VOL. 180 · No.

 7-8
J U LY - AU G U S T 2021
© 2020 EDIZIONI MINERVA MEDICA Gazzetta Medica Italiana - Archivio per le Scienze Mediche 2021 July-August;180(7-8):374-9
Online version at http://www.minervamedica.it DOI: 10.23736/S0393-3660.20.04382-X

ORIGINAL ARTICLE

Incidence of musculoskeletal injuries

among Indonesian volleyball athletes
during a national training and championship
Anita S. MANSYUR 1, Indah S. WIDYAHENING 2 *, Nani CAHYANI SUDARSONO 3

1Sports Medicine Study Program, Department of Community Medicine, Faculty of Medicine, Universitas Indonesia,
Jakarta, Indonesia; 2Division of Family Medicine, Department of Community Medicine, Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia; 3Division of Sports Medicine, Department of Community Medicine,
Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
*Corresponding author: Indah S. Widyahening, Division of Family Medicine, Department of Community Medicine, Faculty of Medi-
cine, Universitas Indonesia, Jl Pegangsaan Timur 16, 10430 Jakarta, Indonesia. E-mail: indah_widyahening@ui.ac.id

A B S TRACT
BACKGROUNDː This study aimed to find out the incidence and characteristics of musculoskeletal injuries among Indo-
nesian volleyball athletes during a national volleyball training and championship.
METHODSː A prospective cohort study involving 34 Indonesian volleyball national team athletes (18 male and 16
female) during one volleyball national training and championship in July-September 2019 was conducted. All athletes
were observed for 11 weeks and the incidence and the characteristics (duration, pain level, severity in loss time, nature,
recurrence, anatomical location and types) of the injuries were documented. Some etiological factors of the injuries such
as the court zone (back, front/net, and un-specified) time of injury (practice, competition or both), injury mechanism
(ball contact, player contact, surface contact, non-contact or overuse), biomechanics (bending, compression, repetitive or
traction) and movements (blocking, digging, passing, serving, spiking, or not specific) were also recorded. Incidence of
injuries was presented in 1000 player hours.
RESULTS: The incidence of injuries was 20.4/1000 player hours. Only one out of the 34 athletes did not have injury.
Injuries occurred most frequently in the knee (36%), followed by the ankle (18%) and waist (16%). The most common
type of injuries was sprain (21%) and tendinitis (21%) followed by low back pain (13%). The overuse and recurrence type
of injuries were much more dominant to the acute one.
CONCLUSIONSː Musculoskeletal injuries were common among Indonesian volleyball athletes. This adds information
to the limited available evidence concerning the incidence, prevalence and etiology of volleyball-specific injuries which
were needed to prevent its occurrence.
(Cite this article as: Mansyur AS, Widyahening IS, Cahyani Sudarsono N. Incidence of musculoskeletal injuries among
Indonesian volleyball athletes during a national training and championship. Gazz Med Ital - Arch Sci Med 2021;180:374-9.
DOI: 10.23736/S0393-3660.20.04382-X)
Key words: Cumulative trauma disorders; Volleyball; Athletes; Sports medicine.

V olleyball is one of the most popular sports in

the world and internationally recognized as
one of the world’s major sports. Globally, it is es-
timated that around 200 million people play the
sports both professionally and recreationally and
is among the most played sports in schools. The
sports which is characterized by some high phys-
ical and technical performance such as jumping,
landing, blocking and spiking/smashing of the
ball, in combination with high level of force pro-
duction which produce rapid movement1 could
put a high burden to the musculoskeletal func-
tion and increase the risk of musculoskeletal in-
juries.

374 Gazzetta Medica Italiana - Archivio per le Scienze Mediche July-August 2021
MUSCULOSKELETAL INJURIES AMONG INDONESIAN VOLLEYBALL ATHLETES MANSYUR
National scale research to determine the inci-
dence of injuries in volleyball had been carried
out in several countries and reported a wide vari-
ation of incidences. One systematic review in-
volving 28 studies reported that the incidence rate
of musculoskeletal injuries in volleyball ranges
from 1.7 to 10.7 injuries per 1000 player hours.2
Absenteeism of the athletes during training
and competition and high amount of costs due to
the treatment of injuries are very detrimental not
only for volleyball athletes but also the society.
Volleyball is also widely played in Asian coun-
tries, yet research on the incidence and character-
istics of musculoskeletal injuries in volleyball in
Asian countries are scarce. The aim of this study
was to find out the incidence and characteristics
of musculoskeletal injuries among Indonesian
volleyball athletes during a national volleyball
training and championship.
Materials and methods
A prospective cohort study involving 34 Indone-
sian volleyball national team athletes (18 males
and 16 females) during one volleyball national
training and championship in July-September
2019 was conducted in a national training cen-
ter located in West Java. Ethical clearance was
obtained from the Faculty of Medicine Univer-
sitas Indonesia – Cipto Mangunkusumo Hospital
(FKUI-RSCM) Research Ethical Committee num-
ber KET-761/UN2.F1/ETIK/PPM.00.02/2019.
All athletes were observed for 11 weeks and
the incidence and the characteristics (duration,
pain level, severity in loss time, nature, recur-
rence, anatomical location and types) of the in-
juries were recorded. Characteristics of the ath-
letes consisted of age, weight, height, body mass
index, years of volleyball playing and history
of any previous musculoskeletal injuries within
one last year. Some indicators of the physical
fitness level were measured at the beginning of
the study. These include cardiopulmonary endur-
ance (VO2max) which measured by beep test, or
20-minutes shuttle run test,3 muscle strength by
hand-grip strength test,4 muscle endurance by 30
second Eurofit sit-up test5 and flexibility by sit
and reach test.6 The physical fitness level was
classified in to very good, good, average, poor
Vol. 180 - No. 7-8 Gazzetta Medica Italiana - Archivio per le Scienze Mediche 375
and very poor in accordance with a standard
norm developed for each respective test.
Musculoskeletal injury is defined as any mus-
culoskeletal symptoms occurred during training
or competition within the study period. The lo-
cation and types of the injury were determined
by a sports medicine resident through history,
physical examination and if necessary, any im-
aging modalities such as X-ray, ultrasound,
magnetic-resonance imaging (MRI) or CT-scan.
The types, nature (acute or overuse) and the re-
currence (new vs. recurring) of the injuries were
classified in accordance with the Orchard Sports
Injury Classification System (OSICS).7
Some etiological factors of the injuries such
as the court zone (back, front/net, and un-spec-
ified), time of injury (practice, competition or
both), injury mechanism (ball contact, player
contact, surface contact, non-contact or overuse),
biomechanical (bending, compression, repetitive
or traction) and movements during injury (block-
ing, digging, passing, serving, spiking, or not
specific) were also documented through video-
recording.
Statistical analysis
Incidence of injuries was calculated by dividing
the total number of injuries with the total play-
ing time of all athletes during observation and
presented in 1000 player hours. All recorded data
is presented descriptively. Numerical data is pre-
sented in mean and standard deviation if the data
was normally distributed or in median and mini-
mum maximum, if did not. Categorical data is
presented in proportion (percentage).
Results
Data collection began on July 11, 2019, un-
til September 22, 2019 (74 days or 11 weeks).
Two athletes did not participate in the baseline
physical fitness test. The total accumulated play-
ing hours were 4903.5 hours. Total injuries were
100 events, so it can be calculated that the inci-
dence of injury was 100/4903.5 player hours or
20.4/1000 player hours (95% Confidence Inter-
val of 16-24/1000 player hours).
Characteristic of the athletes which includes
age, weight, height, Body Mass Index (BMI) and
MANSYUR MUSCULOSKELETAL INJURIES AMONG INDONESIAN VOLLEYBALL ATHLETES

playing history in years is presented in Table I. Table III.—Distribution of the musculoskeletal volley-
Out of 34 athletes, only one athlete had no his- ball injuries by anatomical location (N.=100 events).
tory of previous injury within one year. The most Location N. %
frequent previous injuries occurred in the lower Knee 36 36
Ankle 18 18
extremities. Location of the previous injury and Waist 16 16
the physical fitness of the athletes are presented Shoulder 13 13
in Table II. Thigh 6 6
Table III presents the number of injuries by its Others* 4 4
Achilles Tendon 3 3
anatomical location. Injuries occurred most fre-
Head 2 2
quently in the knee, followed by the ankle and Elbow 2 2
waist. Based on OSICS classification, injuries *Other locations were finger, wrist, abdomen and plantar which
were most common in muscles and tendons (53 occurred once respectively.
out of 100 events), followed by joints and liga-
ments (36 out of 100 events), nerves (8 out of 100
Table IV.—Distribution of the musculoskeletal volley-
ball injuries by types (N.=100 events).
Table I.—Characteristics of the volleyball athletes Types N. %
based on their age, weight, height, Body Mass Index Sprain 21 21
(BMI), and playing history. Tendinitis 21 21
Characteristics Mean (SD) Median Min Max Low back pain 13 13
Age (years) 22.3 (3.2) 17 29 Impingement 9 9
Weight (kgs) 74.4 (12) 55 98 Patellofemoral pain syndrome (PFPS) 7 7
Height (cm) 180.9 (10.2) 161 197 Strain 6 6
BMI (kg/m2) 22 19.1 27.5 Meniscus tear 5 5
Playing history (years) 11.4 (3.5) 5 20 Neuropathy 4 4
Other types* 4 4
Bursitis 2 2
Concussion 2 2
Table II.—Characteristics of the volleyball athletes Herniation of the nucleus pulposus (HNP) 2 2
based on the location of the musculoskeletal injuries, Shoulder instability 2 2
history of previous injuries and the baseline physical Contusion 2 2
fitness level.
*Other types include fasciitis, malunion, tendosinovitis and
Injury history location (N.=34) N. % triangular fibrocartilage complex (TFC) tear, which occurred once
None 1 2.9 respectively.
Upper extremity 12 35.3
Trunk 13 38.2
Lower extremity 28 82.4 events), contusions (2 out of 100 events; 2%),
Physical fitness (N.=32)* and bones (1 out of 100 events; 1%). The most
Cardiopulmonary endurance
Excellent 3 9.4
common type of injury was sprain, followed by
Good 5 15.6 tendinitis and low back pain (LBP). The number
Average 8 25 of injuries by types is presented in Table IV.
Below average 9 28.1 By its nature, the proportion of overuse inju-
Poor 7 21.9
Muscle strength
ries were much higher than the acute one (82%
Excellent 1 3.1 vs. 18%). While based on its recurrence, only 18
Good 6 18.8 out of 100 events (18%) were acute, while the
Average 21 65.6 rest (82 out of 100; 82%) were recurring inju-
Below average 2 6.3
Poor 2 6.3
ries. The occurrence of lost time injuries was 6
Muscle endurance out of 100 events (6%). The severity (loss time)
Excellent 29 90.6 of injuries ranged from 0-18 days. The duration
Good 2 6.3 of injury ranged from 1-11 weeks with a median
Average 2 3.1
Muscle flexibility
value of 5 weeks. Pain levels ranged from 0-10
Excellent 32 100 with a median of 6.
*Two athletes did not participate in the baseline physical fitness Because only one out of the 34 athletes did not
test. have an injury, the relationship between etiologi-

376 Gazzetta Medica Italiana - Archivio per le Scienze Mediche July-August 2021
MUSCULOSKELETAL INJURIES AMONG INDONESIAN VOLLEYBALL ATHLETES MANSYUR

Table V.—Distribution of the musculoskeletal volley- al.2 in their systematic reviews involving 28 stud-
ball injuries based on the etiological factors (N.=100 ies produced an incidence rate of 1.7-10.7 inju-
events). ries/1000 player hours. Verhagen, et al. in their
Etiological factors N. %
study among Dutch national volleyball athletes
Court zone
Not specific 88 88
for nine months reported an incidence of 2.6/1000
Back zone 6 6 player hours,8 while study among world-class
Net zone 6 6 volleyball players which utilized the International
Injury occurrence time Volleyball Federation (FIVB) injury surveil-
Practice 63 63
Practice + competition 34 34 lance system for four years found an incidence
Competition 3 3 of 3.8/1000 player hours.9 The higher injury inci-
Injury mechanism dence found in this study could be due to the dif-
Overuse 82 82 ference in the definition of injury,10 as our study
Non-contact 10 10
Ball contact 4 4 defined injury as any reported symptoms while
Player contact 3 3 other studies mostly restricting it to those causing
Surface contact 1 1 cessation of the athlete’s participation in training
Injury biomechanics or match for at least one day (loss time injury).
Repetitive 83 83
Bending 8 8 Based on the location groups, the most inju-
Traction 5 5 ries in this study occurred in the lower extremi-
Compression 4 4 ties and this is also reported in other studies.2, 11
Movements The most common location of injuries was the
Not specific 87 87
Digging 4 4 knee, followed by the ankle which is consistent
Passing 3 3 with the research conducted among the National
Spike 3 3 Collegiate Athletic Association (NCAA) volley-
Blocking 2 2
ball players11 although in several other studies
Serve 1 1
the most common injuries occurred in the ankles
followed by the knees.2, 8, 9 The knee as the site
cal factors and the incidence of injury could not of the most common injury in this study might be
be analyzed. The number of injuries based on ex- explained by the existence of patellar tendinitis
ternal risk factors and triggering events such as (jumpers’ knee) which is indeed an injury that
time, court zone, mechanism, biomechanics, and is often found in sports which involved frequent
injury movements can be seen in Table V. Most jumping on hard surfaces such as volleyball.12
injuries occurred in areas that were not specific, Another possible cause is that the volleyball court
during training, with overuse mechanisms, re- floor in Indonesia is harder than the floor in the
petitive biomechanics, and movements that were Europe and the United States. Only a few volley-
not specific to volleyball games. ball courts in Indonesia meet the floor criteria by
FIVB standardization. This creates greater strain
Discussion on the athlete’s knee in the long run-in addition
to the burden already caused by lots of jumping
The incidence of injury among Indonesian vol- movements in volleyball.
leyball athletes during a national volleyball train- Most common body part injured in this study
ing and championship was 20.4 per 1000 player were tendinitis and sprain followed by low back
hours. Injuries occurred most frequently in the pain (LBP) while the NCAA study11 reported that
knee, followed by the ankle and waist. The most the most common injuries were sprain, strain,
common type of injury was sprain, followed by followed by inflammation (including tendinitis).
tendinitis and low back pain (LBP). The overuse This difference is related to the much higher pro-
and recurrence injuries were much more domi- portion of overuse injuries reported in our study
nant than the acute one. as compared to the NCAA11 and the Netherland8
The incidence reported in this study is rela- studies. The domination of the overuse type of
tively higher compared to other studies. Kilic, et injuries in our study was also supported by oth-

Vol. 180 - No. 7-8 Gazzetta Medica Italiana - Archivio per le Scienze Mediche 377
MANSYUR MUSCULOSKELETAL INJURIES AMONG INDONESIAN VOLLEYBALL ATHLETES
er findings such as the involvement of overuse
mechanisms, repetitive biomechanical, and non-
specific movements while in the NCAA study,
the most common mechanism of injury was non-
contact, which indicates acute type injuries.
LBP was not reported as the most common
type of injury in the NCAA study as it might be
reported as part of other injuries type. However,
in our study LBP was the most common type of
waist injury. The cause of LBP if further inves-
tigated was non-specific volleyball movements
such as lifting weights in physical exercise.
Weight training in the national training program
needs to become the focus of attention so as not
to increase the risk of injury to the athletes.
Recurring injuries made up the majority of in-
juries (82%) based on a history of similar injuries
in the past year, which was in line with the nature
of injuries that were mostly overuse. Almost all
injuries occurred during training, and some were
carried on up to the match. This indicates that
athletes have had a history of injury since the
beginning of the national training program, oc-
curred again during the training, and some con-
tinued until the match. Further, we also found
that the injuries with no loss of time occupied
the largest proportion. This type of injury pro-
duces pain and discomfort but do not necessarily
cause a player to stop playing, so we can assume
that the athlete continues to play even though
they are in pain. If this condition continues, it is
likely that the injury might get worse and even
stop their career. Further studies need to be done
to ensure the safety and prognosis of the non-loss
time injury. The high number of overuse injuries
without loss of time requires further research to
reveal the causes, involved mechanism, and ef-
fective injuries prevention strategies.
Strengths and limitations of the study
This study has several strengths. Until now, we
could not find any reports on the volleyball in-
juries from other Asia or developing countries.
Epidemiological research on injuries is still lim-
ited and the use of incidence units varies between
hours of play and athlete exposure. This study uses
player time which is more relevant to the amount
of time that can better describe the risk of injury
and it is an international consensus to report the
378 Gazzetta Medica Italiana - Archivio per le Scienze Mediche July-August 2021
incident.10 This study also presents data on the
type (diagnosis) of injury which was established
by physician and documented prospectively so it
could be ensured that nearly all injuries affecting
sports participation have been reported. In addi-
tion, this study defines the injury based on any
complaints. Compared to injury identification us-
ing the definition of time-loss and the need for
medical attention, the definition of injury based
on any complaints is able to illustrates the broad-
er spectrum of injuries and is more suitable for
detecting overuse and non-time loss injuries.13
This definition fits with the characteristics of the
Indonesian volleyball athletes who are not accus-
tomed to seeking doctor’s help or stop playing
when injured. However, the drawback of the use
of this definition was that it caused higher num-
ber of injuries being reported in this study and
much higher proportion of overuse and recurring
injuries found than the acute one. As almost all
athletes in our study experienced injuries, statis-
tical test to determine the relationship between
characteristics of athlete with the occurrence of
injuries could not be performed.
Conclusions
Musculoskeletal injuries were common among
Indonesian volleyball athletes. The most com-
mon type of injury is overuse injuries which
mostly recurrence and endured by the athletes
even before they enter the national training pro-
gram carried over until the end of the program or
even the match. The result of our study adds to
the relatively small number of studies on volley-
ball-specific injuries which is needed in under-
standing its etiology and developing the effective
prevention strategies to reduce the numbers of
musculoskeletal injuries in volleyball.
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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material
discussed in the manuscript.
Funding.—This study was funded by the Universitas Indonesia Research Grant 2019, contract number NKB-0534/UN2.R3.1/
HKP.05.00/2019.
Authors’ contributions.—Anita S. Mansyur, Indah S. Widyahening and Nani Cahyani Sudarsono have given substantial contributions
to study design, Anita S. Mansyur and Indah S. Widyahening to data analysis, Anita S. Mansyur to data collection and manuscript
writing. All authors read and approved the final version of the manuscript.
Acknowledgements.—The authors would like to acknowledge Antonius Andi Kurniawan, Nadia Nastassia, Ade Jeanne Tobing, and
Nora Sutarina, for their valuable inputs in the design and analysis of the study.
History.—Manuscript accepted: March 27, 2020. - Manuscript received: March 10, 2020.

Vol. 180 - No. 7-8 Gazzetta Medica Italiana - Archivio per le Scienze Mediche 379