Pointing Out the Top 10 Pediatric Sports Musculoskeletal Injuries

The Top 10 Sports Musculoskeletal Sports Injury list is a ranking that I'm guessing most athletes don't want to make, and most parents don't want to miss.

How to best know if you belong on this list?

Trust your finger tips.

Speaking at the 2016 American Academy of Pediatrics National Convention and Exhibition, I was asked along with good friend and colleague Hank Chambers to share insight on identifying and managing the Top 10 Pediatric Sports Musculoskeletal Injuries with a Case-Based Review.

Our Top 10 aptly started at the top of the body (neck) and ran down to the bottom (foot/ankle) with several injuries in between.

We looked at:

• stingers
• shoulder pain
• elbow injuries
• wrist injuries
•  low back pain
• hamstring avulsion injuries
•  acute knee injuries
•  shin pain
• ankle sprains
• heel pain in growing children.

Some were fairly serious and activity threatening, others were more of a nuisance.

A pretty diverse offering of injuries, so one would tend to think that there would be little that actually brings them together.

However, for those listening to the talk, they heard us mention a similar refrain over and over again.

The value of your finger tip.

In helping to determine a type of pain that merits medical attention in the first place, and helps sort out the particular diagnosis, the more localized the pain, the greater the potential concern.

For example,. if a child is reporting pain in the lower leg and uses a wave of the hand to indicate that the discomfort runs along the entire inner shin, then there is one level of concern.

However, if that same child takes the tip of their index finger and points directly and emphatically to a single spot on the inside of the shin bone, my concern is amped up several degrees.

While none of us have x-ray vision, that finding of finger-tip pain is a pretty good surrogate and does tend to correlate with a higher potential of a bone injury, be it a fracture, stress injury, or damage to a apophysis where a tendon attaches to a bone growth region.

So, no matter the body part, from elbow to wrist to foot or ankle, if any young athlete opts to use a finger tip to identify their pain, then use your finger tips to dial up your sports medicine specialist and seek out immediate and appropriate evaluation.

Six Common Indoor Volleyball Injuries

Working with Olympic level male and female volleyball players has allowed a unique appreciation for common injuries patterns seen in this wonderful yet demanding sport. Since there are six players on the court, I will identify six  frequently seen injuries and will also focus on key prevention tips for players at all ages.

1) Concussions

Most of the concussions I encounter are seen in liberos or defensive specialists, usually from direct impact either from attempted passes of hits at the net or collisions with other players or objects (poles, chairs on courtside) when diving for a ball. I have also seen a fair amount of concussions resulting from mis-matches on the court, namely defensive players trying to return serves or hits from much stronger and older players.

Any new sign of concern (such as dizziness, headache, blurred vision) or behavior change after head trauma should mandate removing the player from all activity and not returning until appropriate clearance from a sports medicine specialist who is familiar with concussion care. 

For more information about dealing with sports-related concussions, click here.

Prevention tips for the volleyball player include calling  for balls before starting a dive, ensuring defensive players are aware of incoming balls during hitting/serving drills, limiting older and stronger players from hitting into younger players, and protecting the boundaries of the court to limit impact with chairs or other objects.

2) Shoulder injuries

Between serving, setting, passing, hitting, blocking and diving, the shoulders receive an amazing array of demands, so it should be no surprise that shoulder injuries are among the most common volleyball-related concerns.

Most shoulder injuries are due to repetitive use and overload stress  leading to common abnormalities. Tightness in the front of the chest leading to a more forward position of the dominant shoulder can reduce normal function of the rotator cuff muscles, leading to pain and decreased hitting and serving accuracy and speed.  Tightness in the back of the shoulder glenohumeral joint can decrease the follow-through phase of hitting or serving and lead to problems with the labrum (soft tissue past between the ball and socket), the inside of the elbow, and even the lower back.

Appropriate stretching exercises combined with strengthening exercises of the scapula (wingbone) can reduce the risk of shoulder overuse injuries. Avoid hitting and serving with signs of fatigue (balls tend to go long with reduced speed) or any form of shoulder pain. Reducing the overall number of hits/serves can help, but more formal hit or serve count recommendations have not been studied at this time.

3) Finger/Hand Injuries

Tend to see finger joint sprains and dislocations mostly with blocking at the net. Rigid wrists with widespread  and relaxed fingers not only allow better ball placement down in the opponents court, but also reduce the chance for acute injuries.

The widespread finger position does place unique stress on the skin web spaces between the fingers that can lead to lacerations or breaks in the skin that are extremely difficult to heal, even with the placement of sutures. Better to prevent these lacerations in the first place by moisturizing the skin between the fingers on a daily basis. 

4) Low Back Pain

Volleyball-related back pain can come either from leaning forward such as with passing or following through on a serve/hit or more with leaning back such as in setting or initiating a serve or hit. Pain that is more with leaning forward could cause issues with the discs between the bones of the lower spine, while pain leaning back could lead to stress injuries of the posterior spine or joints.

It is amazing how much shoulder dysfunction (discussed above) can lead to back problems in volleyball players. If you haven't already, take the time to review post linking shoulder issues to back problems.

Learning how to initiate movements with the gluteal muscles in the buttock area can reduce stress on the lower back, especially with jumping. Single leg gluteal strengthening activities are particularly recommended. Certain technical errors, such as reaching too far for passing or hitting, can also increased forces on the lower back. Setters should attempt to make contact with balls right above their head- reaching too far forward for front sets or backwards on back sets is not the best for long-term back health.

5) Knee Pain

If you are a volleyball player who doesn't have knee pain, then either you are extremely fortunate or perhaps in a bit of denial. 

The repetitive jumping in volleyball often leads to pain in the front of the knee, especially in the patellar tendon connecting the kneecap to the shin bone. Throw in frequent knee contact with the hard wood court surface and you have a recipe for knee problems.

For healthier volleyball knees, pay attention to the following recommendations:

• Avoid landing on straight knees. Always land and move "softly" with hips, knees and ankles in a bent position.

• Try to land in good alignment, with the hips and kneecaps lined up with the second toe. Don't let your knees collapse in or rotate.

• Initiate jumps with the gluteal muscles in the buttock region. This will improve knee and also lower back function.

• The best time to stretch the muscles that support knee function is after practice or after a match when the muscles are warm. Focus on hamstrings, quadriceps, hip adductors/abductors and calf muscles.

• Knee pads help reduce bruises and pounding, especially with repetitive diving drills. 

6) Ankle Sprains

Ankle sprains are the most common acute injury in indoor volleyball, and very few things spark intense debate in the volleyball community more than the question about using ankle braces to prevent these type of injuries. 

The majority of ankle sprains are when the ankle inverts (rolls in) and this most often occurs with play at the net where athletes make contact with another players foot when landing from a jump during hitting or blocking. More chaotic play such as with bad passes or plays out of system can also put ankles at risk.

The theory behind bracing is to reduce abnormal ankle motion, but some fear that depending on bracing might make lower leg supporting muscles weaker and maybe even increase the risk of knee injuries.

Click here to review the debate on ankle braces.

Once an ankle sprain has happened, little doubt that the combination of bracing and appropriate rehabilitation exercises can reduce the risk of future injuries.

Never hesitate to seek the opinion of a sports medicine specialist with any volleyball injury or to learn additional tips to prevent these problems.

Back Pain with Volleyball Serving or Hitting? Look at Shoulder Function for Possible Cause

Whether you are a junior level or even an Olympic caliber volleyball player dealing with back pain during serving or hitting, chances are that shoulder mechanics are part of the problem.

Starting the serving or hitting motion requires both extension (leaning backward) and rotating or turning of the lower back in the direction of ball contact. For a right handed hitter or server, that would mean having the trunk and lower back rotate toward the right.

Dave Smith (#20) in early hitting phase shoulder position

Finishing a serve or hit requires rotation of the lower back away from the side of ball contact. Again, for that right handed hitter or server, that would mean having the trunk and lower back rotate towards the left after ball contact. 

Kim Hill (#15) with late hitting phase shoulder position

This normal flow of movement puts localized stressors on the lumbar vertebrae bones that surround and protect the spinal cord in the lower back region between the rib cage and the pelvic bones.

Certain parts of these lumbar vertebrae, called the posterior elements which include the pars interarticularis,  pedicles, and articular process/facet joints that are at unique risk for overload injuries due to repetitive compression forces and somewhat limited blood supplies to these regions. 

Courtesy of www.studyblue.com

In medical terms, we would call pain coming from these movements extension or rotational-based lower back pain, and it thus would seem very logical then to focus evaluation and treatment on the lumbar spine mechanics themselves.

However, my experience in working with higher level volleyball players has taught me that often the dominant shoulder can be a primary contributing culprit to this extension or rotational-based back problem, so now when I evaluate any such type of back pain in a volleyball player, I start by looking at the shoulder.

There are commonly two types of shoulder tightness patterns that can lead to both shoulder problems and pain at the lumber spine.

• TIGHTNESS OF THE FRONT OF THE SHOULDER AT THE CORACOID PROCESS

The pectoralis minor, coracobrachialis and biceps short head muscles all attach to the coracoid process, which is a bone prominent coming off of the scapula.

Courtesy of fashions-cloud.com

Tightness at this attachment site can create a hunched over posture that moms always like to warn about, but also can limit the ability to raise and reach back the shoulder which provides the power needed to hit a ball at the high end of a set or the toss before serve. 

If a player has limited flexibility in the front of the shoulder at the coracoid, one frequent way to compensate (or some would say, cheat) is to over-rotate at the lumbar spine in an effort to get the hitting hand far back enough to generate powerful hits or serves.

This over-rotation, while at first might allow the player to maintain high performance, may ultimately cause higher cumulative overload forces on those posterior elements of the lumbar vertebrae and those undesired stress injuries.

This condition causes pain EARLY (before ball contact) in the hitting or serving motions, and  proper identification and correction of tightness at the coracoid process can lead to healthier shoulder and back function.

• TIGHTNESS OF POSTERIOR SHOULDER CAPSULE

The glenohumeral joint is the "ball and socket" joint that is surrounded by a soft tissue joint capsule.

Courtesy of heyyoungbeliever.com

Repetitive overhead motion such as hitting or serving can lead to tightness in the back of this capsule, leading to limitations in shoulder internal rotation or the follow-through phase after ball contact.

Called Glenohumeral Internal Rotation Deficit (GIRD), this tightness can lead to reduced accuracy and speed of hits/serves.

Many volleyball players will compensate (aka cheat) by increasing rotation of the lumber spine away from the side of ball after making contact, and eventually this too will place unwanted forces on those posterior elements of the lumbar vertebrae.

GIRD causes pain LATER (after ball contact) in the hitting or serving motions, and just like with anterior shoulder tightness, proper identification and correction can reduce both shoulder and back issues while allowing more high level function.

PRE-EMPTIVE PREVENTION

Volleyball players do not have to wait for the onset of back or shoulder pain to address potential problems. Fairly quick measurements of both anterior and posterior shoulder motion patterns can lead to suggestions for stretching programs, and I routinely incorporate these into pre-season or pre-participation evaluations as part of sensible injury prevention programs.