"Volleyball Shoulder" is common and under-recognized

[kvball18]

Kvball18 spouse and I are both in the medical profession but were not familiar with this injury until it was diagnosed in two local D1 collegiate teammates this season.  We set to digging for information and found that, while considered uncommon in the general population, various studies that say "volleyball shoulder" is found in somewhere between 13% and 45% of elite volleyball players.  

Suprascapular neuropathy, also called infraspinatus syndrome, or "volleyball shoulder", is an injury to the suprascapular nerve, causing atrophy (wasting away) of the infraspinatus muscle, which is one of the 4 rotator cuff muscles, located just below the shoulder blade.  It appears to be caused by repeated powerful overhead spiking and serving motions and only happens on the dominant (hitting) side.  Sometimes the nerve injury is due to compression by a ganglion cyst or by an enlarged ligament (both of which can be identified on MRI), or by a narrowed bony (spinoglenoid) notch under the shoulder blade (which can be surgically widened).  These can compress the nerve, and these entrapments of the nerve can be reversed surgically.  

More often though, in volleyball players, it appears that the nerve is just damaged by repeated traction during forceful overhead hitting and serving motions.  Some athletes present with shoulder pain but most are asymptomatic except perhaps for noticing some weakness and/or heaviness in the arm.
The first photo is of a pro beach volleyball player (identified as a former world champion) with atrophy of the right infraspinatus muscle.  The second photo is of a 17 year-old indoor and beach volleyball player with the same atrophy on the right side.  Both had no symptoms, except weakness of certain movements on the dominant side.  The infraspinatus muscle is primarily responsible for external rotation of the arm and cross body movements.  So if you bend your arm 90 degrees at the elbow and then try to rotate it outward against resistance, you will be much weaker on the side of the atrophied infraspinatus muscle.  And if you do cross body pulls starting from above and away from your body, pulling down across your body, that will be much weaker also.

One group of medical researchers went to a pro beach volleyball tournament in Europe and got 84 pros to be examined and have MRI's.  They found 30% of the athletes, including the one whose photo I attached, had infraspinatus atrophy in their hitting shoulder and marked weakness in external rotation on that side.  Many of them were completely unaware of it.  They compensated with their other rotator cuff muscles and continued to play at a high level.

For athletes who are found to have a RECENT development of supra scapular neuropathy, Xray and MRI can rule out a cyst or other structure compressing the nerve.  If the athlete has shoulder pain, doctors will often operate. Even without a cyst or other ligament compressing the nerve, some surgeons will operate to widen the bony spinoglenoid notch that the nerve travels through, so that the nerve is not pinched during powerful overhead movements.  If it is not felt to be a surgically reversible condition, then a course of physical therapy for scapular stabilization/mobilization and rotator cuff strengthening, can be helpful.  From what I have found, it sounds like the muscle atrophy is usually not reversible if it has been present for 6 months or longer.

Since this appears to be such a common condition in powerful volleyball hitters, I thought it would be worth a mention so that coaches, trainers, and the athletes themselves are more aware of it.  I would guess there are quite a few of you in the Volleytalk community with backs that show atrophy of the infraspinatus muscle (even if we don't all look like the ripped guy in the photo).   

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[kvball18]

This is another beach shot of the right shoulder infraspinatus atrophy on a female hitter.  It looks more dramatic with the sunlight, but in general, appears as a slightly scooped out area under the shoulder blade (whereas the muscle is rounded on the non-hitting side).  In retrospect, this athlete developed the condition a full year before it was first recognized.

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[dunninla]

yikes. my shoulder is usually sore, but rather than from hitting, I think it is from diving in the sand with fully outstretched arms, which I think torques the rotator cuff.

Thanks for posting this. As an aside, there are neve pinch problems with some female softball pitchers ... it has a name but it slips my mind at the moment. Hazards of over overuse. Softball pitchers, though rarely, also suffer from blood constriction issues in the more developed pectoral area.

[kvball18]

Here is the anatomy of the back of the shoulder.  The nerve gets damaged as it passes under a notch in the shoulder blade, on its way to the infraspinatus muscle.

I also found a couple more photos of pro beach players who look like they have "volleyball shoulder".  (It's much easier to recognize it in beach players without a jersey on.)

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[akbar]

From what I gather, more and more trainers are stressing strength training in the upper and lower back muscles to pull the shoulder capsule back as it naturally moves forward and in from overuse.

Hopefully that made sense.

[vbman100]

Is there some way to prevent this, other than surgery? Are there certain exercises or strength training one can do to avoid this?

Do baseball pitchers or quarterbacks get this?

[kvball18]

One of the players who was found incidentally to have this, was told by her physical therapist that she was more flexible than is typical, in some shoulder movements. That might have predisposed her to stretching the nerve excessively during the hitting motion (though I suspect it might also have contributed to her hitting the ball with more force). Here are a few other tidbits I found.

Physical Therapy
On the basis of reports in the available literature, nonsurgical care should result in a satisfactory outcome in most cases within 6-8 months. Most reports indicate that patients who are treated conservatively are generally able to resume their previous level of function, including high-level sports participation. In athletes without pain or limitations in the performance of sport-specific skills, a simple program of exercises for scapular stabilization/mobilization and rotator cuff strengthening is probably reasonable. Such a program should prevent not only progression of the condition, but also secondary impingement of the rotator cuff.

Longitudinal follow-up findings suggest that muscular atrophy is generally not reversible to a significant extent, although symptoms of pain may improve with time. The athlete may return to play when he or she is able to perform appropriate skills without provoking symptoms.

*Ferretti proposed that suprascapular neuropathy in volleyball players is related to performance of the floater serve. If so, the incidence of volleyball shoulder is expected to decrease because, with the advent of the jump serve or spike serve, the floater serve has become less popular. (Ferretti, who has written extensively about volleyball shoulder, hypothesized that the mechanism of selective injury to the terminal portion of the suprascapular nerve in volleyball players is traction on the nerve due to repetitive, sudden, eccentric activation of the infraspinatus during the deceleration phase of the floater serve.) To the author's knowledge, no definitive study findings implicate specific spiking styles in suprascapular neuropathy; thus, providing technical advice about biomechanics to volleyball athletes with suprascapular neuropathy is difficult. Additional considerations remain unanswered; for example, the duration and magnitude of the load that is sufficient to precipitate volleyball shoulder through chronic overuse is unknown.

Of the two college teammates found this season to have the neuropathy, one had just developed the condition and was having pain.  She underwent surgery to release the nerve entrapment.  The other athlete could look back on photos and video and see that it had existed for a couple years, so the muscle atrophy was very unlikely to be reversed.  She was asymptomatic, and is undergoing shoulder PT while continuing to play.

And, another shoulder:

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[kvball18]

Jan 16, 2015 8:45:25 GMT -5 vbman100 said:

Is there some way to prevent this, other than surgery? Are there certain exercises or strength training one can do to avoid this?

Do baseball pitchers or quarterbacks get this?

Yes, it is also well known in baseball players and any other sport with forceful repetitive overhead motions.  But it seems particularly prevalent in volleyball players.  A sports orthopedist friend of ours, who is an NFL team doctor, had encountered it in a football player who had a prior rotator cuff injury that caused a ganglion cyst that compressed the nerve.  But he didn't seem aware of how common it was in volleyball players, even without any mechanical compression of the nerve.

(It would make sense that doing the kinds of shoulder strengthening/stabilizing exercises that are used in PT to treat the condition, could potentially prevent some young athletes from developing the neuropathy.)  

[papadoc]

It is remarkable to see the pictures of volleyball players who clearly have this and are asymptomatic. There aren't a lot of pictures of athletes with their posterior shoulder exposed, i.e. on the beach, but when they have their arms behind their backs the atrophy is most apparent. It's surprising that this has not gained more attention, and I suspect it is because in the majority of athletes with this, no pain or other symptoms are noted. Since some studies suggest that those with more range of motion in their arm, and hence likely better hitters, may be prone to this, it may be that it is not present in those playing at lower levels (such as high school or club). It would be interesting to do a prospective study on D1 hitters to see if the numbers correlate with those noted in professional beach players.

[volleyhoops]

I heard of this recently with one of my daughters friends. I wonder if testing and prevention will help like awareness of ACL injuries seems to have done.

[bayarea]

It sounds like a good starting place is making sure that youth hitters are doing appropriate shoulder strengthening exercises, and also being aware of this if they notice any weakness and pain in the shoulder, to get an orthopedic evaluation. Seeing the photos now, it seems obvious what the abnormality looks like, and yet most of us have seen these players and probably never noticed it if we weren't specifically looking for it. Same thing for the HS/college kids playing...if you aren't looking for it, you aren't likely to see it.

[Wiswell]

Would this happen in tennis or does the racket mitigate this?

[kvball18]

Yes, it does happen in tennis and baseball, and occasionally in other activities like construction workers pounding overhead nails, etc, but far less often than in volleyball players.

From Medscape: "Athletes who participate regularly in overhead sports are more susceptible to developing suprascapular neuropathy. Sports such as baseball, volleyball, and tennis demand skills that place substantial load on the athlete’s shoulder when the upper limb is in an overhead or abducted and externally rotated position.

Epidemiologic studies have demonstrated that athletes who participate in these and other overhead sports are at higher risk for overuse injuries of the shoulder in particular, including rotator cuff tendinopathy and injuries to the glenoid labrum. Suprascapular neuropathy has been reported to cause 1-2% of all shoulder pain and is therefore often overlooked. However, the prevalence in higher risk athletic populations, such as volleyball players, has been reported to be as high as 33%. Therefore, suprascapular neuropathy should be considered when evaluating shoulder pain in an overhead athlete."

[volleyhoops]

Sounds like we need testing and evaluation similar to ACL studies.

[bayarea]

Is anyone doing routine ACL testing in volleyball? I have seen a lot of girls go down with ACL tears, but wasn't aware that anyone is "screening" for it?