SPORT-SPECIFIC ILLNESS AND INJURY

Volleyball Injuries
Kevin Eerkes, MD
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to be due to more frequent serves and

Abstract
hits because of fewer players per team.
There has been a significant increase in the numbers of people playing
There are a lower number of ankle
indoor and beach volleyball since the early 1980s and, consequently, an
sprains in beach volleyball (6), which
increase in injuries. Most injuries are related to repetitive jumping and
also may be related to the small team
hitting the ball overhead. The ankle is the most commonly injured joint,
size, since with fewer players on the
but the knee, shoulder, low back, and fingers also are vulnerable. The
court, there is less chance of landing on
shoulder in particular is subject to extreme torque when hitting and jump
someone else’s foot. There is a lower
serving the ball. Some injuries have a predilection for those playing on
incidence of patellar tendinitis in beach
sand versus those playing in an indoor court. The clinician caring for
volleyball compared with indoor vol-
volleyball players should be aware of the types of injuries these players
leyball. This may be because the player
sustain and how to help them return to play promptly and appropriately.
cannot jump as high in sand (7) so there
This article reviews the specific injuries that are most common as a result
is less of an eccentric quadriceps load
of participating in the sport of volleyball.
upon landing. The sand provides a softer
landing surface, which also puts less
eccentric load on the quadriceps tendon.
Introduction
The Federation Internationale de Volleyball estimates Ankle/Foot Injuries
that 500 million people play volleyball worldwide (26). The Ankle Sprains
greatest area of the growth has been in beach volleyball, Ankle sprains are the most common acute injury in vol-
which is played on the sand with two people on each side leyball, with one study showing these accounted for 41% of
rather than six on each side as in indoor volleyball. Both all volleyball-related injuries (35). These usually occur
beach and indoor volleyball are Olympic sports and watched when landing onto another player’s foot, often a player
by many. from the opposing team, so these are more common in
Injuries in volleyball are commonly due to jumping and positions that play around the net. When evaluating a
landing as well as from hitting and blocking the ball. The sprained ankle in a volleyball player, there is usually evi-
ball can reach speeds of 80 mph and can cause significant dence of injury to the lateral ankle with swelling and ten-
injury should the ball strike an unintended area of a player’s derness. It is important to not miss a fracture, as the
body. Certain positions are associated with specific injuries treatment would be likely different. The Ottawa ankle rules
(Table). More injuries occur during hitting and blocking can help the clinician decide when a fracture could be
than during passing or setting. Most injuries, whether acute present and radiographs necessary (31).
or overuse in nature, occur during the act of jumping. The initial treatment of ankle sprains is elevation, icing,
Overuse injuries are somewhat more common than acute and protected weight bearing with a stirrup-type brace. This
injuries and are due to faulty technique, amount of repeti- limits the amount of swelling which develops and allows
tion, or type of playing surface. Elite athletes are at greater protected motion while the ligament heals, ultimately
risk of overuse injuries, presumably due to more hours of allowing quicker return to play (RTP). When the pain
practice. diminishes, rehabilitation usually is carried out by a phys-
Beach volleyball has a different injury pattern than indoor ical therapist or athletic trainer with exercises to regain
volleyball. There are more overuse injuries of the shoulder in ankle motion, peroneal strength, and proprioception.
beach compared with indoor volleyball (1), which is thought Cross-training can be employed while healing takes place.
In the latter stages of rehabilitation, the athlete should
reintroduce jogging and then drills specific to volleyball
Address for correspondence: Kevin Eerkes, MD, New York University such as hopping, cutting, and lateral shuffles.
School of Medicine, 3rd Floor, 726 Broadway, New York, NY 10003; Recurrent sprains are common, with one study showing a
E-mail: kevin.eerkes@nyumc.org 42% risk of resprain in volleyball players within 6 months
1537-890X/1105/251Y256
of the initial sprain (5). This emphasizes the importance of
Current Sports Medicine Reports completing a supervised rehabilitation program before re-
Copyright * 2012 by the American College of Sports Medicine turning to play. Balance board training to regain proprioception

www.acsm-csmr.org Current Sports Medicine Reports 251

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Table keeps the ankle in 5- dorsiflexion may be helpful. Some
The function(s) of each type of player in indoor volleyball and the recent studies have shown also shock wave treatment to be
injuries associated with that position. effective (14,28). A recent study found no clinical benefit of
Position Function Injuries
platelet-rich plasma injection over placebo injection when
added to an eccentric training program in chronic Achilles
Setter Set ball to hitter Wrist tendinitis tendinopathy at 1 year (9). Surgery can be considered if
Finger injuries symptoms are disabling despite 6 to 12 months of non-
operative treatment.
Hitter (spiker) Spike ball into Ankle sprains
opposing court Sand Toe
Shoulder instability/ Since beach volleyball is played barefoot, the toes are
impingement vulnerable to injury. In ‘‘sand toe,’’ the great toe becomes
Spondylolysis caught on the sand and the first metatarsophalangeal joint
becomes hyperplantarflexed, injuring the dorsal capsule. In
Patellar tendinitis addition, the plantar base of the proximal phalanx can
Server (all players) Serve ball Shoulder instability/ become compressed into the metatarsal head, causing bony
impingement injury. This injury compromises push-off, running, and
Blocker Block or alter ball Finger injuries jumping. The initial treatment is ice, rest, and nonsteroidal
hit by opponent anti-inflammatory drugs. Wearing a pair of shoes with stiff
soles or orthotics fabricated with rigid carbon fiber will help
Ankle sprains
limit the motion of the injured joint. Later, toe strengthen-
Patellar tendinitis ing exercises can be employed. When returning to play,
Passer Receive serve Contusions taping the toe with a moleskin checkrein on the dorsal and
plantar aspects can limit the first metatarsophalangeal joint
Pass ball to setter Injuries of the motion and protect the toe. This condition may take as long
upper extremities
as 6 months to recover fully.
May need to dive De Quervain
for or ‘‘dig’’ ball Tenosynovitis Knee Injuries
LBP Patellar Tendinopathy
Explosive and repetitive jumping is important to success
[Adapted from Eerkes KJ. Volleyball. In: Madden CC, Putukian M, in volleyball and can lead to pain in the patellar tendon.
Young CC, McCarty EC, editors. Netter’s Sports Medicine.
An estimated 40% to 50% of high-level volleyball players
Philadelphia: Saunders Elsevier; 2010. p. 503Y7.]
develop patellar tendinitis at some point (23). Risk factors
for patellar tendinitis in nonelite athletes are male sex,
higher body weight, and taller stature (37). The most com-
has shown to be effective in preventing recurrences of ankle mon site of pain is where the patellar tendon attaches to the
sprains in volleyball players (34). Wearing a lace-up ankle inferior pole of the patella. There is point tenderness at this
brace or taping the ankle for the remainder of the season site that distinguishes it from patellofemoral syndrome,
also may help reduce the incidence of recurrent sprain. another common source of anterior knee pain in athletes.
Treatment is similar as described for Achilles tendinitis.
Achilles Tendinopathy The patellar tendon also can become degenerated and
The paratenon of the Achilles tendon may become inflamed painful, a condition called patellar tendinosis. This tends to
2 to 6 cm above the calcaneal attachment site, called Achilles be resistant to treatment and recurrent. The volleyball
tendinitis. This is common in sports like volleyball where there player may have to take a considerable period of rest from
are repetitive eccentric loads to the Achilles tendon from jumping to allow the pain to subside. Rehabilitation con-
jumping and landing. There is tenderness and sometimes sists of stretching of the musculotendinous unit and then
crepitus of the tendon. Initial treatment consists of rest from strengthening. As the condition improves, eccentric closed
painful activities, ice, and anti-inflammatory medications. chain strengthening is carried out. One study showed more
Rehabilitation consists of stretching, progressive strengthening, improvement if the eccentric squat exercise was done on a
and gradual return to activities. decline board at 25- versus being done on a 10-cm step (36).
The Achilles tendon also can develop a degenerative For recalcitrant cases, some studies have reported positive
condition known as Achilles tendinosis. This term is used results with dry needling and injections of autologous blood
rather than tendinitis because the primary pathology is ten- or platelet-rich plasma (32). Some studies also have shown
don degeneration rather than inflammation. This condition extracorporeal shock wave therapy to be safe and effective,
tends to occur in older players and is usually chronic and but the studies were not of high quality (33).
difficult to treat. They have a thickened and often nodular
tendon with variable amounts of tenderness. Activity mod- Anterior Cruciate Ligament Injury
ification, heel lifts, and stretches may be tried. In cases Anterior cruciate ligament (ACL) tears are not as com-
resistant to conventional treatment, heavy-load eccentric calf mon as patellar tendinitis but are a much more serious
muscle training has been shown to be helpful (2). In addition, injury. It is well recognized that they occur at a considerably
if the Achilles tendon is tight, wearing a splint at night which higher rate in women than men in landing and cutting

252 Volume 11 & Number 5 & September/October 2012 Volleyball Injuries

Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
sports (18). In addition to female gender and prior ACL
tear, a number of risk factors have been proposed including
intercondylar notch width, generalized ligamentous laxity,
and increased body mass index (15). In volleyball, the
mechanism for ACL tear usually is coming down awk-
wardly from a jump or a cutting maneuver. The athlete is
almost always unable to continue playing after sustaining
this injury. Swelling typically develops within a couple of
hours. The Lachman test is usually diagnostic, provided
that the patient is able to relax their muscles. Magnetic
resonance imaging (MRI) is often performed to confirm
clinical suspicion and look for concomitant injury.
Most people who wish to return to a sport like volleyball
will opt to have the ligament reconstructed. The surgery is
quite successful in yielding a stable knee and thereby
decreases the chance of subsequent meniscal tears; however,
many are not able to return to their previous level of play.
One study showed that less than 50% of athletes returned
to playing sports at their preinjury level or returned to par-
ticipation in competitive sport when surveyed 2 to 7 years
after ACL reconstruction (3). Given that many athletes are
not able to return to high-level sports and the increased risk
of osteoarthritis after an ACL tear, there has been consid-
erable emphasis placed on prevention programs. There have
been numerous studies looking at proprioceptive and plyo-
metric training programs to decrease ACL injury risks in
athletes engaging in sports with cutting, jumping, and
sprinting, with many showing encouraging results. (16,21).
One study included female volleyball players and showed
that a neuromuscular training program significantly re-
duced ACL injuries (17).
Shoulder Injuries
Shoulder Instability
The arm swing during a volleyball overhead serve and
spike traditionally has been thought of to occur in three
phases: cocking, acceleration, and deceleration/follow-
through (13). To forcefully hit an unreturnable ball to the
opponent’s side of the court, the hitter’s arm goes into an
extreme external rotation and extended position during the
late cocking/early acceleration phase (Fig. 1). This position
levers the humeral head anteriorly on the glenoid and may
result in pain and/or a feeling of shoulder instability. The
function of the rotator cuff is to restrain excessive move-
ment of humeral head and also assist in internally and
externally rotating the humerus. The most common cause
of shoulder pain in volleyball players is overuse of the
rotator cuff, which is understandable given the typical vol-
leyball hitter/server hits the ball thousands of times in a
typical season. Shoulder pain also may be due to a variety of
other pathologies such as tearing of the inferior gleno-
humeral ligament or the labrum. Treatment involves
strengthening of the rotator cuff, which limits the amount of
anterior subluxation of the humeral head and provides
endurance.
The athlete also may experience internal impingement
when the rotator cuff and labrum become impinged at the
posterior superior aspect of the glenohumeral joint as a
result of anterior subluxation of the humeral head (10,19).
This pain is felt usually at the posterior aspect of the
shoulder. On examination, the pain is reproduced by placing
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Figure 1: Extreme external rotation and extension of the arm
just before contact with the ball in a professional beach volleyball
player (photo courtesy of Holly Flanders).
the arm in a cocked position and often alleviated with a re-
location maneuver (posterior directed force to the humeral
head). The initial treatment is rotator cuff strengthening as
mentioned.
Hitters and servers who have a long history of repetitively
placing their shoulders in extreme external rotation may
develop where there is limited internal rotation of the
shoulder compared with their nondominant side, a condi-
tion known as glenohumeral internal rotational deficit (24).
This is due to contracture of the posterior capsule of the
joint and may result in obligatory posterosuperior shift in
the humeral head during the cocking position, which is as-
sociated with a variety of painful shoulder conditions such
as internal impingement, external impingement, and labral
tears. If symptomatic, treatment involves stretches of the
posterior capsule using ‘‘sleeper stretches’’ (4) (Fig. 2).
The scapula must not be overlooked in patients with
shoulder pain. Malpositioning of the scapula can contribute
to impingement. Weak periscapular muscles can alter
shoulder kinematics and, in turn, lead to shoulder pain. For
these reasons, therapy of shoulder problems should always
include scapular stabilizing exercises.
Suprascapular Neuropathy
The suprascapular nerve first travels through the supra-
scapular notch at the superior aspect of the scapula and then
goes on to innervate the suprascapular muscle. The nerve
continues and passes through the spinoglenoid notch at the
lateral aspect of the scapular spine and then innervate the
infraspinatus muscle. The nerve can become entrapped at
both locations, but it is at the spinoglenoid notch that
volleyball players are particularly vulnerable. Studies have
shown that anywhere from 12% to 30%, top level vol-
leyball players have infraspinatus muscle weakness and
atrophy (11,22). There are various theories as to the
mechanism of injury to the nerve (12,30). It is generally
thought to occur from traction and/or compression of the
nerve during the extreme motions of the arm during the
cocking or follow-through phases of the arm swing while
serving and hitting. The ‘‘float serve,’’ which involves a
Current Sports Medicine Reports 253
Figure 2: Sleeper stretches: A. The patient lies on their side with the involved arm against the table and the shoulder and elbow flexed to
90-. B. The patient pushes their forearm toward the table with the opposite hand, maneuvering the arm into internal rotation thereby
stretching the posteroinferior capsule. (Reprinted with permission from Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder:
spectrum of pathology. Part III: The SICK scapula, scapular dyskinesis, the kinetic chain and rehabilitation. Arthroscopy. 2003; 19(6):641Y61.)
strong eccentric contraction of the infraspinatus, is also
postulated to cause traction of the nerve (12). Less frequently,
the nerve also can be compressed at the notch by a ganglion
emanating from a tear of the posterior superior labrum. Also in
the differential diagnosis of suprascapular neuropathy is the
Parsonage-Turner syndrome (brachial neuritis).
Suprascapular nerve palsy is occasionally associated with
posterior shoulder pain, but usually the muscle atrophy and
weakness are just incidental findings and the external rota-
tion weakness does not affect their play. The reason this is
tolerated so well is that external rotation strength is not
near as important to performance in volleyball as internal
rotation strength. In addition there is compensation by the
teres minor muscle, another external rotator of the hume-
rus, which is innervated by a branch of the axillary nerve.
Electromyography usually will confirm the diagnosis but
is not necessary in most cases. The electromyography can be
repeated at 6 months, if done initially, to assess recovery. If
the player is symptomatic, the treatment consists of tem-
porarily limiting overhead hitting and physical therapy to
strengthen the rotator cuff and periscapular muscles. Most
cases respond to nonoperative treatment but may take up to
a year for maximal recovery. If the patient is not improving
or has significant initial disability, consider obtaining an
MRI to look for a possible ganglion compressing the nerve.
A newer imaging technique called magnetic resonance neu-
rography may show abnormalities in the affected supra-
scapular nerve and denervation changes in the corresponding
muscles (8). Surgery can be considered if there is a space-
occupying lesion on MRI or if there is significant pain and
decreased performance despite 6 months of the mentioned
treatment. Interestingly, after successful treatment and reso-
lution of symptoms, the infraspinatus atrophy often persists.
Hand/Wrist Injuries
Sprains, Fractures, and Dislocations
Traumatic injuries to the fingers are common in any ball-
handling sport, and volleyball is no exception. Blockers are
especially vulnerable to injury from axial loads to the fin-
gertip and hyperextension of the finger from the ball. Hit-
ters can get finger injuries if they hit the net or another
player during the follow-through phase of the swing.
Radiographs are warranted for most finger injuries to rule
out fracture or dislocation. Most finger injuries involve
254 Volume 11 & Number 5 & September/October 2012
Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
ligamentous injury to the proximal interphalangeal (PIP)
joints of the fingers. They usually respond to brief immo-
bilization followed by buddy taping and early RTP. Sprains
to the metacarpophalangeal joint of the thumb often take
longer to RTP especially in an overhead setter. Thumb spica
taping or splinting may allow sooner RTP. More significant
injuries of the PIP joints that should not be missed are large
fractures of the volar base of the middle phalanx and central
slip ruptures.
Most finger dislocations occur at the PIP joint in a dorsal
direction and are easily reducible after radiographic con-
firmation. Finger fractures that are displaced or unstable
warrant consultation with an orthopedic surgeon. Most fin-
ger fractures and dislocations take closer to 1 month to RTP
depending on the position played and hand dominance.
The mallet finger usually is thought of as a baseball injury
but can affect volleyball players when the ball hits the fin-
gertip. With this injury, the distal phalanx is forced into
flexion, rupturing the extensor tendon. This results in a
flexed distal interphalangeal (DIP) joint, which the player is
unable to extend actively. The treatment is continuous
splinting of the DIP joint in extension for 6 to 8 wk, during
which time the extensor tendon scars back down to the
proximal aspect of the distal phalanx. This treatment is
highly successful. One study showed 90% patient sat-
isfaction rate at 5-year follow-up and average DIP joint
extension deficit of only 8.3- with little evidence of func-
tional impairment (25).
De Quervain Tenosynovitis
During a serve return, the ball typically impacts the volar
aspects of the forearms. If the ball is received incorrectly
repeatedly at the volar radial aspect of the wrists, the
synovium of the sheath of the first dorsal compartment of
the wrist can become inflamed, a condition known as de
Quervain tenosynovitis (29). On examination, there is ten-
derness over the compartment and pain with Finkelstein
test. This test is performed with the thumb inside the fisted
hand and passive ulnar deviation of the hand. The initial
treatment is ice, nonsteroidal anti-inflammatory drugs, and
avoiding further ball impact at the site. Use of a thumb spica
splint while not playing may be helpful also. If symp-
toms are severe upon presentation or persist despite the
mentioned treatment, a steroid injection into the sheath is
Volleyball Injuries
usually highly effective. A review showed an 83% cure rate
with injection alone (27). Recurrence can be prevented by
adjusting the area of ball impact to the correct position on
the volar aspects of the forearms.
Low Back Pain
Underhand passers are susceptible to low back pain (LBP)
due to repetitive lumbar flexion. The upper extremities held
in front of the body act as a long lever arm placing consid-
erable strain on the low back. Passers also are susceptible
to LBP when they must repetitively rotate at the trunk to
accept high-velocity jump serves from the side, when they
do not have enough time to get in front of the ball.
Spondylolysis
Spondylolysis is a stress fracture at the pars interarticularis
of a lower lumbar vertebra (the fifth lumbar vertebra is the
most common). When a player hyperextends the low back
when hitting (Fig. 1) or when ‘‘back setting,’’ there is con-
siderable shear forces placed on this portion of the vertebra.
When performed repetitively, a stress fracture can develop.
Adolescents are especially vulnerable to this injury because
their vertebrae are still weak at the pars. On examination, the
athlete experiences pain to the side of a lower lumbar verte-
bra upon extension.
Radiographs are obtained initially to look for a pars frac-
ture. If this shows a fracture, the condition is usually chronic
and there is little chance of healing. If a fracture is not seen,
an MRI or bone scan with single-photon emission computed
tomography (SPECT) is performed. If there is activity
(increased uptake) in the pars on the SPECT or edema on
MRI, there is potential for healing. Patients must limit
extension activities for at least 6 wk. Also the core is
strengthened and the hamstrings are stretched. Consid-
eration may be given to a rigid lumbar orthosis, which helps
reduce motion of the lumbar spine. There is no agreement on
the specific indications for a lumbar orthosis or the duration
of use.
If the stress fracture has not healed at 4 months despite
what was mentioned, a bone stimulator can be considered.
Healing rates depend on many factors including the dura-
tion of the lysis, whether it is unilateral or bilateral, the
width of the fracture line, and the activity of the fracture on
the SPECT. There is no consensus in the literature on the
healing rates, but it has been estimated that 75% to 100%
of acute lesions heal, 50% of early bilateral lesions heal, and
no chronic defects heal (20).
In established pars fractures, where the defect is seen on
radiographs and/or there is lack of activity on SPECT or
MRI, union of the fracture is not achievable. Painful flares
are treated symptomatically with relative rest, avoidance of
lumbar extension, and wearing a lumbar orthosis until the
pain subsides. Keeping the core strong may decrease future
episodes of pain. Even though bony healing will not occur,
fibrous union of the pars defect often occurs and can lead to
improvement in pain. If there is an established pars defect
bilaterally, spondylolisthesis may occur. A slip of greater
than 50% or development of neurologic symptoms war-
rants surgical consultation.
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Conclusions
Interest in volleyball has flourished, and it is now one of
the most popular events in the international sports world.
While enjoyable, injuries can occur from frequent jumping
as well as from hitting and blocking the ball. Injuries can be
either acute or repetitive in nature. Injuries typically involve
the ankles, knees, and shoulder. With an accurate diagnosis
by a sports clinician, appropriate treatment can commence
and often the player can return to training and competition
with minimal downtime.
Acknowledgments
The author thanks Aresio Souza for reviewing this manuscript.
The author declares no conflict of interest and does not
have any financial disclosures.
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