As Louisville welcomes the NCAA Women’s Volleyball Final Four participants, I wanted to highlight the injuries faced by athletes in this booming sport that is so popular here in Louisville. With the explosion of club volleyball, this sport has become a year round completion for many participants. While having many benefits, this has led to a rapid increase in the number of injuries we as physicians see in this sport. While there are many common injuries seen across various sports such as ankle sprains, ACL tears, and stress fractures, the unique demands of volleyball place these athletes at higher risk of several specific injuries

The near constant overhead motion involved in volleyball places the shoulder at the forefront of volleyball injuries. Overuse injuries such as tendonitis, bursitis, and impingement are amongst the most common conditions faced by these athletes. Inadequate rest and recovery, poor mechanics, and muscle imbalances can predispose athletes for these conditions. More advanced conditions such as labral tears, specifically Superior Labrum Anterior Posterior, or SLAP, are also common in this sport. Similar to baseball pitchers, extreme rotation and torque from serving and spiking places strain on this structure’s attachment site. Over time it can become detached, causing pain, loss of power, and often requiring surgery to heal completely. Stretching and scapular strengthening can be very helpful in preventing and even treating these tears.

Lastly, atrophy and injury to a specific rotator cuff muscle, the infraspinatus, has been documented in surprisingly high numbers in elite volleyball players. Stretch on a specific nerve to this muscle is the likely cause. While generally asymptomatic, this condition which can be quite striking visually may warrant attention if it interferes with players’ ability to compete.

Knee injuries are also seen quite frequently in this population. Similar to basketball players, repetitive jumping, crouching, and landing on hard surfaces place these athletes at risk for patellar tendonitis, or “jumpers knee.” This condition will often cause pain in the front of the knee below the knee cap. It is also an overuse injury similar to shoulder tendonitis. Similarly, rest, proper stretching, and strengthening can help prevent this condition. Patellar straps, icing, and anti-inflammatory medication can provide relief when this condition is present.

Lastly, the low back, or lumbar spine, can take a tremendous amount of stress as athletes use their core to generate power in their swing. A condition known as spondylolysis is felt to be related to repetitive extension, or bending backward, of the lumbar spine. This condition affects a portion of the spinal column and can cause low back pain, and occasionally pain can radiate to the buttock or even leg. If present, aggressive treatment is indicated, including rest from sports, physical therapy, anti-inflammatories, and sometimes bracing. Most patients will be successfully treated without surgery but recovery can be prolonged. Very rarely surgery will be required to heal this condition.

These are just a few, but the most commonly seen, conditions faced by all levels of athletes participating in volleyball. Proper rest, mechanics, equipment, and coaching can prevent many of them. If your athlete is experiencing pain in these areas, the best course of action is to notify your coach and training staff they can get the attention they deserve.

Rotator cuff tears are amongst the most common musculoskeletal conditions facing patients today. Despite that their treatment can often bring more questions than answers. This stems mainly from the fact that not all rotator cuff tears are the same, leading to variability in their presentation, diagnosis, and management. This posting will delve into those questions in hopes of bringing some clarity to this all too common condition.

The rotator cuff is a group of four muscles connecting the shoulder blade to the arm bone, the humerus. They function as a group to stabilize the shoulder joint and assist in lifting and rotation of the arm. When injured, patients will often notice pain, weakness, and often mechanical complaints like grinding or catching of the joint, especially with overhead activities.

Rotator cuff injuries can affect patients of any age. Typically in patients younger than 40 years old, the tissue is rarely torn and more often suffers from conditions such as impingement, bursitis, or tendonitis. In these situations, the structure of the rotator cuff is often sound, however weakness in the shoulder blade, inflammation in the surrounding bursa, or early changes in the quality of the rotator cuff tendon are the source of pain.

Because of this, rotator cuff conditions in this age group can often be managed conservatively through combinations of medications, injections, and physical therapy.

In older patients or younger ones suffering from significant injuries sometimes seen in falls and at work, the rotator cuff tissue can begin to tear. When this occurs, pain can become more constant. It will often be felt on the top or front of the shoulder. It can radiate to the upper arm as well. Pain shooting to the hand is less often caused by rotator cuff tears and more so by issues affecting the spine. Pain often manifests worse at night. In these situations, in addition to a thorough physical exam and x-rays, patients will often undergo an MRI. Shoulder injuries are easier to see when there is fluid within the joint, so your physician will often order an arthrogram, whereby a special dye is injected into the joint, just prior to the MRI.

Even if an MRI shows a full thickness tear, there can be some benefit seen with further conservative treatment such as physical therapy, even though the tear will unlikely heal in this situation. However, in patients suffering persistent pain and weakness, or when there is a fear that the tear will enlarge over time, surgery is often recommended. Traditional open and arthroscopic options exist to fix the torn tendon to the bone. The small incisions and lower blood loss of arthroscopic surgery offers the chance to have decreased pain, less stiffness, and a faster recovery. Healing rates are likely similar between the two options.

After surgery most repairs will require the use of a sling for 4-6 weeks. Complete healing of repairs can take three months, and full recover is often anywhere from 4-6 months. Physical therapy and home exercise play a key role in preventing stiffness and regaining strength in the shoulder muscles.

As you can see, rotator cuff tears present multiple options in their treatment. It is important to talk to your physician about which is the best treatment for your situation.

ACL Prevention

Anterior cruciate ligament, or ACL, tears are one of the most common injuries affecting athletes in the United States. Estimates of between 100,000-200,000 of the injuries occur every year, often from non-contact injuries while engaging in cutting and twisting movements. Females have been estimated to suffer these type injuries at rates between four and eight times their male counterparts. As the number of female athletes participating in sporting competition has exploded in recent years, this disparity has created a near epidemic of ACL injuries in the female athlete.

Numerous reasons for this disparity have been expounded. They range from anatomical differences between the sexes, hormonal variations, environmental concerns like playing surfaces and shoes, and likely most important biomechanical factors such as muscular strength and endurance, movement patterns, position, and patterns of neuromuscular control. It is this factor which has seen a significant amount of research and promise in reducing the rates of ACL injury in these athletes. The Santa Monica Orthopaedic and Sports Medicine Research Foundation, and their partners at the University of Southern California, under the direction of Dr. Bert Mandelbaum and Dr. Christopher Powers, have been pioneers in this field. At the completion of my orthopaedic training I spent a year of specialty training with this group, and was exposed to a range of the newest treatments in sports medicine, including ACL prevention strategies

Their research identified several critical factors where female athletes differed from their male counterparts and were felt to contribute to their increased risk of ACL injury. First, women were found to run more erect, with decreased bending at the hips and knees. This is critical because the forces seen by the ACL are significantly less as the knee goes into more flexion, or bending. Second, diminished recruitment and strength of the hamstrings and hip musculature was seen, again placing the limb into a position known to increase the forces the ACL is subjected to. Third, landing patterns in females demonstrated a propensity for absorbing impact through hip and knee rotation instead of bending at the hips and knees, again placing the ACL at higher risk for rupture. In reviewing this and results of other interventions previously espoused to reduce ACL injury, this group created the PEP, or Prevent injury and Enhance Performance, Program. Five key areas are stressed in this program: avoidance of limb positions that place the ACL at risk, improving flexibility, improving strength of deficient muscles, plyometrics to improve landing techniques, and agilities. Athletes participating in this training program, which is done three times a week for a period of 15-20 minutes during their normal warm up period, demonstrated improvements in multiple areas known to affect ACL injury rates including landing patterns and muscle strength. Most importantly, in the first year of enrollment in the PEP program, they demonstrated an 88% reduction in anterior cruciate ligament injury for their athletes. The same authors demonstrated a 100% reduction in non-contact ACL injuries, the most common type, when they enrolled Division I female soccer players in the program.

With this fascinating data in mind, we at Loeb Orthopaedic Group and Frazier Rehabilitation have applied the PEP program to not just ACL prevention, but ACL rehabilitation. After surgery these same principles are applied to get athletes back in the game, to not just participate, but to excel.