PERFORMANCE VOLLEYBALL CONDITIONING A NEWSLETTER DEDICATED TO IMPROVING VOLLEYBALL PLAYERS www.performancecondition.com/volleyball and in Volleyball with Dr. Jonathan Reeser, Ph.D., M.D., Chair, USA Volleyball Sports Medicine and Performance Commission, Member, FTVB Medical Commission

PC: What is it about the game of volleyball that potentially creates an injury situation in the shoulder?

JR: The first thing about understanding a shoulder injury is first to understand the mechanics of the shoulder. The overhead spiking and jumping serving motions are the causes that create a potential injury situation. The problem with this motion is that it creates the potential for impingement within the . The individual with good scapular control will have fewer problems. What typically happens is that through overuse, the scapular control is lost to a situation of dis-control. This is the number one shoulder problem in volleyball. The other diagnosis that is common is what is called volleyball shoulder. This in medical terms is the peripheral entrapment of the supra scapular nerve. Because of its position it’s vulnerable to impingement, which can lead to the wasting away and atrophy that can result in scapular dis-control. The third situation that has been recently identified is called posterior impingement, which is created by the cocking motion of the arm with the arm maximally rotated and abducted. In this position it is thought that you can posteriorally impinge one of the rotator cuff and possibly the internal capsule of the shoulder by this motion. Prevention of shoulder problem comes down to the ability of the athlete to control and stabilize the . The number one cause of scapular dis- control is muscular imbalances.

PC: Where do these imbalances occur in the shoulder? Where’s the most danger, front to back, left to right?

JR: In volleyball, the biggest problem is the left to right, based on the dominant hitting hand in serving and hitting. The front to back is less of a problem. There is a tendency for athletes to train the posterior (front) side of the body. This is the area they look at in a mirror and is the most visible. It’s a Cadillac up front and a Volkswagen in the rear. The front muscles, the deltoids, pecs and biceps are the ones that look good and make the athlete feel pumped up. The emphasis with the athlete should be the opposite working the posterior muscles as a priority. The athlete should work on scapular control. This leads to another imbalance in the shoulder - scapular elevation vs. scapular depression. Here the deltoids that elevate the humerous of the arm, as part of the abduction of the upper arm in the spiking motion, have to be balanced against the appropriate elevation of the scapula so that there’s not this impingement. If the athlete has inappropriate scapular elevation, the elevation of the humerous is not acting in accordance; therefore, an imbalance occurs.

PC: You hear a lot about the deceleration of the arm as a potential cause of injury to the shoulder in the spiking motion. The theory is that the spike is performed with increased acceleration of the arm with an immediate decel- eration as the player hits the ball. This quick deceleration can cause great problems. What is your opinion on training the deceleration muscles to pre- vent potential problems?

JR: The result of the force generated in the spiking motion has little to do with the shoulder musculature. It starts from the ground through the spine through the shoulder. The rotator cuff (a group of four muscles) is a small muscle group. In the spike, their action is eccentric (lengthening). They provide stability to the keeping the humeral head in the glenoid fassia. If at the end of the spiking motion you didn’t have the eccentric action of the rotator cuff, your arm would literally be flying out after the volleyball. The rotator cuff keeps things in line and in the socket, so to speak. The best prevention to train this area is to train and strengthen the rotator in a functional manner. Isolating internal and external rotation movements with the elbow at the waist is not a functional po- sition (see Figure One). A more functional position for volleyball would be in- ternal and external rotations with the arm abducted (see Figure Two) and the diagonal ad and abduction of the shoulder (see Figure Three). These move- ments are more functional for the volleyball player.

PC: Let’s talk about priorities for the shoulder. As you stated, the number one priority is mechanics. The next is gaining balance in the musculature. Now I would like you to comment on usage or overuse (repetition) and re- covery. What are your thoughts in this area?

JR: This is the $64,000 question. This is a study I have wanted to do for a long time, in terms of what constitutes an appropriate level of repetition for a vol- leyball athlete as they develop. One thing we do know is that the younger, more novice volleyball players need to be monitored more carefully than the mature ones. Their body is trained to withstand the forces placed on it. Each individual has an upper limit, yet to be determined. In baseball there are papers that deal with such things, such as limiting pitch count for the little leaguer to so many pitches per week to minimize the chance of shoulder and elbow problems. Nothing exists for volleyball. For now all we can say is that there is a limit and that it’s an individual thing. Coaches should be aware of this. They want to avoid the overtraining of their athletes. There will be problems even with optimal training and conditioning.

PC: Please complete this statement: “As a coach I should be concerned about overuse when my athlete comes to me and says…”

JR: The concerns should be if the player says they have pain serving or spiking the ball. Pain is the most worrisome sign but it’s usually the last sign. There are more subtle things that a coach can pay attention to, such as “do the player’s mechanics look different?” They may not be hitting the ball as high or killing the ball as effectively. Even if the athlete isn’t conscious of the problem, the body knows that there is a problem and will make subconscious adaptations in terms of mechanics to try to maintain a performance level. These adaptations are less effective and will eventually lead to a drop off in the performance level. Pain is too late. You can ask a player why they are hitting that way and they may say, “If I hit the other way, it hurts.” You know something is wrong.

PC: As far as preventative measures, let’s go beyond the functional exercise you showed us to strengthen the posterior shoulder and the eccentric properties of muscular contraction. Years ago, according to Jim Coleman, he observed players with more ambidextrous abilities, balancing right to left. Today it’s almost never seen. Is this a realistic goal for today’s player and what might be some things a player could do short of being ambidextrous?

JR: I think the issue here is that athletes are starting to specialize in a specific sport at an earlier age. Their motor paths are being in- grained at an earlier age. Within a sport you have even more specificity when you consider position-specific activity. When I was playing in high school, if you were rotating to the left you played left front. If you rotated to the right, you played right front. If you were at the middle, you blocked and hit the middle. This was 20 years ago and our program wasn’t highly advanced. Now you have advanced player specificity. This results in a player hitting the same way earlier in their volleyball career. I don’t know if the coach has the time to encourage the player to hit from both sides. But certainly a good strength and conditioning program should encourage and not neglect the nondominant side. You should train and condition symmetrically. To avoid staleness and a potential overload situation, it may be wise for the coach to have their middles hit on the outside from time to time or give the outside hitter a chance to play back row. Practices should be varied as to avoid the athletes doing the same thing over and over. There may be a way of eliminating repetitions as well, as far as how much is too much and how much is enough.

PC: What recovery method would you recommend, specifically regarding the use of ice after practice or a game. Is this a good recovery method or are they masking agents to overcome pain? Are there other means you would recommend?

JR: There’s no simple answer to this question. The recovery method of icing the shoulder after practice or a game serves as a good . Cold is a good pain reliever. It also limits blood flow to the area, which limits swelling. But to some extent I believe that you want blood flow to occur to aid recovery. If you look at models of muscle regeneration after contusions or trauma to a muscle, or delayed onset of muscle soreness due to unaccustomed muscle training intensity, there is an anti-inflammatory response that the body mobilizes that’s necessary to heal the trauma to the muscle. Then it becomes an issue of how much swelling promotes healing and how much can become a problem. If the joint swells too much you can lose mobilization. Science isn’t advanced enough to know the answers to these questions. But your point is a good one. Athletes should not predispose themselves to injury. Icing before games and/or taking a painkiller just to play the game is playing with fire. I ice my shoulder after I play. I think it’s helpful. You have to rely on the athlete somewhat to monitor his own physiology. If the athlete says, “Okay, I’m sore after a match, I ice, I rest, I feel better and can play or practice the next day and feel fine,” then this is acceptable. But if they cross the line and don’t recover, the coach should start considering modifying their program.

PC: Same question as for the use of ice - what about anti-inflammatory drugs such as ?

JR: There’s a lot of controversy about nonsteroid anti-inflammatory agents such as ibuprofen and tissue healing. I don’t think anyone will give you the answer. A reasonable recommendation is that, used in low dose within the first several days of symptoms, the agents may play a role in reducing inflammation and speeding recovery. In , pain lasting more than several days, evidence is increasing showing that the inflammatory state has already passed. We acknowledge this in our terminology. It used to be called rotator cuff tendonitious. The “itious” meant inflammation. Now we call it rotator cuff tenindopathy, which means an abnormality of the , but it’s not an inflammatory abnormality. By the time you are symptomatic the inflammatory stage has passed. This means the benefits of ibuprofen are going to be minimal.

PC: Can you think of any other prevention methods?

JR: One other thing that needs to be addressed is flexibility. Flexibility relates to the biomechanics of the shoulder joint and the spiking motion through repetitive overload. Studies have shown in volleyball and tennis that athletes need elasticity in the anterior shoulder capsule, which permits them to excessively externally rotate in a spiking motion, for example, the cocked position. But they tend to be tight in the posterior part of the shoulder, which leads to the limiting of internal rotation. You end up with a shoulder imbalance as illustrated in Figure Four. This situation should be addressed from a preventative standpoint trying to maintain an overall functional degree of range of motion. Some of this imbalance in flexibility is unavoidable but I don’t think it’s clear as to how much is detrimental to the athlete. Again, this is an individual basis situation.

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