Treating the competitive volleyball player series, Part 3: Lower Body Assessment

It’s fairly obvious that the shoulder is one of the more commonly injured joints, but just as obvious should be that the knees of a volleyball player are just as beat up. The impact alone, overtime, is enough to wear down a volleyball player’s knees. Both overuse and traumatic injuries can occur in volleyball to the lower extremities.

In volleyball, it is common for a blocker to land on the opposing hitter’s foot as seen below:

The rule is that you cannot land with a whole foot on the side of the dividing line. However, there is a bit of “no man’s land” where if part of your foot goes under the net, it is not called as a fault. This can be dangerous because having even part of your foot under the net can create a hazardous situation and lead to ankle sprains. I have an entire topic series devoted to lateral ankle sprains, here.

ACL injuries also occur often, more common in the women’s game. Mostly due to weakness in hips and decreased balance/proprioception. Biomechanically, many girls often land on 1 leg after an approach, and with decreased stability from their core and hips, there is an increased valgus moment at the knees:

As I mentioned in the first part of this series, many things are out of the athlete’s control, as in the above vide (first 30 seconds shows the ACL injury occurring). The set was pushed too far out and the hitter was reaching behind her, attempting to adjust to the set, resulting in her landing on 1 foot. Now, am I advocating for landing on 2 feet, always? Not necessarily. It is always better to land on 2 feet than 1. However it happens quite often due to the set location, and in the men’s game it is seen quite a bit as well – In the 2016 Olympics, #2 Aaron Russell an outside hitter for the United States often landed on 1 leg following a hit. The difference is neuromuscular control and overall strength. When treating athletes, don’t be quick to judge biomechanics (especially elite level athletes). Recognize that there are many situations that the athlete cannot control in game settings. It is our job, as rehab professionals, to make sure that their bodies are ready to adapt to any situation during matches. Once you have accounted for all aspects out of the control of the athlete, identify what their deficits are and improve their neuromuscular control/asymmetrical strength pattern so that they are able to adapt during a game safely.

When it comes to overuse injuries, many seen in volleyball are forms of tendonitis/tendonopathy, most notably patellar tendonitis/tendonopathy – also known as jumper’s knee. And it’s named rightfully so, first described and seen in athletes who engage in high repetitions of eccentric quad loading. It’s part of the biomechanics of landing from a jump – eccentric quad contraction to decelerate knee flexion; you’d never want to land straight legged and “jam” the tibiofemoral joint. With patellar tendonitis, it has been shown that it is the proximal end of the patella that becomes irritated and thickened when seen under imaging.

When examining these athletes, knowing what movements reproduce their pain will be key in providing the most effective and efficient treatment. Pain can be reproduced in patellar tendinopathy with resisted knee extension (more so in short sitting). Ascending and descending stairs may be painful, sitting for long periods of time and then standing up, as well as hopping/jumping can all lead to reproduction of symptoms.

Initially, depending on the severity and acuity of the patient’s symptoms, you will want to limit and even completely avoid all activities that require jumping and running. This will decrease the amount of impact on the athlete’s joints and allow for some much needed rest. During this phase, you will want to focus on strengthening of the patient’s hip and core (including eccentric quad control), improve joint mobility around the hip and tibiofemoral joints, as well as manual therapy to the patellar tendon (I prefer Graston or any type of IASTM).

It will also be crucial to note the athlete’s feet and observe whether or not their arches collapse. This can alter their biomechanics up the chain, leading to increased medial valgus stress on the tibiofemoral joint. Orthotics and instrinsic strengthening of the foot can help mediate this situation.

At some point in your rehab (I say this because depending on the athlete’s level of fitness and acuity of injury, I sometimes introduce squat progressions early on or later in the plan of care), you will want to re-train the athlete how to squat again – this is very important for return to sport due to the squat jump required during blocking. I will have a post detailing the importance of the squat and form in a later post – for now, I want to share a progression for the overhead squat that I like to use with my athletes.

The above progression starts with the client in quadruped, rocking back and forth working on maintaining spinal neutral – especially in lumbar spine. Then the client is progressed to tall kneeling, working on core and hip stability – all while maintaining lumbar neutral (make sure their lower lumbar spine does not go into flexion). Finally the exercise is progressed into standing with TRX suspension for external feedback and increased lower trap activation overhead. In all 3 parts of the progression, TheraBand can be tied around the client’s knees so that they are required to push against the resistance.

References:

Rath, E. et al. Clinical signs and anatomical correlation of patellar tendinitis. Indian J Orthop. 2010 Oct-Dec; 44(4): 435–437

Rutland, M. et al. Evidence Supported Rehabilitation of Patellar Tendinopathy. NAJSPT. 2010 Sep; 5(3): 166–178.

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