пятница, 9 декабря 2016 г.

GREG DEA: VOLLEYBALL SHOULDER INJURIES

 


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BULLETPROOFING THE VOLLEYBALL SHOULDER

by Greg Dea
Attention Volleyball Athletes and Coaches:
  • Approximately 43% of you will have shoulder pain in any competition week.
  • Your pain will be between 2 and 6 out of 10.
  • About 15% of you will play with pain killing medication.
  • About 20% of you will go into a game with shoulder pain.
  • About 5% of you will injure your shoulder during a game.
  • If you’re earning money as a professional athlete and miss competition due to a shoulder injury, you’ll be costing thousands of dollars to your team.
  • Pain in the shoulder can lead to problems moving through the trunk, which can lead to pain in the low back, which can predict injury as far away as the knee [1, 2]. It’s no wonder the top three injuries in volleyball are the shoulder, back and knee.
These are the common statistics for shoulder injuries in volleyball. [3], [4], [5].
What is common in volleyball is not necessarily normal, or good.volleyball shoulder

This is how bad it could get
The “great shoulder crisis of 2015” was a drama that put a few careers on the line and nearly killed China’s World Cup of Volleyball dreams. That’s what Rett Larson and I called it when all seven of the starting lineup had pain and disability lifting their shoulders. China’s “Iron Hammer,” Coach “Jenny” Lang Ping, told me she’s never had a shoulder problem, and she hadn’t changed her training program, so she was confused.
I believe her. I’ve seen her hit a ball at her players. I don’t know her age, but I can see that her gracefully aging shoulder is very comfortable. The speed and sound does justice to her nickname. So when the crisis hit, she was confused as to why it would happen. We got to the bottom of the reason, and got the problems under control, but not before the pressure built up to worrying levels. Understandably so—these are very valuable players.
Lang Ping used to be in charge at Evergrande Volleyball. Sources tell me she offered the starting Chinese setter of the time $400,000 to play at her club. The offer was turned down. Other reports about the value of elite female volleyball athletes range from $100,000/year to $1million/year. Perhaps an average starting player receives $200,000/year outside of China. With such valuable players struggling to lift their arms a month out from the World Cup, one can see why “it” was about to hit the fan. Strengthening the shoulder three weeks out from the World Cup was NOT the solution. Bulletproofing it was.
In other words, offsetting the effects of training.
If that crisis occurred during the World Cup, or any other competition, it would have been very costly indeed. An average elite female volleyball athlete who isn’t available for match selection due to injury will cost her team approximately $548/day. She’s costing them that much and they’re not getting a match-ready athlete!
In the FIVB Beach Volleyball Injury Study [3], 20% of the 115 players interviewed suffered time-loss injuries ranging from one day to more than three weeks. Simply put, a professional volleyball athlete who suffers a shoulder injury that causes them to miss training or competition can cost a team $548 to $11,550 or even higher for an athlete NOT to be available for match selection. That’s just for wages. That doesn’t include treatment. It also doesn’t include the cost of foreign professionals whose job it is to control these things from happening. If we factor in the immense population interested in the success of this team, anxiety levels could creep up to catastrophic proportions.
With such agitation pending, let’s get some sporting perspective and release the valve a little. Such a crisis doesn’t rank, financially speaking, with the cost of injuries to athletes in the English Premier League [6]. Each day that a player was not available for match selection due to injury will cost, on average, £11,246, or approximately $US17,000/day! For some athletes, the total cost of days missed ran into the eight digits.
Even if your team has deep pockets, financial costs of shoulder injuries aren’t your biggest problem. The number one cause of future injury is past injury. Once a volleyball athlete has a shoulder injury, they are more likely to get another. And we’ve already mentioned how that shoulder injury can predispose them to problems with their lower back, which increases their future risk of low back [7] and knee injury [1, 2]. Don’t let that be the reason a player retires. Don’t let it be the reason you don’t win the trophy. We sure didn’t let it be the case with China winning the World Cup.
The shoulder issue doesn’t just affect the athlete. We’ve seen research coming out of European football about the correlation between injuries and trophies won [8]. Here’s what that research tells us.
And then it gets even worse
Let me break it to you gently:
Coaches of teams with above average injury rates win far fewer trophies. 
Coaches who injure their athletes at one club will injure them at future clubs.
Coaches with above average injury rates take their injury rate with them to the next club. The ability to draw an income as a coach depends on winning trophies, which is related to injury rates. Remember, once a volleyball athlete has a shoulder injury, they are more likely to get another, and a back injury and a knee injury. It seems that once a coach is used to training in a way that causes injuries, they are more likely to keep doing it. Don’t let your training be the reason a player retires.
I’d been with the team since the USA Volleyball Cup in Hawaii in June 2015. There’s a pidgin English saying in Honolulu, “If can, can. If no can, no can.” Usually followed by “It’s all good.” It’s a reflection of the local Hawaiian philosophy about going with the flow. That whatever happens, life is still good because there’s no point worrying about what can’t be controlled.
Life goes on. Don’t worry about it. It’s all good.
Except it’s not good when an athlete’s profession is railroaded by preventable injuries. It’s not good when the 3rd ranked team in the world suffers a shoulder injury epidemic. It’s far from good.
“You’re not supposed to have pain in your shoulder when you play volleyball. It’s common, but not normal. ~ Greg Dea”
The shoulder problem in volleyball
According to the FIVB, only 5% of athletes get a shoulder injury during competition that leads them to miss time in training or competition [4]. Don’t be fooled, though, because up to 20% of volleyball athletes will have an overuse injury to the shoulder that they carry into competition [5]. That’s the 20% that we know about, with the current injury reporting methods underestimating the real extent of shoulder problems [3]. Indeed, in an eight week beach volleyball competition, as much as 43% of women and 26% of men reported shoulder pain in the previous week, with 12-16% using pain medication while playing [3]. Most athletes didn’t miss competition due to these symptoms, but of those that did, most were due to the shoulder symptoms. On average, athletes reported the pain to be between 2 and 6 out of 10, with 10 being the most extreme pain.
pillsIt’s clear then, from long-term studies that most athletes carry pain with them through training and competition, accepting it as a side effect to be expected, managed with painkillers, or tolerated. 
This is the ebb and flow of sport, the demands of the team offset against the risk of future injury. I get it. I work in the industry. However, when you consider pushing on with painful training, think about this:
Shoulder tendon tears and labrum cartilage tears do not heal.
With every problem, we can focus on the dark trouble spots, or we can look to see where the bright spots are, where others have broken through to overcome the trouble.
So where’s the bright spot?
Even though shoulder labrum and tendon injuries don’t heal on their own, they are not always painful. And the problems that occur secondary to the pain can be changed—therein lays the bright spot to focus on and exploit.
If that were not to be the case, I think team China could not have won the 2015 World Cup.
It’s difficult to fathom the depth and breadth of the ripples caused by the Chinese victory in Nagoya, Japan in September 2015. I can tell you I’ve never signed so many autographs or given so many high fives to people who have no idea who I am or what I do, but who cried with delight at China’s victory. I don’t underestimate the effect of what was achieved by treating and rehabilitating that many shoulders in such a short period of time.
It’s a bright spot that proves we can kill the worst problem in volleyball and bulletproof athletes against it.
An injured shoulder is a choice.
China and Japan don’t get along. They are neighbors who do things very differently. The Chinese are approximately 10cm (4”) taller in women’s volleyball than the Japanese. The Japanese overcome such a deficit by designing their training to exploit speed and power in defense and hitting velocity. They are great at design. Here’s another example. The Japanese automotive industry builds cars that don’t require adjusting at the end of the assembly line. Their reason is because “we make sure it fits perfectly when we design it.” This is in comparison to American car manufacturers who have a worker with a rubber mallet who taps the doors of new cars to make sure they fit into place. [9]
This philosophy is not unique to Japanese cars. Countless sporting franchises across the world are designing training methods that aim to fit individual athletes, to ensure they don’t need “rubber malleting” after the fact—it’s too costly. [10], [11], [12], [13]
This system approach aims to make sure the athlete approaches specific markers of robustness and functional fitness when the training is designed. The system also separates pain from problematic movement, to ensure the risk factors for future injury are addressed. These programs shore up an athlete’s ability to withstand adverse conditions, which is the definition of robustness. While the methods are different for each individual, the systems are often similar. This is why the Chinese are recruiting foreign experts to remove the need for the rubber mallet approach. They made a choice to improve design from the outset.
Here are the system choices: You work to prevent shoulder injuries happening from the get-go, monitor and manage the contributing factors regularly, or play on with pain, and retire early. If your livelihood is volleyball, playing on with pain is the same as you taking a future pay-cut.
If can, can, if no can, no can.
It’s all good.
Except it’s not. And you’ve got a choice.
If you’re responsible for loading athletes, and they are playing with shoulder pain, each one that gets hurt on your watch is your responsibility.
Remember, shoulder tendon tears and labrum cartilage tears do not heal.
Serving and hitting & the relationship to shoulder problems
There are two elements of hitting and float serving that are highly stressful on the shoulder and contribute to shoulder injuries in volleyball athletes:
  1. The ratchet style follow-through;
  2. The absent follow-through.
The ratchet style follow-through
The ratchet style follow-through occurs when the arm follows through on the same side of the body.
This is very similar to team handball passing and goal shooting, but very different to most overhead throwing sports like baseball and cricket where the arm finishes on the opposite side of the body. In most throwing sports, the follow-through involves rotation through the trunk and pelvic girdle. In the ratchet style follow-through, this doesn’t happen—leaving deceleration mechanics to occur almost exclusively at the shoulder girdle.
In the ratchet style of hitting and serving in volleyball, once you remove the rotation across the body, you remove deceleration through the trunk and pelvic girdle. This means all the deceleration occurs at the shoulder girdle and glenohumeral joint. This places fast and high strain on the muscle groups and their connective tissues that decelerate scapula anterior tilt and protraction and glenohumeral joint extension and internal rotation; for example, supraspinatus, infraspinatus, middle and lower trapezius. It also places fast and high strain on the long head of biceps tendon and it’s attachment at the glenohumeral joint labrum. Remember what we know about rotator cuff and labrum injuries: they may become non-painful, but they don’t heal back to normal.
The absent follow-through
The absent follow-through happens in a float serve where the athlete’s hand finishes its movement very soon after hitting the ball. It is a stunted follow-through to minimize spin. It can also happen when a middle blocker pulls their hit at the net to prevent net contact. This places high stress on the muscle groups that decelerate glenohumeral joint horizontal flexion, adduction and internal rotation and scapula protraction and anterior tilt; for example, middle and lower trapezius, infraspinatus and posterior deltoid.
Both of these actions contribute to the increased likelihood of injury to the rotator cuff tendon, labrum and suprascapula nerve. These actions also contribute to fatigue-derived inhibition of the above muscles.
So, what can we do about it?
We don’t want to stop athletes from performing these two actions. We want to offset the effects of them through off-court training. As it turns out, specific off-court training for volleyball shoulder injuries appears more general than you think.
Bring fundamental competency up to a higher level.
At most levels of volleyball, including the elite level, off-court training is directed at bringing fundamental competency up; for example, pushing, pulling, rotating, squatting, hinging, and locomoting. We don’t need athletes to get specific in off-court training until they actually need to. Even the highest level volleyball athletes can have such a low training age for some of these fundamental movements that what I have written below about specific shoulder-specific off-court training doesn’t even matter.
For sub-elite population volleyball athletes, they should just be training as if anything we choose to develop fitness is beneficial (with respect to the six fundamentals above).
In both cases, we’re saying that volleyball athletes need to move well, move strongly and move often enough to be fit for their sport. As such, the general physical preparedness can be progressed according to general adaptation syndrome principles as applied to strength, power or endurance.
For those athletes who’ve played at a Division 1 school that had a legitimate strength and conditioning program and they did apply the real rules of science and didn’t think volleyball was different, then, and only then, should those movements above have a muscular pattern of contraction that directly carries over to the volleyball jump and set and block and swing; i.e. powerfully. To reiterate, very few people should be doing this. For general population, you do not need to do any kind of strength or endurance drills that directly carry over to the game of volleyball. The reason why is that the base of their general fitness (as we talk about the six movements above) may be so low that anything will help them and there’s no reason to become special in their training.
Since there will be athletes who’ve come through programs with legitimate development of training competency and capacity, off-court training should change depending on the level the athlete is at, as well as the training volume. USA Women’s National Team coach Karch Kiraly has stated, “When you are trying out for the national team, the question is ‘can you play volleyball?’ not ‘how high do you jump?’ That may matter earlier, but by the time you get to our program, it’s all about how you play the game.” [14] So, at the elite level, most training is skill-based, and for good reason—spiking and hitting accuracy can be improved with skill-based training programs[15]. At a level such as this, off court training should maintain the athletic prowess that got the athlete to the elite level and offset the effects of high volume skills training.
Once we understand that a system to capture painful shoulder movement exists, separates these for treatment and then works to move well in general movements (see six movements above), we can now dive deeper into why the design of off-court training for volleyball should aim to offset the ratchet and absent follow-through styles, not reinforce it.
As volleyball athletes, including those with shoulder injuries, progress in fundamental training age, we look at what movements we have that can support the technical skills of the critical movements that bring success:
  • running vertical jump;
  • non-counter movement vertical jump;
  • lateral agility; and
  • arm speed [14].
For most, the drills that support these technical skills are the fundamental movements mentioned above, done without pain, with load, for time, and for speed. I’ve stated the aim of this article is not to discuss how to increase vertical jump, lateral agility or arm speed, but it’s worth singling out arm speed as it relates to shoulder activity and injury.
This is what we know about high arm speed as a critical factor to success as demonstrated in USA Volleyball. “When comparing elite players against each other, the major difference between the 18 players selected for the special practice with the National Team coaches and those in the A2/JNT group was arm swing velocity. The top group had an average of 33.4 MPH, almost 15% higher than the average of the A2/JNT group.” [14]
Off-court programs that support high arm swing velocity are preferred, not those that train to increase arm swing velocity. The speed of arm swing is very activity specific and will improve most with on-court training and off-court general preparation. 
With respect to the most fundamental areas that support high arm swing speed: they include no pain with neck or thoracic or shoulder movements, at least 80 degrees of neck rotation, beyond 50 degrees of active thoracic rotation, at least 170 degrees of shoulder flexion and beyond 90 degrees of shoulder external rotation. 
The guide to fixing your shoulders, in order:
  1. Go looking for your “handbrake”
  2. Improve your mobility
  3. Add “underbelly” movements
  4. Add movement skills 
The handbrake – Screening for appropriate mobility to support high arm swing speed
At the simplest level, for coaches, a simple screen is found in the Secrets of The Shoulder DVD. [16] At a more thorough level that incorporates pattern and posture screening of more than just the neck and upper limb, you should get familiar with the Functional Movement Screen. Clinicians and coaches use the FMS to communicate between each other.
At a medium level, for clinicians, a screen that clears neck and thoracic mobility is required, beyond the scope of this article. My preferred process as a clinician is that within the Selective Functional Movement Assessment.
Improving mobility to support high arm swing speed
Who has driven with the hand brake on? These days, cars drive fine with the handbrake on, but you know the performance is not quite right—unless you always drive with it on and don’t know any different. The first way to improve vehicle performance is to take the handbrake off, not to put your foot down harder or upgrade the engine size or the timing chip. I say this because in human performance, speed is limited by friction and drag. In swimming, for example, a 10% increase in velocity is caused by either a) a 30% increase in power output, or b) a 3% decrease in drag friction. This example highlights where the most bang for buck is. Similarly with arm swing speed, the biggest increase in speed is not through enhanced power output but through reduced resistance to swing. That means improved joint mobility and tissue extensibility.
To know whether it’s a restricted joint or less extensible tissue that is holding you back requires a clinician.
A good clinician is likely to use a bunch of techniques that include some of the below. 
EXOSTextension
A great starting point is with a thoracic reset technique to improve thoracic extension. Check out EXOS’s well described video. If the thoracic spine has reduced extension and rotation, this requirement for mobility will be passed on to the lumbar spine. It is thus very common to see pain and dysfunction in the soft tissue and joints of the thoracolumbar junction area on both sides of volleyball athletes because of poor thoracic extension and rotation. So get started on your thoracic extension mobilization.
brettzelAfter getting some much needed spinal joint opening, supercharge it with the Brettzel. This drill, named after Coach Brett Jones, makes use of so many elements:
  • Respiration:
    • The positions are held at the point where breathing is comfortable and deep
  • Mobility:
    • Neck rotation
    • Thoracic rotation
    • Scapula rotation
    • Diagonal stretch across the front of the body from one shoulder to the opposite ankle, and across the back of the body from one shoulder to the opposite knee.
  • Stability
    • Grip-facilitated rotator cuff contractions
    • Pelvic and lumbar stability through the locked hip positions
Progressing the thoracic mobility, you want to add shoulder girdle and arm movement. Check out the T-spine rotation with reach.
TSPINE
These first two mobility drills are at low levels of demand. They don’t require you to hold yourself up against gravity. Taking the thoracic mobility to a higher level of nervous system demand is a natural progression. The quadruped position is the natural progression. Once again, EXOS’s exercise library is a great resource for this, the thoracic rotation stretch – heel sit. Adding trunk rotation with a hand behind the head and sitting the backside on the heels gives more benefit than it seems. The advantage of the sitting-back-onto-the-heels technique is that the pelvis has a little bit of posterior rotation and the low back is limited from moving. That, and the hand behind the head, puts all the muscles and the connective tissue across the back of the thoracic cage on a pre-stretch. Adding rotation to the stretch gets you long and rotating, which is what all good movement instructors are eventually looking for. Combining that with deep breathing produces an effective increase in your thoracic rotation.
ExosTRstretchHeelsit
Coach Mike Boyle also uses the double tennis ball for extension mobility, and while he probably adds the Brettzel and quadruped positions, he then follows it up with a rotation up off the floor in sitting, to make use of the newly gained mobility—check it out here.
boylethoracicmob
The above exercises demand that the shoulder get some mobility, but to push that further, you can try a shoulder stretch, as taught by Mark Verstegen from EXOS.
verstegenshoulder
Adding “underbelly” movements – Improving motor control and stability to support high arm swing speed
The “underbelly” references is really a dig at the kind of activity that goes on without us having to think about it. In performance enhancement, we often refer to this as reflex activity. The training of it is often termed reactive neuromuscular training or RNT. The essence is that an exercise task is created in a position, with a purpose for the athlete to think about. The goal for the prescribing professional is often hidden from the athlete. If the athlete can maintain the starting position and complete the movement, underneath all of that is the type of reflex activity the professional is looking for. Here’s the punch—reflex activity drives stability, both statically and dynamically. An example of static stability is when one body part is not moving, but the body moves around it. An example of dynamic stability is when the body is not moving but the body part is moving around it. Both of these variations require control of movement, i.e. motor control.
The supine arm bar, side-lying arm bar, Turkish Get Up and variations are excellent strategies to restore stability and motor control to the shoulder, incorporating the thoracic spine, lumbar spine and lower body. These can be found in the Secrets of The Shoulder DVDs [16]. For a quick reference, though, check out the shoulder mobility page at FunctionalMovement.com. On this page, you’ll see that the stability and motor control drills often involve overhead load. There are several reasons for this that aren’t just related to strength. Gripping a Kettlebell or dumbbell stimulates a rotator cuff contraction around the shoulder joint, an important second step in our nervous system control of the shoulder (the first is breathing normally). Since the weight is some distance from the control center of the shoulder joint, any small movement at the hand/Kettlebell is magnified at the shoulder. The work that has to be done, quickly, and coordinated, by all the small stabilizing muscles of the shoulder (the rotator cuff) is reflex driven, subconscious, and better than we can get from any voluntary command to “contract the rotator cuff.” Lastly, the primary direction of movement is overhead, requiring some upward rotation of the scapula and flexion/abduction/external-rotation of the shoulder joint. The muscles responsible for downward rotation and extension/adduction/internal rotation of the shoulder have to quieten down to allow the bell to be overhead. This is a distinct advantage of these drills for volleyball, for it is often these adducting/extending and internally rotating muscles that are so powerful (hitting muscles) and overactive.
In my experience, however, it is the “reach, roll and lift” that is overlooked by too many people who work with shoulder injuries in volleyball because the athletes find it difficult. Here’s why it’s so necessary: if the thoracic spine has reduced extension and rotation, address that first. If you don’t, it will affect dynamic motor activation of the scapula and we will see a poor reach, roll and lift. Even if you do fix the mobility, the dynamic motor activation of the scapula needs to be checked and restored, or will it lead to low back and shoulder problems, specifically posterior joint compression and anterior distraction at the shoulder. It would be a common error in management to just treat the sites of pain, the thoracic and lumbar areas and the shoulder, without addressing the dysfunction at the scapulothoracic joint that also contributes to the problem. The reach, roll and lift exercise provides a window into dysfunction at the scapulothoracic joint. The Secrets of The Shoulder DVD [16] provides strategies to improve this motor control exercise prior to implementing specific exercises. If you don’t have this DVD to watch this drill, get yourself a free login username and password at FunctionalMovement.com  so you can watch an assisted reach, roll and lift version here. I further describe it in more wording below, as it pertains to how it offsets the effects of volleyball specific
The importance of general mobility
Having movement through all patterns, without pain is so important to provide the nervous system with the feedback it needs from all positions of the upper limb, uninterrupted by pain, to maximize motor (movement) control. If that’s the case, we know that the joints can get into particular positions and can control those positions. This is the essence of mobility underpinning static motor control or stability around the appropriate joints. This gives the appropriate joints opportunity to use the now pain-uninterrupted nervous system to respond, reflexively, to perturbations. After that, we reinforce dynamic motor control and stability around the appropriate joints during an appropriate pattern. Then we reload the appropriate patterns; both the skill of the sport and the opposite directions. We then add load and speed as required. This reset, reinforce and reload process is at the core of the Functional Movement Systems and is very well described for the shoulder and thoracic spine in the Secrets of The Shoulder DVD. [16]
Each part of the reset, reinforce and reload is necessary and important, but this article specifically addresses the latter stages of this process: the acquisition of static and dynamic stability, with load and speed. Resetting and reinforcing of the shoulder movement patterns are the domain, firstly, of professionals in physical therapy who deal with pain and rehabilitation, and secondly, of intelligent coaches to reinforce those patterns through general physical preparedness.
EssenseofAthletes
If you skip the treatment of pain and resetting of mobility, you’ll be missing the opportunity to prime the nervous system for motor control training. In The Essence of Athletes, I wrote about cueing the central nervous system to improve motor control, so that expressions of patterns with strength and speed are optimized. This was also eloquently discussed at the 2015 Perform Better Summit by Gray Cook and Phil Plisky [17], [18]. You’ll read there how the motor control exercises are only as good as the inputs into the nervous system, which are improved by the management of pain and mobility problems.
Adding movement skills – the paradox of specifically general training.
Off-court training for volleyball is highly general, but specifically so. Volleyball off-court training needs to reflect a goal to allow on-court skill-based training to continue. It needs to support arm swing velocity and volleyball specific jumping speed. By allow, I mean that skills training sessions are highly repetitive, are themselves the best form of specialized preparation and carry with them the dangers of overuse. Providing off-court training that maintains capability to do the specialized training is where biggest effect is seen. In other words, I continue to recommend generalized preparation as movement skills. Regain fundamentals where the specialized training causes these fundamentals to disintegrate. That means attending to pain, addressing mobility deficits, addressing leaks in the kinetic chain relevant to jumping, landing and lateral movement and including movement pattern based training that offsets the highly biased patterns on-court. It also means including supersets that caress the nervous system, allowing the athlete to recover quickly for more skills sessions.
pancake
The sport itself has a very high bias towards postures and activities that are associated with anterior tilt of the scapula, with or without protraction. This position is a rotator cuff killer. For example, the receiving pass position, the “pancake” (a protracted pass/dig with one hand,) the block and the hit follow through. With this bias in mind, it’s vitally important to screen for upper limb movement pattern competence before loading with strength training. A protracted scapula is often associated with downward rotation, particularly if anterior tilt is present. In this position, the head of the humerus is often anteriorly positioned in the glenoid fossa, while the acromion process tips to encroach on the subacromial space. With repetitive overhead movements under this circumstance, the rotator cuff tendons are at great risk of insidious trauma.
Movement skills – Let’s get more specific for a solution.
We should be armed (no pun intended) with corrective strategies that improve competency and capacity in patterns opposite to the culprit hitting styles. Competency refers to at least an ability to move in the opposite direction to the hitting styles; i.e. retraction, posterior tilt—the reach, roll and lift is a great example of that competency. Capacity refers to being able to do so against load.
Charlie Weingroff and Mark Cheng Hacking the HingeCharlie Weingroff recently wrote about the misuse or incorrect use of the phrase “corrective exercise,” and how they should not be part of warm ups. He’s right, and wrong. He’s not wrong, it just depends on your preference for terminology and your reference population of those prescribing exercise. A corrective exercise is an entry point, as he points out in “Hacking The Hinge.” It’s the place you start with an individual when you want to enhance their competence or capacity, or address a contributing factor to faulty movement. That it “corrects” something implies something is incorrect. And that it corrects something assumes that we have an agreed upon standard of what’s correct and incorrect.
That argument or discussion will go on in our industry ad nauseum. I’ve written about what I feel is a responsible starting point to determine entry points. So, including these exercises in a warm up, or my preferred phrase, the movement preparation part of sports training, can be valuable. It can be valuable just like three-to-five reps of deadlift at 85% 1RM prior to sprinting can deliver post-activation potentiation. They are valuable in “greasing the groove” of important patterns for the sport.
Don’t just take my word for corrective exercises, or Charlie’s, or Brett Jones’s. As he wrote recently, there is a case against corrective exercise. And the case is all in the misuse of the term. There is no case, however, against reducing pain, improving mobility where it’s needed, improving motor control and movement skills.
So, we’ve established there are two specific overhead hitting patterns that are very stressful. We’ve also established that off-court training should offset the stress. Specifically, the exercises are opposite patterns to the hitting styles. The following exercises are designed to bulletproof the shoulder against the stress induced by these two hitting styles. These opposite patterns are combined thoracic rotation towards the hitting side, scapula retraction or stabilization and GHJ flexion/abduction with external rotation—the D2 Flexion PNF pattern.
d2 flexion
Specific Exercises include:
Benefits are:
  • High unilateral posterior chain scapulothoracic and glenohumeral joint eccentric muscular activity at the bottom of the swing;
  • Torsional stress on the long head of the biceps tendon throughout the pattern, particularly in the swing; such stress is made safer by the power-grip-mediated rotator cuff co-contractions;
  • High unilateral glenohumeral joint flexor concentric activity for the snatch.
These exercises do not look like anything related to volleyball (except maybe the snatch looking like a block). Both the ratchet-style and absent follow-throughs are performed with feet off the ground, so the lower limb position chosen is less important. However, both hitting styles involve significant hip flexion at the moment of hitting and immediately after it. The exercise doesn’t need to look like the hitting position. It only needs to provide an opportunity to reinforce the pattern opposite to the hit: combined thoracic rotation towards the hitting side, scapula retraction or stabilization and GHJ flexion/abduction with external rotation. To reiterate, the objective is to restore mobility and motor control to patterns that have become limited or asymmetrical due to the specificity of the sport.
Variations of the above include:
  • Medicine ball lift/throw in the same diagonal pattern as the FMS style lift;
    • Suitable for faster expressions of strength in the pattern;
    • Has an open handed position closer in neuromuscular pattern of overhead hitting.
  • Kettlebell swings – a good reference is Kettlebells From The Center – Dynami. By Gray Cook and Brett Jones;
  • Kettlebell overhead press
  • Reach, roll and lift (see above);
  • Horizontal and vertical rows;
  • The kettlebell arm bar (see Andrew Read coaching it in the video below), or check it out in Secrets of the Shoulder.
Further benefits of the above exercises include appropriate co-contraction of the muscle groups that balance upward and downward rotation of the scapula. Volleyball players spend large amounts of time in a position of readiness to receive, preparing to pass/dig. This position lends itself to scapula protraction and cervical extension, a shortened position for levator scapula, a downward rotator. Downward rotation is an unwanted scapula position since it predisposes to subacromial impingement.
Be careful with these exercises in volleyball players:
There are some exercises to be performed with caution in volleyball strength training. These exercises are:
  • Pulling or stabilizing from overhead, particularly close grip in forearm pronation. For example:
    • Close-grip pull-ups;
    • Any hangs, like hanging hip flexion, toes to bar (Crossfit style);
    • “The Dragon Flag” popularized by Bruce Lee;
    • Dumbbell pullovers
These exercises place high demand on glenohumeral joint adductors and internal rotators such as latissimus dorsi and teres minor. While in themselves they are useful exercises for increasing strength in the hitting pattern, if the exercises are allowed to affect mobility and motor control, injury or pain to the shoulder joint inevitably follows. They will indeed affect mobility and motor control if they are introduced, reintroduced or increased in a significantly high volume of technical training or competition. They can be used however if they are supersetted with the specific exercises below.
An example of an exercise that attempts to counteract the volleyball bias of scapula protraction, anterior tilt and downward rotation is the reach, roll and lift. This exercise has been described in the previously mentioned Secrets of The Shoulder DVD by Gray Cook and Brett Jones [16]. The athlete adopts the prone rock position. Kneeling, with buttocks resting on the heels, chest on thighs, forehead resting on a foam pad or rolled towel and arms loosely outstretched, palms down. The athlete then slides one hand along the ground as far as possible: the reach. This elevates the scapula, putting the scapula depressors in a lengthened position, primed for force production. It also places the glenohumeral joint in full shoulder flexion, putting the GHJ flexors/abductors in inner range, with active insufficiency.  This position also lengthens the shoulder extensors/adductors, putting them in a disadvantaged length-tension relationship. The athlete then supinates the forearm and externally rotates the upper arm so that the thumb is past the “12 o’clock” position, or past “pointing up.” This is the “roll.” This position of GHJ external rotation further places the shoulder extensors that have an internal rotation action into a disadvantaged length-tension relationship. The final action is the “lift,” the athlete is instructed to elevate the arm from the floor. The only way this can happen is to depress and retract the scapula. It is thus a test of the scapula retractors/depressors. A reach, roll and lift that is noticeably difficult should be a warning sign for volleyball athletes. The decreased ability to retract and depress the scapula simply means there’s a potential issue with dynamic stabilization of the scapula. When dynamic stability is given up, excessive mobility is inevitable, and this mobility will occur above and below the scapula-thoracic joint. That means extra extension/rotation at the thoracic intervertebral joints and extra flexion/abduction/external rotation at the GHJ.
Some general guidelines on strength and power training for volleyball 
As well as fundamentally moving well, there are other factors that contribute to high arm speed that are similar to many activities where speed is critical to success. For starters, a higher power-to-weight ratio contributes to faster speed. Thus, programs that provide a base for power generation in the upper arm and keep arm weight low are preferred. Most female volleyball athletes have very little forearm and upper arm muscle bulk, and indeed shoulder girdle bulk. An advantage is low weight of the limb, facilitating speed. Another advantage is the associated low tone, which surely must work in favor of low passive elastic tension, facilitating a fast whipping action. So, a program that provides a base for power generation in the upper arm and allows low arm weight and suppleness for a whipping action is valuable.
Where then, and how, does power generation fit in?
Previous research has shown a relationship between bench press maximum strength and throwing velocity in team handball athletes [19]. Performance Coach Rett Larson and I used that relationship to our advantage when we worked with Shanghai Women’s Handball through 2014. That team went on to win 15 of 18 games while we worked with them, and the design of training was noticed by the Chinese, such that the national team is now looking at foreign coaches to support their strength and conditioning program. The same relationship has not been reported, to my knowledge, in volleyball athletes. In fact, one study has indicated that throwing speed is the lowest of four factors that relate to player quality and situational efficiency; it follows volleyball specific throwing and spiking speed from the ground, followed by volleyball specific jumping and non-specific jumping and sprinting [20]. So, while the bench press may have a role to play in general preparation of an athlete, and where it has a role to play in balancing out strength development in the lower limbs for explosive jumping athletes, it is not specifically beneficial for volleyball athletes.
Upper body strength training should NOT upset arm swing velocity by gaining limb weight. Repetition ranges should reflect a goal to minimize sarcoplasmic hypertrophy (muscle cell structural protein growth) while aiming for myofribrillar hypertrophy (muscle contractile protein growth). Sets of up-to-five repetitions, at tempo speed, or lower repetitions with slower eccentric components, allow this compromise. Obviously the lower repetition allows higher loads. Even better yet are the post-tetanic potentiation programs.
Summary
Volleyball athletes are not shoulder athletes. They are whole body athletes who suffer shoulder, low back and knee injuries. As such, athletic preparation that offsets the reasons these injuries occur is paramount. At the heart of preparation is understanding the specific skills of the game that contribute to a) winning points and b) causing overuse injuries. We need the ratchet and absent follow-throughs. We don’t need the problems they cause. We can still use it in training and games but we need to program to support opposite patterns to offset the negative effects.
References
  1. Zazulak, B.T., et al., Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med, 2007. 35(7): p. 1123-30.
  2. Zazulak, B.T., et al., The effects of core proprioception on knee injury: a prospective biomechanical-epidemiological study. Am J Sports Med, 2007. 35(3): p. 368-73.
  3. Bahr, R., No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports. Br J Sports Med, 2009. 43(13): p. 966-72.
  4. Bere, T., et al., Injury risk is low among world-class volleyball players: 4-year data from the FIVB Injury Surveillance System. Br J Sports Med, 2015. 49(17): p. 1132-7.
  5. Seminati, E. and A.E. Minetti, Overuse in volleyball training/practice: A review on shoulder and spine-related injuries. European Journal of Sport Science, 2013. 13(6): p. 732-743.
  6. PhysioRoom.com, The 21st Century’s Most Injured Premier League XI’s. 2015.
  7. Cholewicki, J., et al., Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine (Phila Pa 1976), 2005. 30(23): p. 2614-20.
  8. Ekstrand, J., Preventing Player Injuries. UEFA.org, 2013.
  9. Sinek, S., Start with why : how great leaders inspire everyone to take action. 2011, London: Portfolio Penguin.
  10. Bishop, G., Stanford’s Distinct Training Regimen Redefines Strength.http://www.nytimes.com/2013/12/31/sports/ncaafootball/stanfords-distinct-training-regimen-redefines-strength.html?pagewanted=1&_r=2, 2013.
  11. Carroll, W., Inside the 2014 Numbers of Each MLB Team’s Regular-Season Injury Impact.http://bleacherreport.com/articles/2222445-inside-the-2014-numbers-of-each-mlb-teams-regular-season-injury-impact, 2014.
  12. Farnsworth, C., Seahawks return to a series of movement tests.http://www.seahawks.com/news/2013/04/15/seahawks-return-series-movement-tests, 2013.
  13. McAlvey, A., Injury prevention a high priority for Brewers.http://m.brewers.mlb.com/news/article/67962282/injury-prevention-a-high-priority-for-brewers, 2014.
  14. AVCA, American Volleyball Coaches Association Volleyball Performance Index (VPI). 2013.
  15. Gabbett, T., et al., Changes in skill and physical fitness following training in talent-identified volleyball players. J Strength Cond Res, 2006. 20(1): p. 29-35.
  16. Cook, G., & Jones, B., Secrets of the shoulder DVD.http://www.functionalmovement.com/store/secrets_of_the_shoulder, 2009.
  17. Cook, G., & Plisky, P., Balance, Posture and Movement.http://functionalmovement.com/files/Articles/506a_Cook and Plisky – Balance, Posture and Movement_V2.pdf, 2015.
  18. Functionalmovement.com, 2015 PB Summit Special Features.http://functionalmovement.com/articles/Screening/2013-06-12_2015_pb_summit_special_features, 2015.
  19. Marques, M.C., et al., Relationship between throwing velocity, muscle power, and bar velocity during bench press in elite handball players. Int J Sports Physiol Perform, 2007. 2(4): p. 414-22.
  20. Grgantov, Z., M. Milic, and R. Katic, Identification af explosive power factors as predictors of player quality in young female volleyball players. Coll Antropol, 2013. 37 Suppl 2: p. 61-8.

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