Strengthening comes after the swelling is normalized. What is first recommended is Achilles tendon stretching, because tight Achilles are often associated with ankle sprains. Standing on a staircase with the balls of your feet on the stairs and your hands on the handrail, slowly sink down with your heel to get the maximum stretch. Strengthening exercises from a rubber band kit is an absolute necessity to fully heal the ankle. This is easy to follow, cheap and begins after the second week. SPRI Products in Wheeling Illinois (800-222-7774) has a good kit with instructions available. You are finally ready to resume play when all swelling, pain and tightness are gone and you can jump up and down on your toes without pain. At this stage you must continue to protect the ankle while playing for the next few months with high tops, braces or taping.

A rehab program is boring to 80% of the population. Most of us would like to think that if you wait long enough, it will get better on it’s own. The problem is, it either takes a lot longer than you thought or the ankle remains weak. Rehab cuts the healing time way down and is the ONLY thing that will properly strengthen injured tendons and ligaments. Commitment to a daily program is merely starting a new habit. All it takes is a little time and discipline to regain strength. In the long run- you’ll be glad you did.

ACL/CARTILAGE INJURIES

By Bryan Collier D.C.

Worse things could happen in life, but either of these conditions usually led to heartbreak for the serious-minded player. With a mild injury, it’s possible to continue playing, but further damage and pain are often the consequences. Inevitably, you are forced to realize the opportunity for spontaneous healing is nil. As much as you’d like to believe otherwise, chances are good you won’t be seeing over the top of a net for a while.

Anatomy

The knee joint involves two bones, the femur and the tibia, both of which have a poor surface for a good union. This conformity problem is alleviated by the meniscus, or cartilage. The cartilage acts to “fill the space”, while providing shock absorption and lubrication to the knee joint. Additionally, the meniscus prevents the bones from rubbing on themselves. If they wear down, this rubbing will lead to arthritis. There are two oval bands of menisci in each knee, one inside and one outside. These accept the two large rounded ends of the femur and provide a runway or track for gliding as the knee is in motion. Both bands of cartilage are loosely attached to the bone, therefore, they move when the knee is put to flexion and extension. These bands are live tissue, but owe their high incidence of injury to their poor blood supply. Only the outer edge of the meniscus have a viable blood supply, therefore, an injury to this region may heal, whereby the interior sections will always remain damaged or torn. Because they run close to the edge of the joint, injury often produces tenderness at the space between the femur and tibia.

There are several ligaments which act to support the knee, however, there is one that when damaged renders the most instability and consequences. This is the anterior cruciate ligament or ACL, named appropriately by its orientation. This rather large ligament acts to limit the forward excursion of the tibia on the femur. Starting on the mid-bottom of the femur, the ACL traverses forward and attaches to the top of the tibial plateau. Unlike other knee ligaments, you cannot touch this from the outside to check sensitivity. When the knee is straight, all the ligaments surrounding it are tight, thereby protecting the knee. When there is even slight bending of the knee, more play develops in the knee, rendering it more vulnerable. The front-to- back and twisting motions now allowable are held in check by the ACL.

Mechanism of Injury

Although these are two separate injuries, they are closely associated and are occasionally seen together. An external force applied to the knee, such as a collision with another player or a fall, tests the strength and durability of the knee joint. If the force exceeds the strength of the ACL, it either stretches or rips. The injury may also come from planting a foot and turning the body, thus twisting or tearing the internal components. This is the mechanism of damage to the cartilage, where the femur grinds down on the meniscus, causing it to tear. The inside cartilage is four times more likely to tear than the outside, because it is anchored to the tibia in more places. If you are “clipped” by another player on the outside of the knee, you run the risk of damage to the inside cartilage, and the ACL. Direct trauma to the knee easily links us to the injury but sometimes causal relationships tend to be fuzzy. In many cases, a mere landing and pivoting off one leg can create the injury; an innocent task performed hundreds of times in a day of playing. In all likelihood, cases like these often involve several mild, older traumas that cumulatively weaken the joint. One gloomy day, your next jump becomes the straw that broke the camel’s back. And nobody knows that better than Brian Ivie. A starter at the 1992 Olympics and unquestionably one of the best players on our National Team, Brian had squatted down in an early match to wipe up sweat from the court as was routine for all players. As he stood up, his knee locked and wouldn’t straighten. This simple act resulted in swelling and tremendous pain, enough to keep him out of further competition. His diagnosis? Torn lateral meniscus. Only after careful thought and questioning was Brian able to remember similar episodes of locking, starting with a beach tournament many years earlier, which tapered off with a weight-training program.

Symptoms/First Aid

The pain and swelling are immediate with these injuries. If the meniscus rips, you have a sensation that something is giving way in the knee. The knee may actually buckle without warning. If this ripped piece is displaced within the knee, you will lock up, and be unable to straighten the leg. All of this will be accompanied with swelling, which won’t go down for many days. As time passes, you may have days of feeling completely normal, but the tear will continue to plague you. You will feel unstable with running or playing sports. Generally, you lose confidence in your knee, not knowing when it will give out. An ACL injury usually involves feeling and/or hearing a pop during the injury. The knee swells immediately and fills with blood, if a tear is present, and is followed with strong pain. Immediately following injury, you should stop play, and ice the knee. If possible, compress the knee with an ace bandage and elevate it to reduce further swelling. Either of these injuries must be evaluated by a competent Sports Injury Doctor as soon as possible. Typically, an evaluation would involve an exam with orthopedic tests, which would help to identify the source of pain. As might be expected, a knee series of x-rays are requested to rule out any fractures or loose bodies in the joint. The state-of-the- art test however, is the MRI, (Magnetic Resonance Imaging). Their information is unparalleled, as they clearly show tears or swelling of all knee structures. What if you need surgery? Long gone are the old “Joe Namath” type knee surgery, whereby the whole knee was opened and most of the cartilage taken out. Besides the giant crescent-shaped scar, years later arthritis commonly set in due to the invasiveness of the procedure. Most surgery is now done arthroscopically, which involves three holes drilled into the knee, allowing for a camera, surgical tools and irrigation. The surgical time for a partial medical meniscal tear can run around 1/2 hour to two hours for a complete tear. Generally, you can be walking the next day for a partial tear compared to being in a cast for months with the old-type surgery. Exercise can be resumed in 4-6 weeks for a partial meniscal tear, to 3 months for a complete. Of course, you must also strengthen the knee with physical therapy, which goes on during this period and continues after your sport is resumed.

The ACL does not respond well to sewing it back together and letting it heal. Their poor blood supply allows the ligament to fail soon after exercise is begun. Most surgeries these days involve rerouting a section of the patellar tendon or the hamstring, or a donor graft (an ACL from someone else). Typically you can walk in 2-4 weeks, and play again in 4-6 months. Commonly, you are fitted with an oversized metallic brace to protect the ACL while it is still healing. Heard any horror stories about exceptionally long recovery times? Pain and swelling can extend past the recommended healing times, due to many reasons, such as degree of trauma, lack of follow up therapy or even too much therapy. After surgery, follow your doctor’s advice, cross your fingers and hope you are on the short road to recovery.

There is still some debate as to how severe the injury is before surgery becomes absolutely necessary. It is quite possible to have a small tear on the edge of the meniscus where blood supply is minimally present, to heal on its own. Likewise, a stretched or partially torn ACL may have enough integrity to prolong or avoid the prospects of surgery. The ultimate decision is based on your doctor’s opinion and your willingness to carry through with the recommendations. Regardless, in either scenario you will be strengthening and guarding the knee for some time. Truth be told, a well-conditioned knee, which is strengthened in a gym several times a week, is your best insurance against these injuries. Perhaps the best advice for these injuries is mirrored by many veterans of knee surgery- “If only I had kept the knee stronger...”.

BICIPITAL TENDONITIS

You might be lucky to have this condition. A pain in the shoulder amongst volleyball players can be many things, some of which are career threatening, others minor in comparison. A survey of the more common shoulder injuries should start with the greatest fear of all players, a fully -torn rotator cuff. This without question is time to consult your surgeon. Following a close second is repetitive shoulder dislocations, alias mandatory volleyball retirement. Torn shoulder capsule or avulsion fracture results in a long vacation from volleyball, maybe with a nice new scar. Chronic loose shoulder from years of heavy pounding should be time to consider competitive chess. Acromioclavicular separation starts with a shoulder sling, then a fling with weight training. Tendonitis is one of the milder injuries, which almost always results from overuse. It is, however, relatively easy to fix.

First of all, it helps to know what it is. A tendon is found at the end of a muscle and is attached to the bone. It doesn’t contract like a muscle, and is stronger in composition. It can become frayed or irritated with constant use, which leads to the tendonitis. This condition only grows worse with continued playing or exercise. Initially, what happens with tendonitis is after the muscle warms up with use, the pain from the tendon stops. This is because more blood is directed to the tendon, which soothes the injured area temporarily. The pain usually sets in after the activity has stopped, and the blood flow has diminished. Bicipital tendonitis involves the tendon of the long head of the biceps muscle, (there are two muscles of the biceps). This tendon as shown in the illustration runs upward over the shoulder to attach on the scapula. The tendon sits in a groove in the top of the humerus, which is where the friction occurs. Normally, the tendon is secured in place in the groove by a ligament. This ligament often will rip with repeated stress and allow the tendon to migrate out. As the arm is raised over the head as in serving or hitting, the tendon can move out of the groove and produce wear and tear as the tendon scrapes over the bone. The irritation almost exclusively occurs with overhead motions and is worsened when swinging at a bad set or cutting a ball around the block at high velocity. The pain with this condition is almost always found in the same location, which is right over the groove. Referring to the diagram, as your arm hangs down normally at your side, the pain should be mainly at the front of the shoulder, slightly off to the side and slightly down from the top of the crest. The pain is not felt deep inside the joint or behind the shoulder and does not generally hurt unless the arm is raised above 90 degrees. When the shoulder is inflamed, the area of pain can often be isolated with a finger and made worse with deep pressure. It should be noted that pain in this general area is not exclusively tendonitis and may also be other shoulder conditions such as torn rotator cuff, torn bicipital tendon or capsular tears. It always pays to obtain a proper diagnosis from a sports injury doctor especially when pain is prolonged and chronic. There are three stages to bicipital tendonitis. Grade one is the mildest form, whereby the pain is present only after playing, such as that night or the next day. Grade two has pain present while you actively play, usually with a lot of hitting or when you swing hard at bad sets. Grade three has pain on and off, with or without play.

Therapy starts with a reasonable limitation of playing time. No shoulder pain is going to get better if you are on the court every day. It may, however, not be necessary to completely stop all play, usually a rest period of two weeks followed by a one day of play with modified serves and hitting is enough to get the healing process started. Increasing to twice per week initially is fine if pain is low to none. Serving should not involve any high velocity. Floaters or short serves are great to start with, if they don’t produce pain. If these give trouble, the best serve is the Asian serve, as this doesn’t stress the bicep tendon. And there is always the underhand serve, which doesn’t look pretty, but creates no stress whatsoever. This is also the best time to learn how to hit with your opposite arm. There have been many terrific hitters who pinpointed their beginnings of ambidextrousness to a bad shoulder.

Most shoulders respond to ice rather than heat. Always start with ice over the shoulder when the pain is acute. The best way to apply the ice is to use cubes in a baggie, or reusable gel bags that mold to any body part. Ten minutes on, followed by a rest period of 20 minutes followed by ice again is the better program. Often times 3-5 applications are used over the first few days of treatment. It is also advisable to use a thin material such as a tee shirt between the ice and your skin, to prevent ice burns. Heat may feel good as well and a trial is the only way to find out. 30 minutes of heat is the recommended time period for application. If the shoulder is sore afterwards or throbs, go back to the ice.

Shoulder stretches and exercises generally are the only way to truly heal the tendon. Stretches are done initially every day to limit the contraction of other shoulder muscles. Simple stretches are accomplished by pushing the normal ranges of motion of the shoulder joint, such as up, down, forward, backward left and right. The best stretches are arm on opposite shoulder, arm behind the back, forward and sideway windmills and trying to “reach higher” with alternating arms. The stretch that often is most difficult with this condition is reaching behind the back and running the hand up the spine. This is best aided by rolling up a towel held over your head and grabbing it with the involved hand, having it “pulled” up the spine by your other hand. Stretches must always be done before hitting or playing.

Exercising can involve free weights, nautilus/universal and tubing, depending on what you have available. Exercise should only be attempted when you can manage 50% of your normal upper body workout without any pain. The ideal workout focuses on biceps, lats and deltoids although other upper body machines can be utilized. You should start with low weight sets of 10-15 reps with no pain while performing, and little pain afterwards. Always ice the shoulder after workouts. Gradually build up the weights until you can do 3 sets of 10-12 reps while exhausting the muscle. This must be done 3 times per week in order to rehabilitate the biceps. If you don’t exercise and strengthen the muscle, you will never get better. It’s that simple.

Probably the most important item to be considered in helping this condition is a shoulder strap. This is a neoprene Velcro band that wraps around the shoulder snugly, thus securing the bicipital tendon in place. It is worn up high on the arm, in the valley where the deltoid and biceps come together after you make a muscle. Pro-Tec, Body Glove and Professionals Choice all make good products for use as a knee band, which are good substitutes for the shoulder. While wearing this band, the tendon is secured in the groove where it belongs and remains there even when the arm is overhead. The relief from pain is rather immediate if worn properly. This should be worn during weight exercises and during playtime on the court to promote healing.

If you are not showing progress early on, be smart and get a diagnosis from a sports-oriented doctor. A torn rotator cuff along with other shoulder conditions are not helped much by this strap. Following this program should result in a healthy shoulder in a few months. The advantages from this program of course are many. With luck, you will have developed a fierce ambidextrous swing and will have a good shoulder once again. You will have also dispelled rumors of being a full time offensive dinker. And if you start training now, by the time summer begins without a closer look at your new shoulder strap, your friends might be convinced you’ve landed a new sponsor.

Finger Injuries

I can recall a few words of wisdom delivered by a pro-volleyball player several years ago about finger injuries. As he finished taping up his knuckles, he looked up and replied- “If you have never had an injury to your fingers playing volleyball, you just haven’t played enough.” Pretty true, I thought, considering all the taped fingers you see during play. When the injury occurs, several options should be considered; is it necessary to see a doctor, tape it, ice it or just leave it alone? In many cases, if the injury is left untreated, you may have a permanent disability involving pain, stiffness and loss of normal motion.

Most injuries usually occur from blocking or inadvertently jamming the finger with a head-on ball. The finger jam is more serious, usually requiring a much longer time to heal. The shafts of bone in the finger are compressed together longitudinally, causing damage to the connecting cartilage plate. Occasionally, this may result in fracture, which requires surgery of the joint and an incredibly long recovery period. The most common injury involves blocking a high-speed ball off the tip of a finger. Inevitably, the ligaments of the finger are damaged, and depending on whether they are stretched or ripped will determine when you go back to playing the game. The function of the ligaments is to tie the bones of the joint together, which control how much normal motion occurs. A stretched ligament makes the joint looser, whereby a torn ligament allows the joint to dislocate. A similar high- velocity type injury involves the tearing of muscle tendon, which will give a “crooked finger appearance” when you try to straighten out the joint.

The finger should be x-rayed on most injuries to rule out fractures. An examination of the finger joint is done to determine the degree of tearing of ligaments or tendons. The joint is extended and then moved side to side to test if the ligaments are loose. Torn or loose ligaments or tendons should be secured in a finger splint for 4-6 weeks to allow proper healing.

Typical symptoms of finger injuries are pain, loss of motion, stiffness, swelling and occasionally bruising. Therapy should always begin with ice placed over the joint for 5-minute intervals, being careful to avoid frostbite. Ice is generally used until the swelling subsides. Heat should then be applied by using a heating pad for 10 minutes or immersing the finger in a cup of hot water. The swelling can be reduced by compressing the joint with a compression sleeve prescribed by a doctor or simply by wrapping the joint with tape. The swelling and inflammation can also be greatly minimized by taking aspirin or ibuprofen daily for the first few weeks. As mentioned above with severe injuries, the finger may need to be splinted to allow proper healing of the ligaments, tendons and cartilage plate. The splint prevents the area from any further harm and allows Mother Nature to heal the damage. As with any new injury, time away from play is necessary to promote healing. Adequate rest often depends on which hand is hurt (hitting and serving hand requires longer recuperation), and how much swelling, pain and lack of motion is still present from the original injury. When you finally return to the game, taping the fingers to protect from additional injury is crucial. The easiest taping procedure is to secure two adjacent fingers together with tape above and below the involved knuckles. This technique unfortunately limits the surface area of the hand for blocking, interferes with setting and doesn’t work for thumbs. Another similar form of taping involves the same procedure, except the fingers are separated by a “sling “of tape. This of course allows for more movement, and stops extreme ranges of motion, which could add further injury. Taping the single finger is performed according to the above diagram, and is used to add extra support to the surface of the joint that is most painful. For example, if the index finger was injured while blocking and was forced to the side, the tape is applied in an X-pattern over the inside and outside of the joint for support (Figure #4). If a finger is forced backwards during injury, the “X” should be applied on the palm side while the finger is slightly flexed.

As the swelling and pain decrease, a rehabilitation program is begun to strengthen the area. The easiest exercise is to loop a rubber band around the injured finger and a healthy finger. Using the tension from the rubber band, separate the two fingers in different directions until you get fatigued. Squeezing a tennis ball repeatedly is also effective. Both should be brought to work and used repeatedly throughout the day whenever possible.

We all know the importance of finger placement and coordination on ball setting, hitting and serving. Painful or stiff fingers can often leave you feeling “uncertain” that your next handset will come out clean or your serve will float just right. Proper care and rehabilitation will yield a good recovery now and ensure good hands for next year and seasons to come.

Jumper’s Knee

Bryan Collier D.C. C.C.S.P.

Jumper’s knee. What a great name for a disease. Not like Osgood- Schlatter’s syndrome or Chondromalacia patella, other popular unpronounceable volleyball knee conditions. The name pretty much explains where it is and how you get it. And it is not purely a volleyball-related condition; basketball, the long jump and hurdling all share in jumping and makes one prone to developing this as well. Repetitive jumping requires tremendous contraction of the front thigh muscle, also called the quadriceps. Coming from the Latin derivative quad, meaning four, this muscle is unique in that it is the union of four muscles blending together into one tendon, the patellar tendon. Most muscles have one muscle linked to one tendon. The quads therefore, are pulling with 4 times the force. The more you jump and exercise, the bigger your quads get and the more pull is exerted on this tendon. Jumper’s knee (also known as patellar tendonitis), involves an inflammation or slight tearing of the patellar tendon. Ninety percent of the time this occurs just below the kneecap, which is exactly where you will find the pain. Of all knee conditions, this is by far the most common injury associated with volleyball.

Symptoms

The symptoms of jumper’s knee involve pain and stiffness located in the front of the knee; this makes for an easy differentiation over other knee problems, which tend to have pain on the sides, back or deep in the joint. It is relatively easy to diagnose this because the point on the tendon, which is torn or inflamed, will be extremely sensitive to fingertip pressure. The knee will also feel hot. There may be some localized swelling over the tendon, although this is quite rare. The knee will not involve any buckling, locking or unstable feelings, which are more often seen with torn cartilage. The main symptoms are pain during or after playing, and stiffness in the knee when it is not being used. The classic symptom, however, is stiffness and achiness while driving home after a tournament, especially in a small car. A two hour-plus movie in a non-aisle seat would do just as well for the diagnosis.

Diagnosis

X-rays, CAT scan or MRI of the knees for this condition are not of great value, although they are useful in ruling out other knee pathologies. Occasionally on an older, chronic jumper’s knee, an x-ray may reveal a buildup of calcium on the edge of the patella where the tendon attaches. This is due to the chronic pulling and irritation that the tendon has exerted on the edge of the bone. The diagnosis is most commonly made after the history of the patient has been taken, and following the exam. The history always involves repetitive jumping sports and the symptoms that were discussed above. During the exam, the doctor first will rule out cartilage and ligament problems with a series of orthopedic tests. Moderate pressure by the doctor’s fingers in pinpoint areas over the tendon confirm the diagnosis when pain is produced. There is no discoloration or bruising in the area. Spasm or increased muscular tightness of the quadriceps muscle is almost always present. The diagnostic severity of the condition is broken down into three categories:

Grade 1. This is the mildest form of jumper’s knee. Usually there is no pain while playing. Stiffness and/or pain will follow after heavier workouts.

Grade 2. Pain is produced while jumping on the court or crouched in the defensive stance. Stiffness and pain follow most games. Climbing up stairs is a problem.

Grade 3. Pain is present all the time.

Mechanism of Injury

Tendons are normally one of the strongest soft tissue elements of the body. Tremendous stress is repeatedly exerted on the patellar tendon with both jumping and landing, causing wear and tear to occur in key areas. The tendon has been shown to accept over 2500 pounds of force on the initiation of jumping. This along with the strain of "getting low" in the defensive stance constantly irritates the tendon. The primary mechanism that produces the actual problem is thought to be an imbalance in the pull of the four quadriceps muscles. Two of these muscles are found in the midline, and one is on each side of the thigh. Although all four muscles should pull equally, the outer muscle usually dominates in strength over the inner one, which causes misalignment of the patella. By pulling it more to the outside, undue tension is created on a weaker area of the tendon. Foot pronation or "flat feet" can also add to the problem. As the arch of the foot drops, it causes the foot to roll inward which changes the alignment of the leg and knee. This makes the tendon shift in position, placing it at a mechanical disadvantage. Basically this is the same problem as the quadriceps mechanism, except the trouble is coming from below, not above. The surface of the court also plays a big factor in development of jumper’s knee. Hardwood surface is the least forgiving, transmitting the most shock up the leg to the knee with jumping and landing. Grass tends to absorb the shock much better and is a recommended alternative if available. Although sand offers the best cushion, it creates more resistance to movement and takeoff, requiring more power. Additionally, the game of choice on sand is usually doubles, which demands much more jumping and defense over indoor 6's. The player’s position on the court may also contribute to the development of pain. The middle blocker has to react more often than either outside blocker while on defense, which can accelerate tendon wear. Additionally, the direction of approach to the net while hitting determines which knee will accept more stress on takeoff. What about a player's height? Everyone wants to jump higher but shorter players almost have to, in order to compensate.

Therapy

The time to begin therapy for this condition is at the earliest onset of the symptoms, not when the condition has become chronic. I can recall several years ago treating a younger, talented volleyball player with chronic jumper’s knee. At age 18, he had developed a 38" vertical leap with exceptional hang time. Offensively, he was the team’s secret weapon at tournaments. As time went on, his knees began to ache to the point that walking home after a tournament became impossible. He gave up volleyball and all other sports completely for one year to rest and recover. When the next season began, he started to notice severe pain again within the first week of jumping. Unfortunately, with this condition rest is not the only answer. You must engage in an active rehabilitation program to strengthen and protect the knee.

Therapy always begins with ice. A new injury or a re-irritated chronic one should be treated with ice packs for 10-15 minute intervals, or with ice massage several times per day. Ice massage is done with an ice cube rubbed over the tendon in a circular motion for 5-7 minutes. You should progress to applying heat for 30 minutes alternating with the ice on days between play, as the pain improves. The knee must be allowed to rest in order for healing to take place. I find most players dislike this aspect of advice. Traditionally, one should refrain from jumping or climbing stairs for 4-6 weeks, especially in severe cases. While players are on a corrective program, I like to put them on a plan of playing one or two light times per week to allow healing to occur, while preserving their sanity at the same time. If this doesn't work, we need to increase the time restricted from play. Another consideration is foot pronation (flat feet), which needs to be corrected if standard therapy isn't working. This is accomplished by taking a cast or mold of the foot and creating a custom-made arch for the foot to be worn in all shoes. This is somewhat expensive and must be fitted by a podiatrist, orthopedist or chiropractor. Store bought generic brands are only slightly helpful. Treatment, which you can do at home, begins with deep massage to the quadriceps. This group of muscles basically encompasses the thigh. After applying a light cream to reduce friction, begin by using the thumbs to dig into the muscles in a slow, deep massage until every square inch of the front and sides of the thighs are worked. This reduces the pulling of the muscles while they are resting, thus reducing the tension on the tendon. Applying a heating pad to the quadriceps also helps reduce tightness. Next, try grabbing the kneecap in one hand and moving it around in a circular pattern. This helps to realign the kneecap and tendon. Strengthening the tendon comes first by correcting the imbalance of muscle pull from the quads. The best technique is using the knee extension machine available at most gyms. This is the machine you sit in with your knees bent as you attempt to straighten your legs while pushing against resistance at your ankles. I recommend four sets with 10-12 reps/set. The first three sets are done with the feet turned out, the way a duck looks. This isolates the inner thigh muscle and strengthens it to balance against the outer. The last set is done with the feet turned in. If this exercise causes pain, wait a week or so and try it again. I also like to balance the quads with hamstring and calf work on appropriate machines. You must do these exercises for a minimum of 3 times per week for 2 months to strengthen the tendon. Never do squats or plyometric training drills with a symptomatic jumper’s knee; save these until the healing is at 90%. Wearing a neoprene knee sleeve with the hole cut out to stabilize the knee is a good idea. Even better than this is a knee strap, which is a thin piece of material worn just under the kneecap and wrapped around the knee. This creates a "cinching" of the tendon, which locks the patella in place and redistributes the stress on the tendon to a new, healthier area. The best design I've seen was created by Dr. Tim Brown, Medical Director of the AVP, which is distributed by Professionals Choice (800-331-9421). If all of the above therapy fails, consulting a sports-oriented physician is crucial.

Recovery time for this condition varies with the severity of injury, the time it has been present, ability to follow a rehabilitation program, and willingness to stay away from the game during healing.

The average case should get better in 2-4 months if all recommendations are followed. Unfortunately, therapy and healing do take time. The down side is you may end up playing a little less than your buddies during your recovery, but then again, a few extra inches in your vertical after all that gym rehab isn't such a bad reward.

LOW BACK PAIN

Dr. Bryan Collier

It is estimated that 90% of the population will develop severe low back pain at some point in their life. Volleyball players seem to attract an earlier onset of this condition. The reason appears to be in the inherent nature of the game. Good defense involves pivoting, crouching and bending, all of which twist and strain your spinal column. Add to that rolling or diving and a clearer picture starts to develop. Poor technique, such as overextending the low back while hitting or serving , landing on stiff knees or no warm-ups all put the low back at risk. Considering the compressive forces placed on the spine while jumping up and down, the court surfaces (sand/wood) make a significant difference on back pain development. Other contributing factors are poor posture, past injuries, hereditary weaknesses and weight gain.

Your spine is composed of 24 movable vertebras, which function to house and protect the spinal cord and nerve roots while maintaining flexibility and support of the upper body. The vertebras are connected to each other by ligaments, muscles and a series of interlocking joints called facets, which allow for independent movement when properly aligned. Between the vertebra lie cushioning pads called discs, which absorb shock and allow more fluid motion. Their center is filled with a gel-like substance surrounded by a strong, fibro cartilage covering. Connecting the vertebra together are ligaments, which are strong, cable-like bands that act to limit the end range of motion. Likewise, muscles attached to the spine determine what bending and flexing is possible as well as your overall posture. The spinal cord is an extension of the brain, which runs down through the spinal column, casting off pairs of nerves in between each vertebra. These nerves exit the spine and travel off to every square inch of the body to supply sensation and motor commands.

According to Dr. Doug Anderson, Medical Director of the AVP, the incidence of low back pain amongst pro beach players is quite high, accounting for 30-40% of all volleyball-related injuries. “Regarding the onset of lower back pain, we find that 50% are traumatic injuries, which have just occurred courtside. This is largely due to uneven beach terrain, the constant twisting and bending of the lower trunk in court coverage and the fact that players leave their feet constantly, keeping their eye on the ball and not the ground.” The second most common occurrence is pain with a gradual onset, mostly from overuse.

There are many varied factors, which can cause low back pain, however in volleyball, most can be classified in four distinct categories.

FACET JAMMING

The vertebras are joined together like railroad cars on a train with a coupling device known as the facets. These joints glide upon each other to allow all of the normal movements of the spine. With hyperextension of the spine as in jump serving or hitting, the facets tend to jam or dig into each other, producing pain. Classically, pain is felt with bending backwards, and is relieved with forward flexion.

JOINT MISALIGNMENT

If you still have pain a month or two after landing on your backside, you probably knocked something out of alignment. The vertebra and pelvis are all designed to be in their proper placement, much like machine parts. Trauma can weaken the ligaments and muscles, which support the spine and allow the joint to shift. This will still allow normal movement but will produce pain with certain motions and will predispose you to bigger injuries down the road. Why is it that even though you may be warmed up and in shape, a seemingly simple movement while playing can produce pain that lasts for months thereafter? This often can be attributed to joint misalignment. The spine and joints of the body are influenced by cumulative events, and each fall or off-balance twist can force a joint to move a notch or two more out of alignment. You eventually reach the point of pain, where the final trivial movement becomes “the straw that broke the camels back. “

MUSCLE/ LIGAMENTOUS INJURIES

This category accounts for the majority of acute low back injuries. Pain associated with muscle or ligamentous damage generally goes away quickly, 3-6 days for a muscle pull, 4-6 weeks for ligaments. The symptoms can go on indefinitely if you continue to play or irritate the area. Muscles are the one structure of the body that initiate all movement, and must be able to contract and stretch for normal function. If a muscle is not properly warmed up and won’t stretch, a quick motion that calls for the muscle to elongate will rip the fibers resulting in a “pull”. This is why it is so important to stretch before active play and anytime your muscles have had the opportunity to cool down. Ligamentous injuries occur in much the same way, but are not helped by stretching. Because they limit the end range of normal motion of the joint, they are subject to injury if sufficient force is applied to propel the joint beyond normal range of motion. Ligaments are protected somewhat by the contraction of muscles to slow down this end range of motion, but excessive force often will injure both muscle and ligaments. A micro tear in the ligament will heal nicely with proper therapy and rest, whereby a complete tear will not and requires surgery. Ligaments are most often put at risk when the joint is not in proper alignment.

PINCHED NERVES

The nerves exit the spine through an opening carved between two adjacent vertebras. These delicate structures can be pinched between the bones if the vertebra have counter-rotated or tipped out of position. Additionally, the nerve root may be pinched by the disc, in a situation where the inner fluid-filled section of the disc bulges out through a crack in its outer casing. The pain associated with these is often referred to a different location, chiefly the buttocks and legs. The most common symptom is an electrical sensation, although dull ache and burning sensation are common. The granddaddy of pinched nerve conditions is sciatica, referring to the irritation of the sciatic nerve. This nerve is composed of a network of roots originating from the small of the back, which travels into the leg supplying specific areas of the extremity. Pinching any of the component roots will produce pain into their corresponding mapped area of the groin, thigh or leg. Pain from this is often excruciating, and prolonged discomfort often leads to atrophy of leg muscles.

A rehabilitation program for low back pain is essential for proper healing. Any good rehab program should always start with identifying all factors, which can influence your pain. First we must look at the subtle “innocent” things you do on a daily basis. Do you slouch while sitting? This always gives back pain. Think about supporting the curve in your low back with a small pillow or a rolled up towel. If your bed is soft, get a bed board or replace it. Do you lift heavy objects without bending your knees? Even carrying lightweight objects on one side of the body for an extended period of time can throw your back out. Once these daily habits are corrected, a program of reducing inflammation, stretching and strengthening exercises should be implemented. If you don’t choose to participate, you become another volleyball dropout statist