Foothills Sports Medicine is a group of locally-owned Phoenix physical therapy clinics that provide healthcare services to people of all ages across the valley. We believe a hands-on, individualized approach to therapy is the best way to achieve results for our patients. If you think you are in need of physical therapy, schedule a free assessment with one of our PTs online here. For more information about Phoenix physical therapy, follow our blog.

Itamar Stern, the owner of our North Central Phoenix physical therapy clinic, has over 25 years of clinical experience treating many different patients, including young athletes. He is here today to explain what causes knee injuries in female volleyball players, and how to prevent them from occurring.

Injury in any sport can be debilitating, but knee injuries in volleyball can be especially frustrating due to the constant use of the knees during movement in the sport. Common knee injuries seen in female volleyball players include patellar tendinitis and patellar tendinopathy, also known as “Jumper’s Knee”. Patellar tendinitis is caused by inflammation of the patellar tendon (the piece of tissue that attaches your kneecap to your shin bone) due to repetitive loading or pressure on the tendon. Patellar tendinopathy is similar to patellar tendinitis, but it involves tissue degeneration (rather than inflammation) and is believed to be caused by tension created during knee flexion, or bending. However, the exact cause of Jumper’s Knee has not been clearly proven. ACL tears are another injury sometimes seen in volleyball players. While this injury can be catastrophic, the occurrence rate is low in this sport.

Numerous factors play a role in developing these overuse injuries. One important aspect is the athlete’s training volume or intensity. An overload of jumping or a quick increase in jump training can trigger injury, because the tendon has not adapted to intensified training yet. Other contributing factors include muscle weakness of the gluteus maximus and gluteus medius and decreased hamstring and hip flexor flexibility. Without adequate strength in the glute muscles, the quadriceps have to compensate during jumping and landing – adding more strain on the patellar tendon. A lack of flexibility in the hip flexors also places more tension on the quads, which increases pull on the patellar tendon and causes irritation or degeneration. Research has not confirmed the exact cause of ACL tears in volleyball players, but many strongly believe it is linked to poor landing mechanics due to lack of strength.

Following certain preventative strategies can decrease a female volleyball player’s chances of developing these knee injuries. One important tactic is to take advantage of rest periods. Although this concept can seem foreign to athletes, rest is important in avoiding overtraining, the largest contributor to overuse injuries.

Another strategy is significantly reducing plyometric training during the season to decrease the amount of overload on the knees that occurs in practices and games. Plyometric training should be included in preseason workouts to help build the strength of the leg muscles and increase the capacity of the patellar tendon. Proper plyometric and strength training should also focus on using the entire lower body, especially including the glutes. Stronger glutes will reduce stress on the quadriceps during the loading and landing phases of jumps.

You should also continue to regularly integrate glute strengthening exercises during the season. Some examples include side stepping with an elastic band, bridging, and side line hip abduction with minimal ankle weight. Another element of injury prevention is stretching the hip flexor and hamstring muscles. Players can do this by performing the Thomas Stretch, prone hip flexor stretch, and straight leg hamstring stretch. These exercises will help maintain the proper length-tension relationship.

Being sidelined during the season due to an injury can be disheartening. When athletes take the right precautions like enjoying rest, maintaining glute strength, and increasing hip flexor and hamstring flexibility, they decrease their chance of missing playing time.

 

References

Bahr, M. A., & Bahr, R. (2014). Jump frequency may contribute to risk of jumper’s knee: a study of interindividual and sex differences in a total of 11,943 jumps video recorded during training and matches in young elite volleyball players. British Journal Of Sports Medicine, 48(17), 1322-1326. doi:10.1136/bjsports-2014-093593

Kulig, K., Noceti-DeWit, L. M., Reischl, S. F., & Landel, R. F. (2015). Physical therapists’ role in prevention and management of patellar tendinopathy injuries in youth, collegiate, and middle-aged indoor volleyball athletes. Brazilian Journal Of Physical Therapy / Revista Brasileira De Fisioterapia, 19(5), 410-420.

Reeser, J. C., Verhagen, E., Briner, W. W., Askeland, T. I., & Bahr, R. (2006). Strategies for the prevention of volleyball related injuries. British Journal Of Sports Medicine, 40(7), 594-600.

Smith, H. C., Johnson, R. J., Shultz, S. J., Tourville, T., Holterman, L. A., Slauterbeck, J., … & Beynnon, B. D. (2012). A prospective evaluation of the Landing Error Scoring System (LESS) as a screening tool for anterior cruciate ligament injury risk. The American journal of sports medicine, 40(3), 521-526.

 

Foothills Sports Medicine and Physical Therapy is a group of locally-owned Phoenix physical therapy clinics that provide hands-on, individualized therapy to patients all over Arizona. Our highly-trained staff offer a free assessment of any injuries or pain you might have, which can be scheduled online here. To find out more about physical therapy, and how it could benefit you, check out our blog.

Itamar Stern is a licensed PT and owner of our Central Phoenix physical therapy clinic who has over 20 years of experience in the field. After working in an Israeli military clinic, he began practicing therapy in the US, using a hands-on functional approach to treat patients with a variety of injuries. He tells us about the risk of injury for dancers, and their needs when it comes to physical therapy.

What’s different about dance rehab?

Every sport has different requirements of strength, flexibility, and stability. In most sports, actions are performed within normal limits of the human body’s range of motion (ROM)—how far a joint can be moved. However, dancers require an abnormally large ROM to perform their craft at the highest level. The injuries typical of hypermobile athletes like dancers are unique, and require an understanding of what happens to the muscles, ligaments, joints, and bones under that kind of pressure while in positions “normal” athletes can’t achieve.

Dancers are artists, and as such, they are concerned with precision and presentation, clean lines, and perfect body position. The emphasis is more on grace and flow than power and speed. Dancers need to be highly flexible, but when they are lacking flexibility in one joint they compensate by overloading on another structure, which results in an injury. A therapist treating dancers needs to be aware of their concern with body image and create strengthening programs that do not bulk the dancer, while being aware of necessary caloric intake and eating disorders that can unfortunately be common in the sport. Most dancers have less exposure to trainers, therapists, and doctors than athletes in other sports, due to less exposure and financial compensation for dancing. Dancers often lack education about non-dance related training that might contribute to their success, like nutrition, core strengthening, and other strategies.

Dance injuries can occur in various parts of the body—in all types of structures and tissues. The following lists break down where injuries come from, and why they occur.

Causes of dance injuries by structure:

  • Bone: Fractures, stress fractures and stress reactions can be caused by overuse, poor nutrition, and falls.
  • Ligament: Tears and sprains are caused by muscle weakness, fatigue, poor proprioception (balance), and poor technique/mechanics.
  • Muscle: Tears and strains are caused by overuse, weakness, lack of rest, and poor hydration and nutrition.
  • Joint: Sprains, cartilage injuries and ultimately arthritic changes are caused by poor mechanics, overuse, weakness, and poor nutrition.

Common dance injuries by joint:

  • Neck: Strains of muscles caused by sudden high velocity movements.
  • Shoulders: Strains along with rotator cuff and labrum injuries related to lifting can occur. This is caused by weakness, lack of control, and lack of core strength.
  • Low back: Muscle strains, spondylolisthesis (displaced vertebra) and disc injuries are related mostly to poor lifting mechanics and weakness of core muscles.
  • Hips: Hip flexor tendonitis occurs due to weakness and ROM limitations (in the hamstrings), impingement syndrome (pinched nerves), and labrum tears also occur, due to relative weakness and lack of appropriate mobility.
  • Knees: There are many different ways dancers can injure their knees. Strains to tendons and ligaments can occur due to poor hip strength and limited ROM. Patello-femoral pain is caused by weakness of quad muscles and poor hip and foot position and strength. Meniscal tears can also occur due to twisting injuries.
  • Shins: Shin splints, stress reactions, and fractures are caused by overuse, poor mechanics up and down the kinetic chain, and possible poor nutrition.
  • Foot and Ankle: Ankle sprains are a common injury among dancers and become much more complicated with added plantar flexion (point position). Tendon injuries, metatarsal stress injuries, big toe injuries (due to arch collapse), forced turnout, lack of ROM, and ankle impingement due to poor mechanics, weakness and overuse are all possible injuries.

Physical Therapy Evaluation: What do we look for?

Because there are so many different injuries that can affect dancers, it is important to be evaluated by a physical therapist that can identify the exact cause of the problem, and then determine how to fix it. The goal of a physical therapist’s evaluation is to get a complete picture of an individual dancer’s areas of concern, pain, weakness, and hypo-mobility. We then design a program to correct these issues, prevent further injury, and allow function at the highest level. A physical therapist will evaluate:

  • General posture of the shoulders, pelvis girdle, and feet.
  • General ROM and mobility of the trunk, pelvis, extremities, ankles, and feet/toes.
  • ROM and mobility relating specifically to dancing. This includes body movements in turnout, point position, grand battement (straight leg raise in flexion, extension and abduction), lumbar flexion/extension, and big toe mobility.
  • Functional mobility. We evaluate how dancers squat in parallel and turnout, perform a drop test, a straight leg raise, forward and center split, and hip extension.
  • Strength (generally and specific to dance) of the abdominals, hips, knees and ankles, and general upper body.
  • Proprioception (balance) is measured by single leg stance tests and step-to-stability tests in three planes of movement and point position.

Prevention:

It is imperative to recognize limitations in strength, flexibility and mobility prior to injury by utilizing a professional evaluation, and then designing a program to address these limitations in order to allow pain-free performance. Prevention evaluation on an individual basis is more accurate, but a general program addressing common limitations can be applied to benefit groups as well.

Treatment:

Treatment is specific to the individual dancer’s dysfunction and deficiencies, utilizing specific physical therapy techniques developed over years of experience.

The Foothills Sports Medicine-Phoenix physical therapy clinic specializes in the treatment and prevention of dance injuries. We treat dancers from all dance disciplines, young to professional, from companies and studios in Arizona to parts of the Western U.S. Additionally, we have designed prevention routines specific to one’s dance discipline, age, level, and goals. Dancers are some of the hardest working athletes, and they are under-served when it comes to injury prevention, education and treatment when needed.