PART I – Symptomatology and associated risk factors

Athletes generally present themselves in an advanced stage of the disease with debilitating symptoms of digital ischemia in the spiking hand, like coldness, discoloration and paresthesia. These symptoms result in an inability to play volleyball and reduced daily quality of life. In an early stage of the disease, symptoms might only manifest after overhead movements in volleyball as a result of embolization into the digital circulation of the spiking hand. This can lead to a wide range of symptoms during or directly after volleyball. Similar symptoms will often be caused by, and attributed to, musculoskeletal injuries, and might therefore initially be perceived as minor, and thus ignored by the athlete. However, since there is a risk of necrosis and amputation, awareness of these symptoms, with a timely detection, is warranted.

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The objectives of chapter 2 were twofold. The first objective was to determine which symptoms are most likely to be associated with PCHA pathology (PCHAP) with distal embolization (DE) in the spiking hand in volleyball players. Using literature-based data on symptoms reported by volleyball players with confirmed digital ischemia as a result of PCHAP with DE, together with data retrieved from medical files of volleyball players treated for this injury, complaints of cold, blue and pale digits during or immediately after practice as well as competition were most strongly associated with DE as a result of PCHAP. Questions were formulated based on these symptoms of digital ischemia and included in the Shoulder PCHA pathology and digital Ischemia – Questionnaire (SPI-Q).

The second objective was to assess the prevalence of these symptoms in the spiking hand among elite male volleyball players in the Netherlands. Ninety-nine of 107 elite male volleyball players in the Netherlands completed the SPI-Q in a national survey in 2011: 91 indoor- and 8 beach volleyball players, a participation rate of 93%. An unexpectedly high percentage of 31% of these volleyball players reported symptoms of digital ischemia that are associated with PCHAP with DE in the spiking hand. These athletes are considered potentially at risk for developing critical digital ischemia since these symptoms might be the result of an early stage of the disease. Therefore further analysis of the presence of PCHAP and DE, and a better insight into modifiable risk factors to achieve effective prevention, is warranted.

Related articles:

Van de Pol D, Kuijer PPFM, Langenhorst T, Maas M. High prevalence of self-reported symptoms of digital ischemia in elite male volleyball players in the Netherlands: a cross-sectional national survey. American Journal of Sports Medicine 2012;40:2296-2302. – link

– Van de Pol D, Kuijer PPFM, Langenhorst T, Maas M. Hoge prevalentie van zelf-gerapporteerde koude en ontkleurde vingers bij mannelijke topvolleyballers in Nederland. Sport & Geneeskunde 2012. – link

In chapter 3, we assessed whether personal-, sports- and work-related risk factors are associated with self-reported symptoms of digital ischemia in the spiking hand. A national questionnaire survey in 2011 assessed the presence of symptoms and risk factors in 99 elite male volleyball players in the Netherlands: 91 indoor- and 8 beach volleyball players. Two sports-related risk factors were independently associated with symptoms of blue or pale digits in the spiking hand: a total volleyball career duration of 18 years or more (OR=6.70; 95%CI 1.12-29.54) and often or always performing weight training to increase dominant limb strength (OR=2.70; 95%CI 1.05-6.92). The identification of these sports-related risk factors is a first step in signalling and preventing apparently innocuous symptoms of digital ischemia.

Related article: Van de Pol D, Kuijer PPFM, Langenhorst T, Maas M. Risk factors associated with self-reported symptoms of digital ischemia in elite male volleyball players in the Netherlands. Scandinavian Journal of Medicine & Science in Sports 2014;24:e230-e237. – link

The next step of implementation of the SPI-Q for periodic surveillance of elite volleyball players at risk for digital ischemia was to test its measurement properties. In chapter 4, the test-retest reliability of the SPI-Q was assessed with a two-week interval among 65 elite male indoor volleyball players, assessing symptoms of cold, pale and blue digits in the spiking hand during or after practice or competition. The results showed that the SPI-Q is a reliable questionnaire for: 1) detecting elite male indoor volleyball players with symptoms of digital ischemia in the spiking hand (kappa=0.83; 95%CI 0.69-0.97); and 2) for grading the severity of these symptoms (ICC=0.82; 95%CI 0.72–0.88). These findings indicate that the SPI-Q can be used for periodic surveillance of elite volleyball players.

Related article: van de Pol D, Zacharian T, Maas M, Kuijer PPFM. Test-retest reliability and agreement of the SPI-Questionnaire to detect symptoms of digital ischemia in elite volleyball players. Journal of Sports Sciences. 2017 Jun;35(12):1173-1178.– link

Since the exposure to sport-specific demands is different in beach volleyball compared to indoor volleyball, the aim of chapter 5 was to assess the prevalence of ischemia-related symptoms in the spiking hand, and associated risk factors, among international world-class beach volleyball players. A questionnaire survey was performed during an international beach volleyball tournament in which 60 beach volleyball players participated: 26 males and 34 females from 17 countries, a participation rate of 49%. Thirty-eight percent of these volleyball players reported symptoms of digital ischemia that are associated with PCHAP with DE in the spiking hand. A total volleyball career duration of 14 years or more (OR=4.42; 90%CI 1.30-15.07), and sex (female) (OR=4.62; 90%CI 1.15-18.57) were independently associated with an increased risk of ischemia-related symptoms. Compared to elite indoor volleyball players assessed in chapters 2 and 3, the prevalence of symptoms of digital ischemia in the spiking hand was higher among elite beach volleyball players (38% versus 31%), and total volleyball career duration was a joint risk factor.

Related article: Van de Pol D, Alaeikhanehshir S, Maas M, Kuijer PPFM. Self-reported symptoms and risk factors for digital ischaemia among international world-class beach volleyball players. Journal of Sports Sciences 2015;5:1-7. – link