Predisposing Factors & Movement Deficiencies in Youth Female Volleyball Athletes with Patellofemoral Pain Syndrome

Female youth athletics has become more popular over the last few decades with volleyball specifically reaching some all-time highs with nearly ½ million girls currently involved in playing high school volleyball (Olson, 2024). However, females involved in this sport specifically, or other similar sports which involve higher volumes of jumping, cutting, reactive movements, and other aspects of explosive power can be more vulnerable to a variety of pain and injuries during their adolescent years. According to data from 2004-2014, an epidemiology study of high school volleyball players found that 62,000 total injuries occur each year in volleyball. However, this statistic is encompassing all types of acute or chronic pain, not knees specifically. Knee injuries account for up to 26% of total injuries so an estimated knee pain/ knee injury yearly incidence rate in adolescent female volleyball is around 16,120 (Mizoguchi et al., 2024).  Knee injuries (e.g. ACL), and knee pain (e.g. patellofemoral pain syndrome (PFPS) and patellar tendinopathies) are common issues with volleyball players, namely females, around their growth spurts/ “peak height velocity” due to several known factors (Chen, Liu & Hong, 2026). More specifically, PFPS has 28.9% prevalence amount adolescents with females having 2-10 times the incidence compared to age-related male counterparts (Kalatzis et al., 2025).

A specific cross-sectional study of an elite teenage female volleyball squad reported slightly lower prevalence at 19.5% (Mizoguchi et al., 2024).  Knee pain and/or injury can not only limit the athletic potential, but also impact quality of life and possible be career-ending. PFPS has a track-record being difficult to fully remedy resulting in many years of pain. Approximately 50% of individuals with PFPS are resistant to treatment and may live with pain for up to two decades (Kalatzis et al., 2025). Other types of knee pain and injury (like ACL) have under a 50% return to pre-injury performance level (Jandhyala et al., 2024). With prevalence over 20% of female adolescent athletes having PFPS, this is a significant portion dealing with knee pain and medical care costs estimated at $1500/ year for management (Tan et al, 2009).

Several elements are understood to be contributors to knee pain and injury in this population. Early sport specialization is regarded as a major risk factor of knee pain, especially PFPS (Kalatzis et al., 2025). In fact, a retrospective cohort study which included 66 high school female volleyball players found that PFPS incidence was 1.5 higher with early single-sport specialization compared to multisport athletes (Hall et al., 2015). The anatomical changes of both the growing female’s musculoskeletal system and neuromuscular system have been implicated via multiple mechanisms.

First, the widening of the female pelvis increases the Q-angle of the knee which mechanically put the knee into more valgus and knee abduction stresses. Secondly, the rate of skeletal growth (especially surrounding the peak high velocity/ growth spurts) exceeds the growth of the thigh muscles (e.g. rectus femoris) and tendons and connective tissue which leads to increased chronic strain of the tendons crossing the knee; this increased basal level of tendon strain coupled with high volumes of jump contacts in volleyball across a week specifically is regarded as ingredients for developing knee pain. Thirdly, a sequalae of the rapid skeletal growth and delayed lengthening of the tendons and muscle crossing the knee and hip results in distorted joint and muscle proprioception akin to looking into a funny-house mirror at a carnival. The proprioception input is distorted, and unlike males with increased testosterone, there is a lag period for this “re-wiring” of accurate neuromuscular and proprioceptive pathways (Chin, Liu & Hong, 2026). Forth, lack of trunk/ core stability and appropriate motor-control patterns are postulated to increase knee valgus, knee abduction moment, and higher knee flexion angles which when added to 1000’s of jump contact across the week, lead to biomechanical dysfunction and local tissue excess stress (Kalatzis et al., 2025).

References:

Chen S, Liu Q and Hong Z (2026) Dual benefits of neuromuscular training in adolescent volleyball players: knee injury prevention and athletic performance share a common mechanistic foundation: a structured narrative review. Front. Sports Act. Living 8:1849255. doi: 10.3389/fspor.2026.1849255

Kalatzis, D., Zoumpoulis, G., Zygogiannis, K., Kaoullas, K., Fotoniatas, I., & Thivaios, G. C. (2025). Patellofemoral Pain in Elite Female Volleyball Players: Correlation With Trunk Muscle Strength. Curēus (Palo Alto, CA), 17(7), e88729. https://doi.org/10.7759/cureus.88729

Jandhyala, A., Elahi, J., Ganti, L., & McAuley, D. (2024). Volleyball Related Injuries in Adolescents: A Decade of Data. Orthopedic reviews, 16, 123665. https://doi.org/10.52965/001c.123665

Hall, R., Barber Foss, K., Hewett, T. E., & Myer, G. D. (2015). Sport specialization's association with an increased risk of developing anterior knee pain in adolescent female athletes. Journal of sport rehabilitation, 24(1), 31–35. https://doi.org/10.1123/jsr.2013-0101

Olson, E. (2024, November 4). Volleyball popularity at all-time high for girls amid US olympic success and college game’s exposure | AP News. Volleyball popularity at all-time high for girls amid US Olympic success and college game’s exposure. https://apnews.com/article/youth-sports-volleyball-e63cee43e560e7098db0741109d5767e 

Mizoguchi, Y., Suzuki, K., Shimada, N., Naka, H., Hall, T., & Akasaka, K. (2024). Prevalence and associated factors of non-traumatic knee pain in high school volleyball players: a cross-sectional study. The Physician and sportsmedicine, 52(6), 614–620. https://doi.org/10.1080/00913847.2024.2348439

Tan, S., van Linschoten, R., van Middelkoop, M., Koes, B., Bierma-Zeinstra, S., & Koopmanschap, M. (2009). PMS60 COST-UTILITY OF EXERCISE THERAPY IN ADOLESCENTS AND YOUNG ADULTS SUFFERING FROM THE PATELLOFEMORAL PAIN SYNDROME. Value in Health, 12(7), A444–A444. https://doi.org/10.1016/S1098-3015(10)75198-6