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Journal of Back and Musculoskeletal Rehabilitation 20 (2007) 115121 IOS Press

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A prospective study of injury incidence among elite and local division volleyball players in Greece
A. Beneka, P. Malliou, G. Tsigganos, A. Gioftsidou, M. Michalopoulou, E. Germanou and G. Godolias
Department of Physical Education and Sport Science, Democritus University of Thrace, Komotini, Greece

Abstract. The aim of the present study was to record prospectively the injury incidence rate among elite and local division players in Greece and compare them in terms of their injury prole. A total of 649 Greek male and female volleyball players participating in the Greek Volleyball championships involving rst division and local division, were observed on monthly basis for the 2005-06 period. The injury incidence rate, severity, diagnosis and the anatomical location of the injuries, which occurred during practice and competition in all the championship period, were recorded prospectively. Data were statistically analysed using X2 analysis of SPSS statistical package. In terms of professional volleyball exposure time, elite athletes reported fewer injuries than the local division players. Although, ankle sprain was the most frequent injury for both groups, nevertheless chronic injuries were less for elite compared to local division players. Moreover, the most important injury factors aside from step on others foot were for elite players fatigue while for the local division players were incorrect sprawls and wrong technique. Most injuries occurred during training and competitive season in middle heaters and universals. In conclusion, elite players reported fewer injuries compared to local division players and their injury prole was different. Keywords: Injury rate, acute injury, chronic injury, elite volleyball players

1. Introduction Volleyball is a complex discipline with high technical tactical and athletic demands on the players [22]. Serving, passing and setting the ball are accompanied with spiking or attacking actions [7]. Starting with an approach followed by a vertical jump, one of the objectives of the volleyball spike is to hit the ball at the highest possible speed [25]. A highly skilled attacker with 16 to 20 hours of weekly practice time spikes for example about 40000 times a year [22]. Considering the various technical requirements and the popularity of the sport, studies have studied injury incidence and indicated that they are quite frequent [13,
Address

27,29,30]. The injury incidence is between 1.7 and 4.2 per 1000 hours of play [1,4,29] and it is the fourth most common source of sports injuries [29]. Despite the large number of studies for injury incidence in volleyball and factors related to them there is a gap concerning the inuence of expertise level professional players or not in injury rate related to all the factors mentioned, such as type, severity, anatomical location of injuries, if they occurred during practice or game or during competitive or pre or postseason. 2. Materials and method 2.1. Study population A total of 649 Greek male and female volleyball players participating in the Greek Volleyball championships involving rst division and local division, were observed on monthly basis for the 20052006 period.

for correspondence: Dr. Anastasia Beneka, Department of Physical Education and Sports Sciences, Democritus University of Thrace, Campus, 69100 Komotini, Greece. Tel.: +30 2531039681; Fax: +30 2531039662; E-mail: ampeneka@phyed.duth.gr.

ISSN 1053-8127/07/$17.00 2007 IOS Press and the authors. All rights reserved

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A. Beneka et al. / A prospective study of injury incidence among Greek volleyball players Table 1 Age, anthropometric characteristics and training prole of the volleyball players in relation to playing division and sex Characteristic Sex Age (years) Weight (kg) Height (cm) Training years Hours training per week Values are means (SD). Elite (n = 310) Male (n = 159) Female (n = 151) 25.69 (4.9) 21.99 (5.4) 84,93 (10.5) 64.66 (9.5) 190.94 (7.7) 174.9 (11.4) 10.59 (4.9) 9.9 (5.3) 13.05 (6.0) 11.4 (4.7) Local division (n = 339) Male (n = 159) Female (n = 180) 24.08 (6.5) 22.35 (5.3) 183.48 (8.1) 172.1 (5.6) 78.41 (11.5) 62.16 (6.7) 8.01 (6.0) 8.2 (5.0) 6.0 (2.2) 6.4 (2.3)

Table 1 gives the age, the anthropometric characteristics and the training prole of the involved participants. The aim of the present study was to record prospectively the injury incidence rate among elite and local division players in Greece and compare them in terms of their injury prole.

3.1. Injury rate During the period of the study (12 months) the total sample (n = 649) reported 455 injuries. In order to study the different injury rate in relation to playing division, the 649 male and female players were divided into two groups, the elite group (n = 310, professional volleyball players of the rst division) and the local division group (n = 339, volleyball players of the local division) (Table 1). The 310 elite volleyball players reported 248 injuries during a total exposure time of 131000 h per year, representing overall incidence 0.8 injuries per player per year. In terms of professional volleyball exposure time, they reported 1.89 injuries per 1000 hours of training per player. Also, the 339 local division volleyball players reported 207 injuries during a total exposure time of 72613 h per year, representing overall incidence 0.61 injuries per player per year. In terms of local division volleyball exposure time, they reported 2.8 injuries per 1000 hours of training per player. 3.2. Training or game Table 2 reports that the injury rate during training session was statistical different in comparison to game injury rate (X 2 = 35.53, p =< 0.05, X2 = 36.53, p =< 0.05) in both groups. There were not found any difference in injury rate during game or training in relation to playing division (X 2 = 0.641, p = 0.423 >0.05). 3.3. Time of season

2.2. Data collection and denition of the injury An orthopaedic surgeon, a physiotherapist, and a trainer made up the questions that included in the interview. The injury incidence rate, the characteristics of the injuries (severity, diagnosis) and the anatomical location of the muscle skeletal injuries, which occurred during the practice and competition in all the championship period, were recorded prospectively during the period. Injury was dened as "any mishap occurring during scheduled games or practices that cause an athlete to miss a subsequent game or practice session". Injuries were classied into three grades of severity: minor (absence from training or competition for less than one week); moderate (absence from training or competition for one week to one month); major (absence from training or competition for more than one month). This classication has been used in many studies [911,20, 21].

3. Results The data were statistically analysed using X 2 analysis of SPSS statistical package to determine whether any of the previously mentioned factors had a relation to the incidence of injury. In all cases, the null hypothesis was rejected when p < 0.05. Subdividing the year into three periods: the preseason season (that lasted 2.5 months), the competitive season (period that lasted 6 months), and the postseason (period that lasted 3 months) allowed assessing the role that each period might have to injury occurrence. According to the results the injury rate in competitive season was statistical different in comparison to

A. Beneka et al. / A prospective study of injury incidence among Greek volleyball players Table 2 The injury rate for the volleyball players during training and game in terms of different playing division Category Elite Local division Total Injuries in training (cases) 172* 136* 308 Injuries in games (cases) 76 71 147 Total Injuries (cases) 248 207 455

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3.6. Severity of injury and injury factor The severity of injuries is presented in terms of absence from competition or training after the injury. No statistical differences between severities of injury in relation to playing division (X 2 = 0.642, p = 0.625 > 0.05) were observed (Table 7).

*Statistical different.

4. Discussion
Table 3 Injury occurrence for both groups in terms of the season of the year Category Preseason Competitive Season Postseason Missing injuries injuries injuries cases Elite 84 155* 8 0 Local 69 132* 5 2 division Total 153 287 13 2 *Statistical different.

preseason and postseason injury rate for both groups (X2 = 20.4, p =< 0.05, X2 = 19.174, p =< 0.05) but there were not any difference in relation to playing divisions (X2 = 0.035, p = 0.851 > 0.05) (Table 3). 3.4. Playing position in relation to injury occurrence Table 4 reports the position of the injured and not injured players in terms of category groups. There were not nd any difference between the two playing divisions for all volleyball positions (Setter: X 2 = 3.197, p = 0.0.074 > 0.05, Libero: X2 = 0.805, p = 0.352 > 0.05, Outside hitter: X2 = 0.070, p = 0.791 > 0.05, Universal: X2 = 0.033, p = 0.856 > 0.05, Middle hitter: X2 = 0.127, p = 0.721 > 0.05). 3.5. Type, anatomic location and diagnosis of injury Table 5 shows that, for the total sample, injuries were distributed throughout the body. According to the results the acute injuries were signicant different in comparison to chronic injuries (X 2 = 107.9 p < 0.01) and the ankle was the most common injured anatomical location (X 2 = 168.2 p < 0.01) for all players. No differences were found in relation to the playing division (X 2 = 0.409 p = 0.522 > 0.05). According to the physicians diagnosis, 455 cases were analyzed. Therefore, according to X 2 analysis the sprains were signicant different in comparison to the other injuries (X 2 = 508 p < 0.01) (Table 6).

The results of the present study revealed that the players of the rst national division reported 248 injuries during a total exposure time of 131000 hours/year representing overall incidence 0.8 injuries per player per year. The players of the local division reported 207 injuries during a total exposure time of 72613 hours per year representing overall incidence 0.61 injuries per player per year. The prevalence of the injuries for elite players is higher than that reported by Augustsson et al. [3] who noted a rate of injuries corresponding to 0.68 for elite male Swedish division. However the differences in study design might partly explain the difference in study results. In the present study the teams were introduced to the survey at the beginning of the season through their physical therapist and the data were collected prospectively. On the contrary, in the study of Augustsson et al. [3] the teams were introduced to the survey at the end of the season through their team coach and the data were collected retrospectively. One common problem that is associated with retrospective studies is that there might have been players who did not receive the questionnaire and the response rate was 70%, while in our study data were collected from all the players that were asked for participating. Another problem with retrospective studies is that many players might forget minor injuries because of a major injury. Gathering data prospectively as in the present study, every single injury is recorded. Another problem associated with epidemiological studies on sports injuries is the denition of injury. A broader injury denition based on the time lost which has previously been recommended was used in this study [18]. The disadvantage however of this denition might be that one player may elect continue playing volleyball, while another player would stop playing with a similar injury. The report from one player may therefore result in the recording of an injury, while another will not. This problem might be quite common in volleyball as well as in other sports, as overuse injuries often do not keep some players from participating in

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A. Beneka et al. / A prospective study of injury incidence among Greek volleyball players Table 4 The position in terms of category group of the injured and not injured volleyball players Specialty of players Setter Libero Outside Hitter Universal Middle Hitter Total Elite (n = 310) Injured Not injured 37 21 20 15 22 21 50 23 54 43 183 123 Local division (n = 339) Injured Not injured 30 33 21 24 35 37 51 25 44 39 181 158 Total (4 missing value) Injured Not injured 67 54 41 39 57 58 101 48 98 82 364 281

Table 5 Acute and chronic injuries for the volleyball player in different playing divisions in terms of anatomical location Location Volleyball players Ankle-foot Knee Thigh Shoulder Hand Spine Elbow forearm Leg *Statistical different. Acute injuries (n = 338)* Elite (n = 179) Local (n = 159) 75* 72* 24 21 21 25 22 13 13 18 10 3 4 6 8 3 Chronic injuries (n = 117) Elite (n = 69) Local (n = 48) 1 0 9 6 4 1 15 20 29 9 3 Total injuries (n = 455) 148 38 51 70 31 51 10 14

training or matches. Moreover, other factors, such as the importance of the players or the match, could affect the decision of the player to participate [1,23]. Professional athletes are usually more hesitated in reporting an injury because this might be a cause to be excluded from the next competition, meaning less money. However, the time lost denition represents a useful measure of the severity of injury and takes account of those injuries that most probably have an important impact on the players performance [18]. When injury occurrence has been examined in relation to the total exposure time of the players (total amount of training hours and game play) the incidence rate for elite players was lower than that of the local division players. In more specic, elite players reported 1.89 injuries per 1000 hours of training or game per player, while local divisions players reported 2.8 injuries per 1000 hours of training or game per player. A previous study on soccer players with different skill and training levels also showed that injury incidence was inversely related to training level [12], since elite soccer players experienced less injuries. The fact that elite players are treated by professional team which is expert in medical care before and after their injury might partially explain the fact that they report lesser injuries than local division players who usually have no medical assistance or complete rehabilitation. Verhagen et al. [32] evaluated the cost effectiveness of a proprioceptive balance board training program for

the prevention of ankle sprains in volleyball. The authors concluded that the introduction of a proprioceptive balance board training programme to prevent ankle sprains requires nancial investment in the short term, meaning that only professional athletes can enjoy the privilege of this treatment. In addition, step on others foot and fatigue are the most common injury factors for elite volleyball players (X 2 = 423 p < 0.01). Also, incorrect sprawls and step on others foot are the most common injury factors for local division volleyball players (X2 = 150.9 p < 0.01) (Table 8). Moreover, this result might be also supported by the fact that motor excellence of elite athletes is due to their excellence in basic abilities. The cognitive, psychological and perceptual abilities which are improved through the training process possibly reduce injury factors such as wrong technique, or incorrect sprawls, or step on others foot found in the present study. In more specic, Kioumourtzoglou et al. [19] found that elite (expert) volleyball players were superior in judging coincidence, a nding which is in accordance with a study on expert tennis players [9]. These authors also found that experience inuences scores on coincidence anticipation timing. Finally, the authors found that expert volleyball players appeared to score better in multilimb coordination, explained by the fact that specic motor demands of the sport impose the need for accurate and precise movement for the manipulation of the ball.

A. Beneka et al. / A prospective study of injury incidence among Greek volleyball players Table 6 Type of injury in relation to different categories Type of injury Sprain Strain Rupture Fracture Tendonitis Dislocation Chondropathy Low back pain Other Injuries of elite players (n = 246) 99* 38 32 9 19 4 10 27 10 Injuries of local division players (n = 207) 93* 30 24 7 21 5 6 12 9 Total injuries (n = 455) 192* 68 56 16 40 9 16 39 19

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*Statistical different. Table 7 Severity of injuries in terms of different category group Volleyball players Elite Local division Total *Statistical different. Table 8 Injury factor in different categories Category Injury factor Incorrect sprawls Wrong technique Step on others foot Ball contact Fatigue Inappropriate warm up Other Missing values Elite group Injuries (n = 246) 31 39 81 13 65 12 5 2 Local division group Injuries (n = 207) 59 29 63 13 30 12 1 Total injuries (n = 453) 90 68 144 26 95 24 6 2 Minor injures (cases) 80 62 142 Moderate injuries (cases) 126* 114* 240 Major injuries (cases) 42 31 73

The results of the present study are also supported by evidence on injury mechanisms in volleyball and risk factors. Bahr et al. [4] suggested that specic technical training on take off and landing technique during attack and two-man blocking might be an intervention strategy for injury prevention in that sport. This means that as long as the athlete is getting more and more experienced or skilled in volleyball technique, the possibility of getting injured is reduced. This conclusion is also supported by Verhagen et al. [31] who showed that a minimal prophylactic programme of balance board training during warm up effectively reduced the incidence of ankle inversion injury among both male and female indoor volleyball players, but only among athletes with a history of prior ankle sprain. This suggestion might explain another important result of the present study for injury factors differentiating elite from local division players. The most important injury factors aside from step on others foot

were for elite players the fatigue while for the local division players were incorrect sprawls and wrong technique. This result explains also why elite players in the present study report more chronic injuries compared to local division players but less acute injuries. This conclusion is in accordance with other studies reporting that overuse injuries are also frequent complaint that sends volleyball players to their athletic trainers [26]. Similarly other studies supported that an important injury occurrence in volleyball players is referred to be overuse syndromes such as Achilles tendinopathy or tendinopathy of the patellar tendon [16]. Concerning the most frequent injury, ankle injuries accounted for almost half of all acute injuries recorded in the present study, and previous studies have also shown that ankle sprains account for one quarter to onehalf of all acute injuries in volleyball [6,14,15,17,26, 29,34]. Moreover, it is stated that in 78% of the cases,

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the players had a history of at least one previous ankle injury during their career [5]. This high incidence of ankle injuries is associated with blocking, followed by spiking [26,33] both of which require a jump. A 1987 review of outpatient rehabilitation records of 106 patients treated for volleyball injuries found that 63% of the injuries were related to jumping [15]. Most players injure their ankles when they land after blocking or spiking in the front court. The most common mechanism of ankle injury is forced supination that occurs when the blocking players foot lands on an opposing spikers foot that has come underneath the net and is in the conict zone. This mechanism explains also the ndings of the present study concerning the rate of step on others foot and incorrect sprawls as signicant injury factors. Similarly, Reeser et al. [24] stated that the blocker, who for tactical reasons jumps later than the attacker, may land on the attackers foot within this conict zone under the net. Approximately one quarter of indoor volleyball related ankle sprains occur when a blocker lands on a teammates foot when participating in a multiperson block. Consequently, middle blockers and outside attackers are at greatest risk of ankle sprains, and setters and defensive specialists are at comparatively low risk. An important observation in the present study was that most injuries occurred during training than during game, results which are in accordance with Augustsson et al. [3]. This is probably because of the fact that the players spent more time training than competing. Moreover, the higher injury incidence rate has been observed during competitive period related to the preseason period and the post season period. This result seems logical since in the competitive period the training load is usually bigger which requires more effort resulting in generally more severe fatigue. These high demands make athletes function under more pressure not only physically but also psychologically, resulting in anxiety and tension [2]. The majority of injuries were of moderate severity, fewer were of mild severity and very few were of major severity. This result is not in accordance with that of Augustsson et al. [3] and of Aagaard et al. [1] who found that the majority of injuries were of minor severity but they included only elite players in their studies which were retrospective and not prospective. Concerning the playing position the present study revealed that the majority of injuries for both elite and local division players occurred in middle hitters and universals. All of them are responsible for blocking,

hitting and generally are staying for more playing time in the court [28]. The results of the present study are in agreement with many authors reporting that defense is associated with a smaller number of injuries, and serving, passing and setting with even fewer [8,15,26, 33,34].

5. Practical implications Examine the injury incidence rate in relation to the total exposure time (training and game) and prefer prospective studies than retrospective Skill and training level inuence the acute injury rate in volleyball players Ankle injuries are the most frequent in volleyball players in all age categories, meaning that prevention programs should always be a part of the training program in volleyball. Overuse injuries are also very frequent, especially in elite players meaning that training load and intensity should be taken under consideration when designing the training program. In competitive period where the injury rate is more important, athletes should not forget their prevention exercise program.

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