Concussions: Prevention strategies from USA Volleyball’s Dr. Chris Koutures

Chris Koutures MD, FAAP, is a dual board-certified pediatric and sports medicine specialist who practices at ActiveKidMD in Anaheim Hills, Calif. In 2008, served as the medical team physician for USA Volleyball and Table Tennis in the 2008 Beijing Summer Olympics. He is continues to serve as a team physician for the USA Volleyball national teams for both Men and Women, the U.S. Figure Skating Sports Medicine Network, Cal State Fullerton, the Chapman University Dance Department, and Orange Lutheran High School.

By Dr. Chris Koutures for VolleyballMag.com
In working with elementary through Olympic-level indoor and sand volleyball players, I have found key warm-up, training, and even competitive adjustments that can greatly reduce the risk of concussion. 

There is no doubt that concussions can occur in volleyball. Yes, volleyball is not a contact/collision activity like some sports. However, when you combine high-speed hitting/serving along with aggressive diving and digging, there is definitely a risk for head impacts for both sand and indoor players.

The bad news is indeed, concussions are part of volleyball and some are truly accidental consequences of fast action. The good news is that many others are definitely preventable — especially those that occur due to poor practice and warm-up organization.

Pre-Practice and Pre-Game Preparation
Before stepping on the court, never minimize the role proper selection of player match-ups and organization of the court and practice/warm-up drills.

• When selecting match-ups either in practice or competition, realize that a fair amount of concussions result from mismatches on the court, namely defensive players trying to return serves or hits from much stronger or older players. This is particularly important in sand volleyball. Matching players by overall ability, age, ball awareness, and even gender can make for more balanced play and less injury risk.
• Before practices or matches, take the time to review the placement of ball cages, white boards, chairs and other objects near the court. There have been many times players have collided with these objects when chasing loose balls. Many gyms also have limited room between courts. Moving objects out of the way, putting pads on poles and nearby walls, or stationing observers to catch players before they hit something can reduce injury risk. Anyone on or near the court – players, coaches, staff and spectators — need to be aware at all times about flying balls (and possibly flying players) and should never turn heads away from the court.

Reducing Risks during Warm-Up and Hitting/Serving Drills
While most concussions tend to be found in competition, practice and warm-up drills have their own particular risks, especially when multiple balls are in play. To minimize these risks, the following guidelines should be followed.

• Proper ball control is absolutely essential to reduce inadvertent hits to the head during hitting or serving drills. Chaotic situations where multiple players simultaneously serve/hit into opposite courts at the same time are a recipe for disaster, as is unsupervised play or situations where players are kicking balls or messing around before practice.
• Reduce the number of free balls in the air during serving drills and hitting lines.
• Always serve in one direction. Always hit in one direction. Serve or hit all the balls, shag all the balls, then once all the balls have been collected, turn around and serve or hit in the other direction.
• Never turn a back to a hitter or server — this includes huddles during practice time.
• Don’t be afraid to shag for opponents — that way no one has to go under the net or turn a back towards an incoming ball.
• Ideally only one ball should be in play for each defensive player. Players must call balls out before hitting/serving, and any defensive player should be aware and even call for all incoming balls. Anyone chasing or picking up loose balls on or near the court also needs to be constantly aware of incoming balls.

No matter the level, volleyball players should routinely call for balls to reduce the risk of collisions (or balls falling helplessly to the court while players watch). Also, players should be taught how to best use their hands and arms to protect the head and face from direct hits or serves. These skills ideally are first practiced in drills where the athlete is one-on-one with the incoming ball. Diving drills are best done with plenty of open court to allow learning of more efficient diving techniques.

How Concussions Occur in Scrimmages or Matches
The risk of concussions during blocking drills, full scrimmages, or competitive matches seems to be related to the level of play.

• Less-experienced athletes are likely to have more chaotic plays. A setter who has to chase more “out of system” balls is at risk for collision with others and the playing surface. Multiple players diving or chasing after a free ball may run into each other. Middle blockers in lower levels may be at higher risk for contact with the net and poles. Defensive players who are just learning to dive and roll may not be as effective and have a higher tendency to hit their head on the court or other players/objects.
• Passing and digging at higher levels (including my experience with USA Volleyball national teams) puts liberos and outsider hitters at risk during serve reception and other defensive activities. They usually occur from direct ball to head impact or collisions with other players or objects (poles, chairs on courtside) when diving for a ball.

Realize that many volleyball concussions occur when players are tired. This might be at the end of a longer practice or in the third match of a day during a weekend tournament. Players who are slower to react to balls can definitely be at higher risk.

Coaches who identify athletes who are fatigued and make modifications (change drills, shorten practice, rotate players out) can reduce the risk of concussions and other injuries. Coaches should also not hesitate to remove any athlete who appears to have suffered a concussion. It is key to remember that a player’s health is best served by the statement, “When in doubt, take them out.”

Return-to-Play Considerations for Volleyball Players
— Never return to play after a concussion without being evaluated and receiving recommendations from a qualified medical provider.
— Be aware of your state-specific return-to-play laws and follow those policies, which often call for a step-wise return to sport over the course of several days.
— The step-wise return usually begins with individual activities and finishes with return to full scrimmage and eventual match play.
— Any new or increased symptoms during the return process requires re-evaluation by your medical provider.

Once a player is cleared to resume physical activity, particular volleyball considerations include:

• Importance of eye tracking: many concussed athletes have difficulty with following objects that move side-to-side, up-and-down, or start further away and more closer to the face. Obviously, issues with vision can be a big challenge with volleyball. Make sure your concussion medical evaluation includes checking eye movements, and if any problems are found, they are corrected before starting with ball or court work.
  • Volleyball-specific exercises that are fairly safe and can help with eye tracking include self-setting an individual pepper
• Evaluation of single-leg balance: concussed athletes often have poor balance which can affect jumping and landing. 
  • Work on standing on one leg while doing daily activities (brushing teeth, combing hair) and also doing forward and backward heel-toe walking in a straight line.
• Initial Individual Return to Receive and Passing: Once an athlete is cleared to begin ball activities, work on ball tracking  with 1:1 (concussed player and one other player) light pepper, then move to individual reception of hits and serves using only one server/hitter without blockers, tips,  or anyone else in defensive court
• Initial Individual return to serve/hitting: Start with a float serve into an open court, then can advance to jump serve. Initial hitting can be against the wall, then move to hitting off simple sets without a block. This helps with regaining confidence in balance, timing, and approach/landing skills.
• Return to group activities:
  • Hitting against single block and defensive drills behind block — limit the number of repetitions and expect early fatigue. Add in tips as the athlete shows more endurance.
  • Return to 4 v 4 (indoor) or 2 v 2 (sand) once able to go through the usual number of practice hitting/serving repetitions and normal timing with tracking serves/hits
  • Finally, return to full 6 v 6 scrimmages and matches — again, expect early fatigue and the need to substitute out more frequently

Follow Dr. Koutures on Twitter at @dockoutures or visit activekidmd.com.