Recovery after volleyball

by Elizabeth Kwon, SPT

There are a variety of recovery methods used to enhance the performance of athletes; however, the specific techniques and dosage are debated among various individual sports and athletes. Volleyball is an intermittent sport requiring bursts of high intensity movements during gameplay and with often little recovery time in between matches. While there is limited evidence on recovery techniques specific for volleyball players, several methods are discussed including the following:


  • Nutrition for athletes requires a higher caloric intake, proper carbohydrate and protein intake, and sufficient nutrients and hydration
  • Overall, female volleyball players tend to consume less than the recommended caloric intake per day as well as proper levels of protein, fiber, iron, carbohydrates, iron, and calcium
  • Current recommendations may lack sex-specificity.
    • Female volleyball players were able to improve their power, speed, and body composition despite maintaining a lower caloric intake than recommended
    • Female volleyball players require less carbohydrates compared to the recommended dosage suggesting that they may be less reliant on glycogen during exercise and less responsive to glycogen synthesis during recovery
    • Female volleyball players consumed more protein on average than the recommended amount
  • It is recommended that volleyball players maintain an increased carbohydrate to protein ratio to facilitate muscle recovery rather than a direct focus on the absolute amount of consumed protein
  • Antioxidant supplementation shows promise in enhanced antioxidant defense against free radicals during periods of intense training
  • Proper hydration prior to a match is important to improve performance and recovery
    • In a study of beach volleyball athletes, players lost an average of 1.4 L of sweat during a match.


  • It is recommended for athletes to obtain 7-9 hours of sleep with upwards of 10-12 hours for athletes who are adolescents or train 4-6 hours per day
  • Lack of sleep led to a depletion of energy and decreased time to exhaustion during exercise, and athletes with higher levels of insomnia were associated with decreased performance
  • Quality of sleep is also important in athletes, where those with greater sleep quality and won their games exhibited decreased stress levels and lower levels of confusion in comparison to those with lower sleep quality

Mental and psychological techniques:

  • Athletes who have a decreased amount of perceived recovery time are at a higher risk for injury
  • Spending time with friends, team building activities, and amusement are associated with promoting recovery and preventing injury
  • In a study of 11 female intercollegiate volleyball players, a program focusing on cognitive behavioral skills demonstrated that increased use of imagery and using a routine increased serving performance
  • High levels of anxiety and stress may lead to impaired performance, yet few athletes utilize mental or emotional recovery techniques

Cold water immersion (CWT) and Laser therapy (LLLT):

  • Limited evidence is available for CWT and LLLT for athletes, and there is no consensus on the effectiveness or dosage for either recovery technique.
  • CWT is suggested to improve submaximal muscle function in comparison to active recovery and suppress post-exercise levels of creatine kinase (CK) and lactate dehydrogenase (LDH)
  • LLLT is suggested to reduce post-exercise CK levels and other inflammatory markers of muscle damage; however, the research is limited by some of the studies using rat models as well as there being mixed results among studies.

Overall, current nutrition recommendations for female athletes lack sex specificity, and athletes may benefit more from maintaining a high carbohydrate to protein ratio rather than using absolute numbers. Supplementation using antioxidants may be beneficial in improved recovery among athletes. It is important to maintain an adequate amount of sleep as well as quality of sleep to improve performance levels. In terms of mental and psychological techniques, routines involving imagery for closed activities, like serving, and managing anxiety and stress levels may improve performance. It is essential to educate athletes on recovery time as perceived recovery time is a risk factor for injury, and likewise, it may be beneficial to encourage activities, such as team bonding and spending time with friends to decrease risk of injury and improve recovery. At Physical Therapy First, your physical therapist can provide you with protocols for proper warm-up and cool down activities as well as discuss the factors listed above with you to maximize your recovery, decrease your risk of injury, and improve your performance.


Closs, Brian. Burkett, Connor. Trojan, Jeffrey D. Brown, Symone M., Mulcahey, Mary K. “Recovery after volleyball: a narrative review.” The Physician and Sportsmedicine, Volume 48, Number 1: 8-16, (2020).

My Shoulder is Frozen-What?

By Joseph Holmes, PT, DPT, CDN, FNCP

Adhesive capsulitis, more commonly known as frozen shoulder, is a debilitating and rapidly developing impairment of the shoulder. Adhesive capsulitis is defined as having a painful shoulder with pain present vaguely throughout the whole shoulder, with subsequent and rapidly progressing stiffness limiting range of motion in all directions (1). The typical loss of motion presents in the following manner, external rotation is most limited then abduction, and followed by shoulder internal rotation (2). The following images defines external rotation, abduction, and internal rotation:

basic shoulder movements

Image courtesy of

Primary adhesive capsulitis affects 2%-5.3% of the general population (3,4). Secondary adhesive capsulitis affects 4.3%-38% of the population (3,4,5). Secondary adhesive capsulitis is that which derives from a known injury or an underlying systemic disease such as diabetes mellitus (type I or type II) or thyroid disease). A study by Milgrom et al discovered that of people with adhesive capsulitis, approximately 30% have diabetes, and around 21% of women had hypothyroidism (6). This is a disease and subsequent impairment which has a debilitating effect on a large portion of the population, and as seen above affects those with diabetes and thyroid disease at a higher rate than those without diabetes or thyroid disease. Adhesive capsulitis has also been found to be most common in people 40-65 years old, women>men, and those who have had adhesive capsulitis previously in the opposite shoulder, as well as those with Dupuytren’s disease (6,3,7).

Categories of Adhesive Capsulitis (1)

  1. Primary: Of unknown cause or origin
  2. Secondary: Of known cause or origin, especially injury or systemic disease
    1. Systemic: Diabetes or other metabolic conditions
    2. Extrinsic: Stroke, Heart Attack, Parkinson’s Disease, etc.
    3. Intrinsic: Rotator cuff tear, labral tear, biceps tendinopathy, etc.

Stages of Adhesive Capsulitis:

Adhesive capsulitis occurs in 4 progressive stages, which typically runs through a time period of approximately 18-24 months total. Adhesive capsulitis, unlike most other musculoskeletal conditions, dissolves of its own accord after this time frame and people typically return to pre-disease levels of pain and function, however residual stiffness and muscle tightness can be present.  The stages of frozen shoulder are as follows (8,9,11):

  1. Onset (0-3 months from onset):
    1. Sharp pain at end ranges of motion
    2. Achy pain at rest
    3. Sleep disturbance
    4. Minimal to no ROM restrictions
  2. Freezing/Painful (3 months-9 months since onset)
    1. Gradual loss of overall shoulder motion due to pain
  3. Frozen (9 months-15 months since onset)
    1. Severe pain
    2. Extreme loss of shoulder motion all directions
  4. Thawing (15-24 months since onset)
    1. Pain begins to resolve
    2. Significant stiffness still persists

What Do I Do if My Shoulder Freezes?

The best recommendations based off the 2013 Clinical Practice Guideline for Adhesive Capsulitis recommends a combination of the following treatment interventions in order from strongest to weakest support from the evidence:

  • (Strong Evidence): Corticosteroid injections from a qualified practitioner in combination with the shoulder stretching and strengthening.
  • (Moderate Evidence): Patient Education on the course of adhesive capsulitis as well as activity modification to allow a minimal pain lifestyle, and physical therapy activities which match and do not aggravate the person’s current level of irritation and pain.
  • (Moderate Evidence): Stretching exercises which match the intensity of your pain and irritability.
  • (Weak Evidence): Modalities and passive interventions such as shortwave diathermy, ultrasound, and electrical stimulation.
  • (Weak Evidence): Joint mobilizations or deep joint stretching to the affected shoulder with the goal of decreasing pain and improving range of motion.
  • (Weak Evidence): Manipulation under anesthesia. This is a common practice but has in recent years been performed less frequently as most often the stiffness returns after the manipulation under anesthesia.

Physical Therapy First

Your physical therapists at Physical Therapy First will provide you with the highest quality of care for your full 60-minute session. Physical Therapy First is the only outpatient physical therapy clinic in the Greater Baltimore area providing 1-on-1 care with your physical therapists for your full treatment session. Call in any of our four locations in the greater Baltimore region today to be seen immediately for your shoulder pain!


  • Webpage:
  • Cyriax J. Textbook of Orthopedic Medicine. Diagnosis of Soft Tissue Lesions. Baltimore, MD: Williams & Wilkins; 1970.
  • Aydeniz A, Gursoy S, Guney E. Which musculoskeletal complications are most frequently seen in type 2 diabetes mellitus? J Int Med Res. 2008;36:505-511.
  • Bridgman JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis. 1972;31:69-71.
  • Lundberg BJ. The frozen shoulder. Clinical and radiographical observa­tions. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabo­lism. Acta Orthop Scand Suppl. 1969;119:1-59.
  • Milgrom C, Novack V, Weil Y, Jaber S, Radeva-Petrova DR, Finestone A. Risk factors for idiopathic frozen shoulder. Isr Med Assoc J. 2008;10:361-364.
  • Balci N, Balci MK, Tüzüner S. Shoulder adhesive capsulitis and shoulder range of motion in type II diabetes mellitus: association with diabetic complications. J Diabetes Complications. 1999;13:135-140. http://dx.doi. org/10.1016/S1056-8727(99)00037-9
  • Hannafin JA, Chiaia TA. Adhesive capsulitis. A treatment approach. Clin Orthop Relat Res. 2000:95-109.
  • Neviaser AS, Hannafin JA. Adhesive capsulitis: a review of current treatment. Am J Sports Med. 2010;38:2346-2356. http://dx.doi. org/10.1177/0363546509348048
  • Neviaser RJ, Neviaser TJ. The frozen shoulder. Diagnosis and manage­ment. Clin Orthop Relat Res. 1987:59-64.


The Effects of Vitamin D Deficiency and Benefits of Supplementation

by Logan Swisher, PT, DP


Vitamin D (VITD) is important in bone health, skeletal muscle growth, inflammatory modulation, immune and cardiopulmonary function. VITD can also interact with extraskeletal tissues to modulate injury recovery and influence of the risk of infections. It is estimated that 1 billion people in the world currently have VITD deficiency and that number is on the rise. The major cause for the VITD deficiency is the lack of awareness in the population that sun exposure is the main source of vitamin D. In relation to food sources of VITD, it is difficult to obtain vitamin D through the diet because very few foods naturally contain the vitamin, exceptions being eggs, cheese and fatty fish such as salmon, sardines, herring.

How is Vitamin D Metabolized?

Vitamin D is an organic compound in food needed in small amounts for growth and good health but the human requirement can actually be met entirely through synthesis in the skin upon exposure to sunlight. The ultraviolet-B (UVB) radiation in sunlight converts to D3 and the newly synthesized vitamin D (as well as vitamin D obtained from the diet) is escorted to the liver. In the liver, vitamin D is rapidly converted to 25(OH)D, the main storage form. Further activation in the kidney is driven by parathyroid hormone (PTH) when blood calcium and/or phosphate concentrations fall below the normal range.

Benefits of Vitamin D

Sufficient levels of Vitamin D provide multiple musculoskeletal benefits such as: increased muscle protein synthesis, ATP concentration, strength, jump height and velocity, exercise capacity, physical performance, decrease muscle protein degeneration and reverse myalgias. It is also well known that vitamin D plays an important role in bone health, fracture prevention and reducing the risk and impact of diabetes, multiple sclerosis, certain cancers, cardiovascular diseases and hypertension, cerebrovascular diseases, infectious diseases, asthma, depression, and other autoimmune and chronic inflammatory disorders.

How much Vitamin D do you need?

In order to properly assess levels of Vitamin D, blood levels of total 25-hydroxy vitamin D (25(OH)D) must be taken. There are studies which suggest that a value of 25(OH)D >30 ng/mL should be considered as acceptable for maintaining bone health and reducing the risk of fracture in healthy young people and adults, while others suggest that necessary levels should be set at >40 ng/mL. 25(OH)D levels above 40 ng/mL are required for fracture prevention, including stress fractures. Optimal musculoskeletal benefits occur at 25(OH)D levels above the current definition of sufficiency (> 30 ng/mL) with no reported sports health benefits above 50 ng/mL. The Institute of Medicine recommended dietary allowance (RDA) of vitamin D for the US and Canada is 600 IU for children and adults under 70 years of age and 800 IU for those over 70 years old. It is important that you discuss this with your primary care provider prior to taking any Vitamin D supplements.


De la Puente Yagüe M, Collado Yurrita L, Ciudad Cabañas MJ, Cuadrado Cenzual MA. Role of Vitamin D in Athletes and Their Performance: Current Concepts and New Trends. Nutrients. 2020 Feb 23;12(2):579. doi: 10.3390/nu12020579. PMID: 32102188; PMCID: PMC7071499.

Shuler FD, Wingate MK, Moore GH, Giangarra C. Sports health benefits of vitamin d. Sports Health. 2012 Nov; 4(6):496-501. doi: 10.1177/1941738112461621. PMID: 24179588; PMCID: PMC3497950.

Treating Your Low Back Pain: But my MRI says….

By Joseph Holmes, PT, DPT, CDN, FNCP

The likelihood that any adult in the United States will experience some form of low back pain each year is 1.5%-36%. Moreover, about 25% of adults report having at least 1 day of low back pain in the past 3 months (1). There are many factors that affect the likelihood of this happening (2). Most people assume that when back pain occurs, whether it is aggravating or debilitating, an x-ray or MRI is needed and that they should be prescribed muscle relaxers and/or painkillers. However, updated guidelines from the American College of Physicians recently announced that, “doctors should avoid prescribing opioid painkillers for relief of back pain and suggest that before patients try anti-inflammatories or muscle relaxants, they should try alternative therapies like exercise, acupuncture, massage therapy or yoga” (3). Furthermore, previous guidelines stated that imaging, such as an MRI, demonstrated no value to the patient and can also lead to worse and more costly outcomes. Thus, imaging should only be prescribed if severe neurological symptoms are present (4).

To address the growing demand for treatment of the increasing number of people who have low back pain, physical therapists have created the Low Back Pain clinical practice guidelines. These are rigorous guidelines which synthesize all the available evidence on low back pain assessment, diagnosis, and intervention/treatment. The most recent version of the guidelines, published in 2012 by the American College of Physicians, stated that people need an active intervention in order to show the quickest improvement in healing their pain and returning to normal function. Often low back pain will heal on its own eventually, that is, if the proper actions are taken.

Physical therapists, guided by the clinical practice guidelines, use the most up to date information to help the approximately 30-50 million Americans who experience low back pain every year. Because most back pain cannot be directly associated with a specific cause of injury, this leads to many inaccurate findings on MRIs, CT scans, and X-rays, including people with no back pain symptoms whatsoever being diagnosed with “abnormal” findings of the lumbar spine 32% of the time (5). Thus, the best available evidence supports a classification approach that de-emphasizes the importance of identifying specific anatomical lesions after red flag screening is completed. There is still so much that experts do not understand about low back pain. What we do know is that the best physical therapists will diagnose and treat your back pain based on your individualized symptoms and reported limitations.  We will work with you to create goals and interventions that will help to alleviate your pain and allow you to return back to your regular function.

The 2012 Low Back Pain Clinical Practice Guidelines utilized the four treatment-based classifications to categorize low back pain that were created in 2007 (6). They are as follows:

  • Manipulation (based on strong evidence from the Flynn et al Clinical Prediction Rule):
    • A person is a great candidate for manipulation if they meet most of these criteria:
      • No symptoms below your knee
      • Recent onset of symptoms less than 16 days
      • Low fear avoidance based off a validated questionnaire (FABQ-work <19)
      • At least 1 stiff/hypomobile segment of the lumbar spine
      • At least 35 degrees of internal rotation, a measurement of hip rotation, in 1 hip
    • Stabilization:
      • A person is a great candidate for the stabilization if they meet most of these criteria:
        • <40 years old
        • Post-partum or straight leg raise >90 degrees
        • Positive prone instability test
        • Poor rhythm of bending over and flexing the spine
      • Specific Exercise, Centralization, or Directional Preference:
        • A person is a great candidate for specific exercise if they meet most of these criteria:
          • Symptoms below the buttock
          • Older age
          • Preference to bend over in to flexion or back into extension to get relief
        • Traction:
          • A person is appropriate for intermittent traction if they meet most of these criteria:
            • Signs and symptoms of nerve root compression, weakness, or crossed SLR
            • Peripheralization of symptoms or worsening of symptoms in the legs with both bending forwards and backwards

            After your physical therapist categorizes your clinical presentation into one of these four categories, your individualized program will be created using the support of the best evidence available combined with years of clinical expertise. Additionally, the low back pain clinical practice guideline recommends the following interventions which best match your treatment-based classification (7). A is considered the best evidence and E is the worst evidence.

            • (A): Manual therapy such as soft tissue mobilization, core stabilization, directional preference, and progressive endurance training and exercise.
            • (B): Patient Education: Do NOT increase patient’s fear or perceived threat
            • (C): Flexion or bending forward for lumbar stenosis: people with lumbar stenosis should be performing strengthening, stretching, and increased endurance activities
            • (D): Lumbar traction: If a person is classified in to the above traction classification, then traction can be slightly helpful, otherwise it is of no benefit
            • Not listed: no grade or recommendation was made towards heat, ice, electrical stimulation, or dry needling

            Physical Therapy First

            At Physical Therapy First, you are provided with more individualized time in your initial evaluation and treatment sessions than with any other provider in the region. Our physical therapists perform 60 minute 1-on-1 initial evaluations and all follow up sessions are 1-on-1 for 60 minutes with your physical therapist. We provide the best care in the region with the highest qualified clinicians. Call or email any of our four locations in the Greater Baltimore area to set up your appointment today.


            1. Deyo RA , Mirza SK , and  Martin BI . Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976). 2006;31:2724-7. [PMID: 17077742]
            2. Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24:769-781.
            3. Amir Qaseem, Timothy J. Wilt, Robert M. McLean, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med.2017;166:514-530. [Epub ahead of print 14 February 2017]. doi:10.7326/M16-2367
            4. Chou R, Qaseem A, Snow V, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med.2007;147:478-491. [Epub ahead of print 2 October 2007]. doi:10.7326/0003-4819-147-7-200710020-00006
            5. Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6:106-114.
            6. Fritz, JM, Cleland, JA, Childs, JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007;37:290–302.
            7. Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. Low Back Pain: Clinical Practice Guidelines. J Orthop Sports Phys Ther 2012;42(4):A1-A57. doi:10.2519/jospt.2012.42.4.A1

Blood flow restricted exercise for athletes: A review of available evidence

by Stephanie Beatty, SPT

Introduction: What is blood flow restriction and how does it work?

– Blood flow restriction (BFR) involves the placement of a cuff around an arm or leg in an effort to prevent venous return, or the flow of blood through the veins of the limb back to the heart, while still allowing blood to flow from the heart to the limb through the arteries. By occluding blood flow, lighter weights and lower exercise intensities can be used to achieve similar benefits to those that would be achieved with higher intensity exercise without blood flow restriction. While the exact mechanisms are unclear, when used during exercise, blood flow restriction is thought to induce both short- and long-term changes in muscle characteristics, muscular development, and overall performance. Blood flow restriction is commonly used in older patients, patients recovering from an injury, and other patients who are unable to tolerate exercising with higher loads, but it has been shown to be beneficial to athletic populations as well. The objective of this literature review was to assess the evidence of acute and longer-term adaptive responses to exercise with BFR in trained athletes.


– The authors in this literature review identified twelve papers that fit their established inclusion criteria and assessed acute and adaptive responses to different types of exercise with BFR in various athletic populations, including track and field athletes, football players, netball players, rugby players, basketball players, and ice hockey players.

Summary of Evidence

– Training responses to BFR combined with low-load resistance exercise included:

o Decrease in metabolic stress imposed on muscles during exercise
o Increase in growth hormone concentration with a decrease in the concentration of chemical indicators of muscle damage
o Increase in squat, bench press, and leg press 1-RM (depending on activity during which BFR was applied)
o Decrease in sprint and acceleration times
o Increase in muscle strength
o Increase in muscle endurance
o Increase in muscle torque production
o Increase in muscle cross-sectional area and girth
o Improved performance on sport specific physical assessments

– Training responses to BFR combined with moderate-load resistance exercise included:

o Increase in squat and bench press 1-RM
o Improved jump and sprint performance
o Increase in levels of testosterone and cortisol
– Training responses to BFR combined with low-intensity cardio included:
o Improved aerobic capacity and anaerobic power
– It should be noted that many of these studies reported that training adaptations were sport specific and varied by athletic population (i.e. endurance-dominant athletes experienced different adaptations than strength-dominant athletes). Additionally, low intensity exercise with BFR has not been shown to produce significant changes in connective tissues. For this reason, authors stressed the importance of combining low-intensity BFR exercise training with high-intensity strength training without BFR to allow proportional changes to occur in the tendons and reduce the risk of tendon injury.

Conclusion and Clinical Applications:

– BFR can be used with low-intensity resistance training to produce changes in muscle and improvements in performance in higher-level athletes.
– Exercise training with BFR should be sport specific.
– It is important to combine low-intensity BFR training with high-intensity training without BFR to continue to stress the connective tissues and reduce the risk of tendon injury.
– BFR with low-intensity exercise can be used as an adjunct during de-loading weeks or during recovery from injury.
– Exercises done with BFR should still be progressed for continued improvements.

At Physical Therapy First, we treat a variety of patient populations including well-trained athletes, recreationally active patients, post-operative patients, and deconditioned patients, all of whom blood flow restriction has been shown to help. We offer individualized therapeutic exercise and home exercise routines. During your evaluation, your therapist can further discuss blood flow restriction and how it may help you recover from an injury and improve your function.


Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Blood flow restricted exercise for athletes: A review of available evidence. Journal of Science and Medicine in Sport. 2016; 19(5):360-367. doi:10.1016/j.jsams.2015.04.014