Sports Med DOI 10.1007/s40279-014-0203-9

INJURY CLINIC

Injury Risk Management Plan for Volleyball Athletes

Lachlan P. James • Vincent G. Kelly • Emma M. Beckman

Ó Springer International Publishing Switzerland 2014

Abstract Volleyball is an increasingly popular team sport. outdoors [2]. The sport involves repeated, whole-body As with any competitive sport, there is an inherent risk of injury maximal ballistic actions in addition to rapid lateral that must be recognized and collaboratively managed. This movement in response to external stimuli. As such, there is article provides a practical approach to the management of an inherent risk of injury that must be recognized. In order volleyball injuries within a team or organization. A brief to manage this risk, specific injury prevention strategies are review of the epidemiological data is presented which estab- needed and should serve as an essential component to the lishes (i) ankle sprain, (ii) shoulder overuse injury, (iii) patella training plan for volleyball athletes. However, untargeted tendinopathy, and (iv) anterior cruciate ligament injury as the methods aimed at reducing injuries may misdirect resour- primary injuries to address amongst these athletes. The inter- ces and training time, thereby limiting the benefit of the action of modifiable and non-modifiable risk factors for these intervention. An effective injury prevention plan must be injuries are used to classify athletes into high-, medium- and directed towards those athletes at greatest risk [3]. How- low-risk groups. Targeted training interventions are suggested, ever, a targeted injury risk management plan that denotes based upon the risk level of the athlete, to minimize the at-risk volleyball athletes has yet to be presented in the occurrence of these injuries. Practical methods for integrating literature. The purpose of this article is to assist the sports these activities into a training plan are also discussed. medicine professional in categorizing these athletes into low-, medium- or high-risk groups based upon the inter- action of modifiable and non-modifiable risk factors for the 1 Introduction major injuries amongst volleyball athletes. Furthermore, a detailed theoretical programming strategy has been Volleyball is recognized as one of the most popular sports designed to manage and reduce the occurrence of injuries. in the world amongst men and women [1], in large part due This article is intended to provide a practical solution to to its accessibility to a wide age group, minimal equipment decrease injury rates in volleyball players with recom- requirements and the ability to play both indoors and mendations underpinned by the current body of literature.

L. P. James Á V. G. Kelly Á E. M. Beckman 2 Search Methods School of Human Movement Studies, University of Queensland, Brisbane, QLD, Australia Searches were performed of academic databases including PubMed, SPORTDiscus and MEDLINE. Google Scholar L. P. James (&) 2611/939 Expo Blvd, Vancouver, BC V6Z3G7, Canada was also accessed. The search period extended from Jan- e-mail: [email protected]; uary 1970 to March 2014. Search terms included the fol- [email protected] lowing: volleyball, injuries, epidemiology, ankle, sprain, overuse, shoulder, ACL, risk factors, tendinopathy, patella, V. G. Kelly UQ Sport Academy, University of Queensland, Brisbane, QLD, and prevention. Additional key terms used included plyo- Australia metric, neuromuscular, and motor control. The reference 123 L. P. James et al. lists from resources obtained through database searches categorized as modifiable through physical or behavioural were also consulted. interventions, or non-modifiable through such interventions [20]. Presented here is a detailed description for these risk factors drawn from both volleyball and other relevant 3 Epidemiological Research populations. Table 1 provides a summary of these influ- ences for each of the aforementioned injuries. An injury is commonly considered to be a physical com- plaint sustained by a player as a result of match-play or 4.1 Ankle Sprain training [4–6]; however, other studies use differing meth- odology to define this term. Similar injury patterns have Prospective analysis has reported that 80 % of volleyball been noted amongst both male and female volleyball players who have experienced an ankle injury will have players [2]. Of these injuries, it has been reported that ankle that injury reoccur [21]. For this reason, those athletes with sprains predominate, accounting for nearly half of all a history of such injuries are at a considerably increased reported incidents [1, 2, 7–9]. A high rate of reoccurrence risk. Such athletes have notable deficits in ankle kinaes- exists for these injuries [10] and, in the majority of cases, thesia and joint position sense (JPS) [22]. Additionally, in a symptoms for a lateral ankle sprain may linger for up to prospective investigation, Beynnon et al. [23] concluded 18 months following the incident [11] and typically result that men with an increased talar tilt and women with in 4.5 weeks away from training and competition [1]. increased tibial varum and calcaneal eversion range of Patella tendinopathy (PT) is reported to affect approxi- motion (ROM) are at greater risk of suffering ankle liga- mately 50 % of male volleyball athletes [12] and represents ment trauma. Lower neuromuscular control about the ankle 88 % of all knee injuries in some studies [13]. Due to its also contributes to an increased likelihood of ankle injury insidious onset, these injuries may go underreported, making [24], while a higher ROM through extension at the first it challenging to fully determine the impact on lost playing metatarsophalangeal joint is a documented risk factor time [14]. Regardless, the high frequency of patella tendin- preceding ankle sprains amongst female athletes [25]. A opathies makes it an important consideration when designing lower dorsiflexion ROM has been reported to be a strong an injury prevention plan. Although less common, this injury predictor of ankle sprain [26]. However, when a previous is also pervasive amongst women, with abnormal patella history of ankle inversion sprains is controlled for, this tendon imaging, indicative of possible tendinopathy, factor becomes less clear. In populations that have not appearing in 43 % of female volleyball athletes [15]. suffered a grade one or two ankle inversion sprain, Willems Shoulder overuse injury is common amongst high-level et al. reported that reduced dorsiflexion ROM was not a volleyball athletes. Specifically, 16 % of injuries to elite strong predictor of ankle injury amongst athletic women US national volleyball players [5] and 32 % of injuries to [25], yet it was amongst men [27]. English division one players were to the shoulder [16]. Volleyball ankle injuries mainly occur at the net due to Mjaanes et al. [17] determined that these injuries repre- unsafe blocking or striking methods; thus, middle, left- and sented 24.8 % of all injuries to elite US players. right-side hitters are most susceptible [7, 14, 28]. The Although less common, anterior cruciate ligament primary mechanism for this injury is a spiking strategy at a (ACL) injuries can be particularly devastating to an athlete. trajectory that displaces that athlete on or over the centre Verhagen et al. [1] reported only 5 % of all volleyball line [8], resulting in foot contact with an opposing team’s injuries were acute knee injuries, while Agel et al. [14] player [8, 14]. Additionally, it has been reported that noted 3.7 % of injuries were to the ACL. However, an incorrect lateral movement and take-off technique causing extended rehabilitation period exists for such an injury, the athlete to land on the foot of a teammate following a represented by an 11-month return-to-play duration [18], in two-person block is another major mechanism for ankle addition to potentially permanent disability [19] and should injury [8, 14]. therefore be included in an injury prevention plan for these athletes. Taken together, the injuries to be targeted within 4.2 Patella Tendinopathy this population are (i) ankle sprain, (ii) PT, (iii) shoulder overuse injury, and (iv) ACL injury. Repeated ballistic and stretch-shortening cycle actions that result in high levels of eccentric loading on firm surfaces, such as the activities commonly found in volleyball, have 4 Risk Factors been proposed as the primary cause of PT [29, 30]. Ferretti et al. [31] determined that the rate of incidence increased An essential step in the process of establishing injury with the number of playing years in volleyball athletes. causation is the identification of risk factors. These may be Similarly, it is understood that large increases in training 123 Injury Risk Management Plan for Volleyball Athletes

Table 1 Modifiable and non-modifiable risk factors for the most common volleyball injuries Risk factor Modifiable Non-modifiable

Ankle sprain Striking technique with excessive horizontal displacement [8] Previous ankle injury [10] Faulty two-person blocking strategy [14] Increased tibial varum ROM [23] Lower weight-bearing ankle dorsiflexion ROM (men) [26] Increased calcaneal eversion ROM [23] Less accurate passive joint position sense in eversion [25] Higher range of motion through extension at the first metatarsophalangeal joint (women) [25] Patella Large increases in training load [32] Playing history duration (exposure to repetitive low tendinopathy Lower flexibility in hamstrings [36] body ballistic efforts) and previous patella tendinopathy [31] Lower flexibility in quadriceps [36] Less knee flexion upon vertical landings [38] Faulty horizontal landing strategy [39] Reduced dorsiflexion [15] Increased waist to hip ratio [15, 35] Greater vertical jump performance [79] Shoulder Serving or spiking style [40] Previous shoulder injury [2] overuse Weakness in external shoulder rotation strength [5] Age [40] injuries Limited internal shoulder rotation [5] Playing history [5] SICK [2] Weak core stability [42] Large increases in training load [2] Position [5] ACL injury Faulty landing and take-off technique (knee valgus collapse Family history [46] combined with excessive internal or external knee rotations, and Previous ACL injury [19] insufficient knee flexion) [44] Weakness in hamstring to quadriceps ratio [45, 80, 81] Fatigue [47] Overall injury Preseason practice Playing in either middle, left- or right-side hitting occurrence Regular season games [14] position [14] ACL anterior cruciate ligament, ROM range of motion, SICK scapula malposition, inferior medial boarder prominence, coracoid pain and malposition, and scapular dyskinesis loads are a leading pathoaetiological component of this injuries [5, 40]. A previous shoulder injury and dramatic condition [32–34]. A number of other factors have been increase in training load are also considered risk factors associated with PT, such as higher waist-to-hip ratio in [2]. Reeser et al. [40] reported that non-traditional serving both women [35] and men [15], and reduced quadriceps styles put the athlete at increased risk for shoulder injury, and hamstring flexibility [36]. Certain movement strategies while middle, left- and right-side hitters execute more have been implicated in PT; this includes less knee flexion asymmetrical actions which lead to greater risk of injury to upon landing from a spike jump [37, 38] and a horizontal the dominant shoulder [5]. Muscular imbalances whereby landing action that involves increased knee flexion com- the external relative to internal shoulder rotation strength is bined with excessive hip extension [39]. proportionally weak, and increased external rotation with reduced internal rotation are risk factors for volleyball 4.3 Shoulder Overuse Injury athletes [5]. Due to the biomechanical similarities between the overhead actions in volleyball and other overhead The overhead striking and serving strategies in volleyball sports [41], it has been suggested that athletes expressing require a high degree of dynamic stabilization to secure the the condition characterized by scapula malposition, inferior glenohumeral joint. Due to the playing time accumulated, medial boarder prominence, coracoid pain and malposition, high-level volleyball athletes with an average of 11.5 years and scapular dyskinesis (SICK) are at increased risk of of playing experience are at increased risk of overuse shoulder injury [2, 5]. Furthermore, it has been suggested

123 L. P. James et al. that deficits in spinal stability, whereby the ability to theoretically determine high-risk players is described transfer forces effectively throughout the kinetic chain is below. compromised, causes greater stress upon the musculature about the shoulder and therefore should be considered a 5.1 Ankle Sprain risk factor for shoulder overuse injury in volleyball athletes [42]. Finally, it is unclear whether gender is a risk factor for Intrinsic risk factors such as a previous ankle injury, poor such injuries amongst these athletes [5, 17, 40, 43]. postural control and JPS in addition to the ROM indicators presented earlier combine to designate a predisposed ath- 4.4 Anterior Cruciate Ligament (ACL) Injury lete. If such an athlete is a right, middle or left hitter with unsafe striking and blocking strategies, they are at a high The leading cause of ACL injuries amongst volleyball risk of injury. It is also proposed that a hitter with a pre- athletes are via non-contact mechanisms such as jumping vious ankle injury without other intrinsic risk factors would actions, in particular the landing phase of a spike or block also be at high risk when combined with unsafe blocking [14, 18]; therefore, middle, left and right hitters are most at and striking strategies. risk [18]. The combination of multi-planar movement factors is suggested to be involved in non-contact ACL 5.2 Patella Tendinopathy injuries. In addition to a large knee valgus collapse, this includes excessive internal or external rotation and shallow The repetitive ballistic actions executed by middle, left- knee flexion angles [44]. Additionally, hamstring relative and right-side hitters place these athletes at increased risk to quadriceps weakness can increase the potential for of PT. When combined with a previous diagnosis of tendon anterior tibial shear [45]. Goshima and colleagues [46] disrepair or degeneration and hazardous landing tech- noted that many of the risk factors for ACL injuries are niques, such athletes are considered to be at a high risk of passed through families. Thus, a family history of ACL developing tendinopathies. As these factors alone are a injuries places the athlete at increased risk. It is important potent combination for this pathology, athletes both with to recognize that fatigue can further increase the threat of and without higher waist-to-hip ratio, lower hamstring and these traumas also [47]. quadriceps flexibility, reduced dorsiflexion, and a history of tendon loading are included in this category. 4.5 Timing of Injuries

It has been reported that injuries are considerably more 5.3 Shoulder Overuse Injury likely to occur during games than practices [1, 14, 48]. Furthermore, injury rates amongst female volleyball ath- The increased exposure of middle, left- or right-side hitters letes during regular season games were significantly higher to overhead actions, places such athletes with a previous than post-season games, while preseason practice session shoulder overuse injury at high risk when combined with injuries occurred more than twice as frequently as they did mobility impairment, muscular imbalances and SICK. in regular-season practices [14]. The timing of injuries may Additionally, athletes playing in these positions with an suggest that lower fatigue resistance due to a decreased extensive playing history who present with SICK, and a level of physical fitness contributes to an increased injury weaker external shoulder rotation strength with reduced risk. internal rotation, are considered at high risk of injury.

5.4 ACL Injury 5 Interaction Between Modifiable and Non-Modifiable Risk Factors An athlete predisposed to ACL injury would possess attributes such as weak hamstring to quadriceps ratio, and A synthesis of both modifiable and non-modifiable risk poorer physical fitness. A predisposed athlete becomes factors of these injuries provides a means by which to further susceptible executing faulty movement strategies classify athletes into high-, moderate- and low-risk groups. which cause increased valgus torque about the knee, Similarly, the convergence of intrinsic risk and extrinsic excessive internal or external rotations and shallow knee factors creates a susceptible individual which, when flexion angles, particularly when landing and jumping. A exposed to an injury mechanism, leads to a high risk of predisposed hitter with this movement strategy is at high injury [20]. Table 2 defines a construct to denote low-, risk of ACL injury. Even without the predisposed factors, a medium- and high-risk athletes for each of the aforemen- hitter demonstrating this movement dysfunction is classi- tioned injuries. The interaction between risk factors to fied as high risk. 123 Injury Risk Management Plan for Volleyball Athletes

Table 2 Risk factors for Injury High risk Medium risk Low risk volleyball athletes Ankle injury Right, middle or left hitter Hitters with no history of Setter or libero with no with previous ankle injury ankle injury with unsafe history of ankle injury employing unsafe blocking blocking and striking Hitters with safe blocking or striking strategies tactics and striking strategies With or without: poor A setter or libero with a without previous ankle postural control, poor JPS, previous ankle injury. injuries ROM indicators Patella Middle, left- and right-side All remaining hitters Setter, libero without tendinopathy hitters with history of PT Setters, libero with history of history of PT who display hazardous PT landing techniques Shoulder Hitters with a previous All remaining hitters with a All remaining players overuse shoulder overuse injury history of shoulder overuse injury who possess mobility injury impairment, weakness All remaining hitters with an through external rotation extensive playing history and SICK scapula, Hitters without an extensive regardless of serving style training history who Hitters with extensive express at least two of the playing history, who following: mobility demonstrate mobility impairment, weak external impairment, weakness to internal rotation ratio, through external rotation SICK scapula, reduced and SICK, regardless of core stability serving style Setter or libero with a previous history of shoulder overuse injuries ACL injury Any hitter demonstrating A setter or libero Hitters who are not valgus collapse about an demonstrating valgus predisposed and execute PT patella tendinopathy, JPS internally or externally collapse about an internally healthy jumping and joint position sense, ACL rotated and excessively or externally rotated and landing strategies anterior cruciate ligament, ROM extended knee excessively extended knee Liberos and setters with range of motion, SICK scapula A hitter with weak hamstring optimal jumping, malposition, inferior medial to quadriceps ratio or landing technique, with boarder prominence, coracoid poorer physical fitness, and or without pain and malposition, and healthy landing mechanics predisposition scapular dyskinesis

6 Injury Prevention Plan practice and game situations. Superior increases in mea- sures of lower body strength over 7 weeks have also been 6.1 Integration of Injury Prevention Strategies reported using this session design when compared with a traditional dynamic warm-up [53]. Athletes tend to have hectic training schedules, thus simply adding on additional sessions may not be the most effective 6.2 Ankle Injuries method for integration. Additionally, Myklebust et al. [49] reported low compliance rates for injury prevention train- Significant decreases in firing frequency of the peroneus ing. To address these issues, it is proposed that the fol- longus have been reported in individuals with chronic lowing injury prevention tasks be delivered in the form of a ankle instability (CAI) [54]. When coupled with reports of dynamic warm-up within training sessions and games. This low correlations between strength and ankle stability [23, programming strategy has been effectively employed dur- 55], these findings suggest that motor control, rather than ing practice sessions for soccer players [50–52] and resis- strength, is an important factor in preventing ankle injuries. tance training sessions of recreational athletes [53]. In It has been reported that deficits in neuromuscular control addition to long-term injury prevention, many of these [56–58] and joint force sense (JFS) [59] are present in exercises may provide acute benefits, through pre-activa- athletes with CAI. Therefore, prevention programmes, tion of inhibited musculature, and opportunities to imme- particularly for moderate- and high-risk athletes, should diately apply newly learned movement strategies in focus on functional neuromuscular control in addition to

123 L. P. James et al.

Table 3 Injury prevention strategies for all players Type of strategy Injury Activities

Example neuromuscular ACL injury Single-leg squat tasks Ankle sprain Shuffles or Cariocas—progress to change of direction reaction (mirror partner or coaches cue) Lateral or 45° bound and balance, landing on opposite leg Single-leg hops over line, or ladder drills Jump to 45° turn—progress to reaction (‘jump left’, ‘jump right’), further progress to dual task (catch and pass, set, dig) Submaximal single-leg landing drills, depth jumps and variations Progressions to pivoting and cutting activities after capacity is developed Motor learning and ACL injury Precise movement mechanics to ensure lower-limb joint congruency and encourage active, soft coaching strategies Patella landings whilst maintaining the centre of mass over the base of support tendinopathy Close qualitative analysis to identify these movement dysfunctions Combined visual and verbal feedback Use of implicit learning strategies Cognitive teaching describing both the injury prevention and performance benefits of prescribed activities Load management Patella Cautious introduction of tendon-loading activities during the preseason or following a period of tendinopathy inactivity Structure high, medium and low tendon-loading days Tracking of ‘ground contacts’ during plyometric and ballistic activities in strength and conditioning sessions Application of valid periodization strategies to prevent fatigue-related injuries, particularly in preseason and regular season Rotator cuff strengthening Shoulder External rotation and external rotation with scapular plane abduction exercises in functional, overuse injury athletic positions (Fig. 1) Such exercises can also be conducted with eccentric emphasis. Here, the athlete externally rotates against light elastic tubing, steps away and along the line of action to create more tension while the free hand supports, then completes, the eccentric action These exercises can be performed between sets during resistance training ACL anterior cruciate ligament

motor control tasks (Tables 3, 4). These activities would movement tasks are recommended, as interventions aim to develop JPS, kinaesthesia and JFS. involving these movements have resulted in improvements For moderate- and high-risk athletes, pre-activation of in functional capacity amongst individuals with CAI [62]. peroneus longus could be undertaken at the beginning of Drills with greater sports specificity, in particular plyo- the warm-up to aid in motor control. Following this, single- metric and ballistic exercises, should also be included [63] leg static balance on a stable surface could follow for all (Table 3). Moderate- and high-risk athletes could progress athletes. All athletes who have had a prior ankle sprain to more complex versions of these tasks. In accordance should complete an 8-week course of daily single-leg with Bahr et al. [7], technical training to safely reach a balance neuromuscular programme following their injury. ‘tight set’ and land from a two-person block should be As capacity improves over the duration of the season, conducted during training sessions with moderate- and unstable apparatuses can be introduced. Similar activities high-risk players. Such training will require collaboration have resulted in significant improvements in plantar-dor- with sports-specific coaches, and will involve a more ver- siflexion JPS [60]. Manual partner perturbations may be tical trajectory for both techniques. added to further challenge the athlete [61]. Use of external ankle supports such as taping or bracing More dynamic and ballistic activities to further chal- has been reported to reduce the risk of ankle sprains in lenge neuromuscular control and JFS could follow for all athletic populations, particularly amongst those athletes athletes. This can include single-leg squats on a stable with a previous ankle sprain [64]. Mickel et al. [65] surface in addition to more general dynamic warm-up- reported no difference in the effectiveness between ankle activities such as basic squat and lunging patterns. Lateral bracing and taping methods in reducing ankle sprains in

123 Injury Risk Management Plan for Volleyball Athletes high-school athletes. However, it should be noted that Table 4 Additional injury prevention strategies for volleyball ath- taping is reported to decrease dynamic balance during jump letes according to specific risk factor profiles landings in athletes without a history of ankle injury [66]. Moderate- to Moderate- to Moderate- to Moderate- to For this reason, the use of such strategies is recommended high-risk of high-risk for high-risk for high-risk of for high-risk athletes only. ankle injury patella shoulder ACL injury tendinopathy overuse injury

6.3 Patella Tendinopathies Tubing ankle Tracking of Tracking and Deceleration eversion pre- ground frequency tasks such as It is theorized that excessive tendon loading causes teno- activation contacts management depth drops during of aggressive and drop cyte apoptosis, resulting in pathology and pain [67]. In Single-leg static practice and overhead jumps accordance with this, close monitoring and manipulation of balance. games if actions May require tendon loading may be an effective strategy for injury Progress feasible Stretching closer prevention (Table 4)[30]. It has been reported that the from floor to Limiting the activities to monitoring process of collagen synthesis within a tendon peaked 96 an unstable number of improve and more apparatus ground internal feedback hours after the loading was applied [68]. This suggests that Manual contacts ROM throughout 4 days of recovery from higher tendon-loading stimuli may resistance during Technique warm-ups, be required for optimal adaptation. As increases in tendon can be practice and training for practices and load can be a cause of tendinopathies, particular caution applied in all strength and those athlete games conditioning should be applied following periods of time off, such as at these with non- Additional conditions sessions, traditional hamstring the beginning of the preseason and following injury or particularly Technical serving and strengthening following illness. To address this, a prevention strategy would training to spiking styles exercises games with include the use of high, medium and low tendon-loading encourage a Increased during high tendon days over the course of a training plan (Table 5). The more vertical focus on resistance loads training intensity of each day will differ based on the susceptibility trajectory structural when spiking Quick drop resistance sessions of the athlete, with those at higher risk exposed to lower and blocking squat and training Higher volume lunging tendon loads than less susceptible athletes. In addition to Taping or exercises of plyometric patterns to load management, the use of eccentric focused activities bracing of activities (for emphasize the those at low are recommended for those in the degenerative stage of eccentric previously risk of patella tendinopathies (Table 4)[69]. activity injured ankle tendinopathy) Limited ballistic and plyometric activities should be employed during the preseason resistance training sessions. ROM range of motion, ACL anterior cruciate ligament As the tendons adapt, capacity increases and greater intensities and volume of ballistic activities may be a stimulus that more closely resembles the overhead employed both in practice and strength and conditioning actions in volleyball. The eccentric action of many of these sessions. Neuromuscular training and motor learning exercises will also be emphasised. For example, an athlete strategies to improve landing biomechanics would also could take the shoulder concentrically through external prove valuable provided the tendon load is managed rotation with low tension, then step away from the resis- appropriately (Table 3). In particular, eccentric horizontal tance along the line of action to create more tension before and vertical landing activities will focus on soft contact the eccentric action is performed. These exercises could be with the ground to effectively absorb ground reaction for- combined with other aforementioned injury prevention ces. Vertical landing drills will aim for increased knee tasks to form a single, athletic movement. For example, an flexion, while horizontal stop-jump tasks will aim to athlete may perform a ‘quick drop squat to external increase hip flexion and decrease knee flexion in at-risk shoulder rotation’ (Fig. 1). Here, the athlete would rapidly athletes. drop into a squat and pause while holding the tubing; the external shoulder rotation could then be performed before 6.4 Shoulder Overuse Injury ascending from the squat. This would challenge neuro- muscular control and promote eccentric activity in the Activities that strengthen the rotator cuff are recommended lower limb, in addition to strengthening the rotator cuff. to rectify strength imbalances, and should be included for This exercise may even be performed on an unstable sur- these athletes (Table 3)[5, 70]. Low to moderate tension face for those athletes also at high risk of ankle injury. elastic tubing can be used to provide resistance through this Such an activity also creates a more athletic, complex movement pattern. Movement involving external rotation movement which would likely lead to greater compliance combined with abduction should be emphasised to provide from the athlete. 123 L. P. James et al.

Table 5 Tendon loading schedule for volleyball athletes Monday Tuesday Wednesday Thursday Friday Saturday Sunday

ML H L MHL L low tendon load, M medium tendon load, H high tendon load

increased focus on structural resistance training activities should be included for athletes deficient in this region. Athletes with at-risk serving and spiking techniques would benefit from altering these movements to an action that places less stress about the shoulder [9, 74, 75]. Such technique modifications have improved performance in these actions while reducing the risk of shoulder impingement [75]. Activities to both strengthen the rotator cuff and improve internal rotation ROM should be included alongside load management of overhead volleyball actions. Shoulder overuse prevention methods for all athletes are included in Table 3. Table 4 details specific strategies for moderate- and high-risk athletes.

6.5 ACL Injuries

Athletes susceptible to ACL injury would benefit from strategies that improve landing mechanics. These methods would aim to minimize both knee valgus collapse and excessive internal or external knee rotations, and increase Fig. 1 Quick drop squat with external shoulder rotation knee flexion. To minimize the risk of these injuries, neu- romuscular control tasks such as basic movement patterns progressing to more complex plyometric and deceleration Close tracking of serves and spikes throughout training exercises are recommended (Table 3)[19]. Neuromuscular is required to manage the load on the shoulder and prevent training such as this is reported to increase semitendinosus overuse injury. For example, a player who executes a relative to quadriceps activity during pre-landing and particularly high volume of these actions during a match landing phases of cutting manoeuvres [76]. This results in may need a reduced training load of overhead movements an altered motor control programme which decreases the in the following week. risk of dynamic valgus collapse. Addressing mobility impairments in the shoulders of at- Optimal absorption of initial ground reaction forces can risk athletes should also form a key component of this be achieved by encouraging soft, controlled and ‘quiet’ injury prevention plan. Stretching to improve posterior landings which aid in increasing knee and hip flexion, and capsular tightness is recommended for these athletes [2, ensuring precise lower-limb alignment upon vertical land- 70]. Such interventions conducted over the course of a ings [77, 78]. These qualitative analysis and feedback season have resulted in considerable reductions in shoulder techniques should be applied throughout practice and injuries amongst overhead-sport athletes [42]. strength and conditioning sessions. Moderate- and high- Training to improve core strength should also be con- risk players may benefit from a greater volume of plyo- sidered for at-risk athletes. Adequate strength in this region metric activities in strength-power training sessions to allows for effective summation of forces throughout the provide greater motor learning opportunities. However, this kinetic chain, from proximal to distal, allowing the shoul- intervention would only be suitable for players at a low risk der to play a greater role in expressing the force, rather than of patella tendinopathies. Additionally, this increased vol- producing it [71]. Research has indicated that dynamic ume would have to be within the volume-load bandwidth resistance training activities performed in an upright posi- for the particular training block. Table 3 presents injury tion elicit an improved activation of the trunk musculature prevention strategies for all athletes. Interventions for than alternate methods [72, 73]. For this reason, an moderate- and high-risk athletes are included in Table 4.

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