“You’re not alone in an examining room, anxiously awaiting the results of your MRI. You think back to how the injury occurred, blocking your best friend in practice. The doctor comes in and delivers the sobering news, “You have ruptured your ACL, which will require reconstructive surgery and keep you off the court for the next six months to a year.” Pow!

Don’t worry. This doesn’t have to happen to you. The key to prevention is understanding how these injuries occur and what can be done to lower your risk. If injury prevention doesn’t excite you, get motivated by knowing that proper training programs can make you stronger, reduce your risk of fatigue and enhance your performance.

Research shows that with the increasing physical demands and court time of juniors and college volleyball players, there has been a rise in the number of young players suffering knee injuries. Although the ACL, or anterior cruciate ligament tear, is the most notorious injuries to other parts of the joint such as the MCL (medial collateral ligament) and meniscus, are just as important to understand and avoid. Two-time Olympic beach gold medalist Misty May-Treanor sprained her MCL earlier this year (2011) in a tournament, and two members of the U.S. Indoor National Team – Cynthia Barboza and Destinee Hooker – were also recently slowed by knee injuries.

In sports classified as high-risk such as soccer, gymnastics, basketball and volleyball, female athletes face a staggering chance of getting hurt during their careers. Dr. Chris Koutures, team physician for the U.S. National Volleyball Teams, says one out of every 20 high school females will suffer a knee injury. Once the female athlete reaches college, the odds go up to one out of every 10.

The knee injury risks in volleyball are related to the movement patterns required to play the game, which includes abrupt changes of direction and landing on one leg. Experts report that more injuries occur in practice than matches, owing to the higher number of training hours on the court. Koutures says the majority of all volleyball knee injuries occur when players are playing defense, and blocking is an area of concern because athletes often have to make adjustments and block next to another player, which increases the risk of landing on someone’s foot.

Many factors affect the chance of injury to the knee, including age, overall muscular strength, hormonal changes, technique, recovery and gender. Statistically, female players are anywhere from two to eight times more likely to suffer an ACL injury than their male counterparts, according to Koutures.

One possible reason: girls and women have wider hips than men, which leads to a larger angle where the femur (thigh bone) meets the tibia (shin bone) at the knee. This is referred to as the quadriceps or Q angle, and because it is wider in women, it may contribute to a higher risk of injury. The angle of the femoral notch, which is the space where the ACL moves, is narrower in women than in males, potentially leading to the pinching and even rupturing of the ACL. The female ACL is less stiff and fails at a lower load level than that of males. Some studies suggest that hormonal cycles can increase the likelihood of join injuries, but there is simply not enough consistent data to make concrete recommendations based on this factor.

Let’s examine the knees anatomy. Static stabilizers are the four major ligaments and the joint capsules of the knee. The ligaments are the ACL, MCL, the posterior cruciate (PCL) and the lateral collateral (LCL). Dynamic stabilizers are the tendons and muscles that surround the joint. You cannot tighten or strengthen static stabilizers, but you can protect them by building the dynamic stabilizers.

A tear of any ligament is called a sprain. This damage is graded by three degrees of severity. Grade I (mild) s a minimal tear, Grade II (moderate) is a partial tear with mild instability and Grade III (severe) is a complete rupture where every fiber is torn and there is significant instability of the joint. The major parts of the knee can be injured separately, in tandem or, worse, all at once with a tear of the ACL, MCL and meniscus at the same time. This injury is aptly name the ‘Unhappy Triad.’

An ACL injury usually occurs due to an abnormal turn or landing with a fairly straight knee, often with a rotational element. The athlete immediately feels a pop and goes down. Repairing this injury is a more involved process than repairing other ligaments. The majority of young people with a torn ACL who wish to return to high-demand sports like volleyball need to have it surgically reconstructed through autograft (part of your own hamstring or patellar tendon) or allograft (from a cadaver). The entire process from surgery through rehab can last six months to a year. Further, anyone who has had a severe ACL tear will likely develop early onset osteoarthritis no matter what is done to repair and rehabilitate the joint.

Typically, athletes injure their MCL because of an extreme inward stress on the knee, causing the inner side of the joint to stretch or collapse. In volleyball, this usually occurs when a player lands or moves laterally. Fortunately, most MCL injuries don’t require surgery, and when it is needed, it usually involves the stretching of the ligament and not reconstruction. This may lead to a lengthy recovery, but a more favorable long-term outcome. Depending on the degree of discomfort and damage, clinicians will modify activity, brace the ligament and prescribe exercises that incorporate range of motion and strengthen the glutes, hamstrings and quads on down. If there is a risk of an inward force on the knee, you may use a “false ligament” brace to limit that motion of the joint and protect the healing MCL.

Menisci are shock-absorbing pads of thin, fibrous cartilage between the tibia and femur and are injured by rotational movements and abnormal landings where the meniscus is pinched between the two bones. Meniscal tears very greatly in extent and location, but outer lining menisci have a better blood supply, which speeds healing.

If you think you’re immune to these injuries on the beach, think again. Players face the danger of getting stuck in the sand, and those who play doubles subject their knees to the extreme physical demands of the lateral movement needed to cover such a wide area of court.

Rehabilitation and timelines for return from these types of injuries are individually designed according to details such as degree of the tear and what other musculature is involved. As activity is resumed, the use of bracing may be implemented to safeguard against setbacks or re-injury. For junior athletes who play frequently and begin to have overuse injuries, muscle stiffness and soreness, there may be a role for various advanced treatments that release muscles and help reduce pain.

“To access this, you need to work with somebody that has a good command of the technique, be it an athletic trainer, physical therapist, massage therapist – people who have learned (the technique) and have worked with junior level to higher level players and understand the demands of the sport,” advises Koutures.

‘Prehabilitation’ – often called ‘prehab’ – is taking a healthy athlete and being proactive with programs to aggressively reduce the risk of injury. For instance, to protect the MCL, an athlete may spend time working on the supporting groin musculature. Such programs can involve stretching, strengthening and coaching correct movement patterns.

“As a sports medicine and performance professional, I want to make sure our athletes are strong and prepared for such vulnerable situations by incorporating appropriate strengthening exercises and teaching proper biomechanics,” says Jill Wosmek (MA, ATC), head athletic trainer for the U.S. Women’s National Volleyball Team.

Practices and training sessions need to be balanced with rest, recovery and, when necessary, rehab. Technique suffers and landing patterns can become unhealthy when neuromuscular fatigue sets in. Wosmek recommends dynamic (moving) pre-workout stretching to prepare the body for exercise and static (still) post-workout stretching to recover and increase flexibility. Athletes should pay daily attention to proper hydration and good general nutrition such as consuming enough calcium to support the bone structure. Eating balanced and nutritious meals throughout the day helps reduce the risk of fatigue and speeds recovery after workouts.

An effective preventative program should include exercises that are sport-specific and use as much of the body as possible. The most efficient way to prevent injury and ensure durable performance is to focus on progressing from the basics of movement to the basics of the sport. First, gain proper movement characteristics such as efficiency, joint mobility, balance and coordination. Next add performance characteristics including strength, quickness, conditioning and flexibility. The final priority should be volleyball-specific skills such as spiking, passing and blocking.

For volleyball, jumping falls into all three categories. Players need to be able to jump appropriately so that they will be more efficient in movement and better able to execute the skill by getting higher at the net, timing jumps more appropriately and getting to a defensive position more quickly. Landing is the key. Athletes must learn how to land softly, in proper alignment and ready to assume their next movement. The safest technique is landing on the mid-foot to promote hip hinging and secure a wider balance of support for the knee and hip. TI’s okay to land squarely on the ball of the foot, but players should definitely avoid landing on the toes.

Studies reveal that injury prevention programs are most effective in athletes between the ages of 14 to 18. It is especially beneficial for girls to continue to learn movement patterns during puberty as they develop wider hips, longer limbs and maturing coordination.

“The sooner they can ingrain those proper (movement) patters, the better thy are going to be down the road,” Dr. Koutures says.

However, research has not yet determined the safety of conducting jump training with an athlete during puberty in addition to their sports training. Some experts believe the best way to children to various movement patters, techniques and mental strategies is to play multiple sports from an early age.

Many families and young athletes have limited access to resources such as an athletic trainer, physical or massage therapist or personal trainer. Dr. Koutures suggests taking advantage of free online options such as Sportsmetrics or the Santa Monica Sports Medicine Foundation’s PEP program for help with injury prevention. These programs can be downloaded and incorporated into individual or team training.

The more prepared you are through preventative measures, the lower your chance of major injury and faster you’ll recover if you are injured. Just look at world-class athletes such as Reid Priddy, Heather Bown, May-Treanor who continue to excel at the highest level into their thirties.

No matter how seriously you play volleyball now or in the future, proper planning will help keep you in the game and out of the doctor’s office.

Healthier knees: 5 tips

  • Avoid landing on straight knees. Always land and move “softly”
    with hips, knees and ankles bent.
  • Try to land in good alignment, with the hips and knees lined up
    with the second toe. Don’t let your knees collapse in or rotate.
  • The best time to stretch is after practice or after a match when the
    muscles are warm. Focus on hamstrings, quadriceps, hip adductors/abductors
    and calf muscles.
  • Don’t hesitate to ice sore knees for 20 minutes after practices
    or matches.
  • Knee pads help reduce bruises and pounding, especially
    with repetitive diving drills. “

Eric Hammond

See article at its source.