Swim Injuries

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Epidemiology

  • Incidence of shoulder, knee, and spine injuries appear to increase with greater training volume
    • Freshmen swimmers suffer the most injuries compared with more experienced swimmers
      • due to a substantial increase of training volume
  • Females had significantly more injuries to the knee, back/neck, shoulder, hip, and foot
  • History of injury to the same anatomical location and history of injury at other anatomical sites, both correlate to incidence of future injuries
  • Pain and injury are greater in swimmers with a poor stroke technique
  • See Injury Etiology

SwimBackStrokeResizedCompressed.jpg

Injury Prevention

  • Stroke-specific mechanics instruction, monitoring, and timely feedback
  • Carefully program and monitor training volume, intensity, and duration
  • Teach swimmers how to recognize injury (pain) and the importance of reporting injury so it can be properly treated before it becomes worse
  • Coaches should identify early signs of injury
    • Stroke alterations occur in the swimmer with a painful shoulder (possible subacromial impingement)
      • Wider hand entry
      • Dropped elbow in the recovery phase of the freestyle stroke
      • Externally rotated shoulder when hand close to thigh
      • Early hand exit or shortened pull-through phase
    • Abnormal kicking mechanics can often be seen in swimmers with knee pain
      • Swimmers with medial patellar facet pain keep their hips more abducted and utilized greater hip and knee flexion
      • Swimmers with MCL pain derotate and plantar flexed the ankles as the knees extended
      • Swimmers with knee pain performing the breast stroke showed high angular velocities at the hip and knee and increased external tibial rotation
  • Evaluate athletes to determine individual strength, endurance, or flexibility deficits.
  • Dry land conditioning program
    • Strengthening, stabilization, and flexibility
    • Shoulder
      • supraspinatus, serratus anterior, rhomboids, lower trapezius, and subscapularis
    • Knee
      • vastus medialis obliquus
      • possible hamstring stretch if inflexible
    • Hip
      • possible stretch for hip external rotators, if hip internal rotation is inadequate
      • Possible hip flexor stretch if inflexible
    • Spine
      • Abdominal strengthening

Rehabilitation

  • Athletic Trainer
    • Diagnosis
    • Possible rehab/therapy when appropriate
      • as determined by athletic trainer
    • Ice therapy up to 1 week
  • Swim Training
    • Prolonged warmup
    • Temporarily reduce training distance and frequency
    • Active rest by temporary avoidance of strokes and positions that cause pain
      • typically freestyle and butterfly
    • Alter strokes more frequently to reduce stabilizer fatiguing and repetitive shoulder stresses
    • Avoid use of hand paddles, kick board, and surgical tubing
    • Use swim fins to enhance the propulsion from the legs, so stress on shoulder can be reduced
    • Dry-land exercise should be modified or eliminated if it irritates injury
  • Contingency (if pain persists)
    • 3-day period of absolute rest is recommended
    • Athlete should then be reassessed prior to resuming modified training
    • Evaluation by physician (sports medicine or orthopedic surgeon) if pain persists upon resumption of training
      • Less common more serious problems should be ruled out
      • 10-14 day course of Anti-inflammatory medication may be recommended
    • Reevaluation by physician if treatment is not successful after 2 weeks
    • Subsequent physical therapy may be indicated

Shoulder

  • Risk Factors
    • Glenohumeral laxity with subsequent shoulder instability
      • 20% of swimmers may have generalized ligamentous laxity
      • Both genetic and acquired components
      • Acquired anterior laxity allows for excessive external rotation
        • but places greater demand on rotator cuff and long head of biceps
          • as to reduce humeral head elevation and anterior translation
    • Overuse and fatigue
      • Fatigue combined with glenohumeral laxity leads to excessive humeral head migration
      • Example:
        • Fatigued serratus anterior fails to stabilize the scapula in upward rotation
          • Scapula fails to protract and upwardly rotate and the subacromial space may be compromised
          • The space between the humeral head and glenoid increases
            • contributing to more laxity
    • Impaired posture
    • Muscular imbalance or neuromuscular control
    • Specific populations
      • Females have shorter arm strokes and may have greater risk of overuse injury due to greater arm revolutions per lap
      • Tendonitis can first occur in adolescents with long arms that are not heavily muscled
        • They may be in the middle or end of a growth spurt
        • Long limb length provides an advantage, but muscles, tendons and joints are not yet fully developed
  • Injuries
    • 91% out of 80 young elite swimmers (13-25 years old) reported an episode of shoulder pain
      • 84% demonstrated signs of shoulder impingement
    • 69% show signs of supraspinatus tendinopathy diagnosed by magnetic resonance imaging (MRI)
    • Swimmer's Shoulder
      • Subacromial impingement
        • tendonitis, bursitis, capsulitis, or arthritis
      • Biceps tendonitis
      • Rotator cuff tendonitis
        • typically affecting supraspinatus
      • Sometimes symptomatic glenoid labrum fraying
  • Stroke Techniques
    • Body roll:
      • Shoulders and hips roll equally about 45 degrees
        • Places arms under body and close to the planes of the scapula
        • Emphasizes shoulder adduction over extension
          • Distributes work more equally between internal and external rotator muscle groups
          • Reduces the stress of soft tissue structures in the anterior shoulder region
        • Reduces scapular protraction
          • Reduces demand on scapular muscle, particularly the serratus anterior
      • Lack of body roll
        • Cause the humerus to compensate by moving into further horizontal adduction for adequate propulsion
        • Emphasizes shoulder internal rotators which may increase risk of over-use injuries to the shoulders
        • A hand entry that crosses the midline of the long axis of the body causes impingement of the supraspinatus and the long head of the biceps.
      • Excessive body roll
        • May cross the midline of the body during the pull through phase
        • Increased horizontal adduction can lead to impingement
      • Bilateral breathing may help some swimmers who have asymmetric body roll
    • Elbows bend upon entry
      • Keeping arms straight delays propulsion and overloads shoulders increasing risk of developing an over-use injury.

Knee pain

  • Risk factors
    • Second most reported source of injury in competitive swimmers
    • A study of Elite swimmers showed the rate of knee injuries was 0.17 for every 1000 hours of swimming
    • Patellar instability, subluxation, or maltracking (Quadriceps conditioning abnormalities).
    • Breaststroke
      • Knee pain in breaststroke swimmers correlates with the number of years of training, the volume of training, the caliber of the athlete, and increasing age
      • Overuse in breaststroke swimmers contributes to knee pain and injuries
      • Breaststroke has the greater incidence of knee pain compared to all other swimming techniques
        • > 10 fold risk over freestyle
  • Injuries
    • 86% of competitive breaststroke swimmers had at least 1 episode of breaststroke related knee pain
      • medial compartment of the knee
      • anterior knee pain also common
      • strain injuries of hip flexors, adductor magnus and brevis
  • Kick Techniques
    • Hip Adduction in breaststroke
      • breaststroke generates higher valgus loads due to adducted hip position
      • higher risk of injury when hip adduction angles are <37° or >42° at initiation of kick
    • Whip Kick
      • Increased strain of MCL due to high valgus load
    • Flutter Kick in freestyle swimming
      • Overuse resulting in patellofemoral overload
    • Wall push-off
      • Knee in high degree of flexion during starts in turns may result in patellofemoral overload

Spine

  • Risk factors
    • Undulating motion of breaststroke and butterfly
    • Training intensity and volume
    • Use of training devices such as fins, kick boards, or pull buoys
      • May produce excessive hyperextension of the lumbar spine
    • No sex differences
  • Injuries
    • Swim athletes have greater incidence of degenerative disk changes compared to control group
    • Incidence of low-back pain
      • 33.3%-50% of butterfly swimmers
      • 22.2%-47% of breaststroke swimmers
    • Prevalence of demonstrated degenerated disks at various levels
      • 68% of elite swimmers (mean age 19.6 years)
      • 29% of recreational swimmers (mean age 21.1 years)
    • Elite swimmers most frequently injure L5-S1
    • Spondylolysis and possible spondylolisthesis
    • Muscle and ligament sprains

References

Becker, TJ (1984). The Coaches Guide to Bicepital Tendonitis. ASCA 1984 Yearbook. 71-78.

Chase KI, Caine DJ, Goodwin BJ, Whitehead JR, Romanick MA (2013). A prospective study of injury affecting competitive collegiate swimmers. Res Sports Med. 2013;21(2):111-23.

Rushall BS (2013). Relevant Training Effects in Pool Swimming: Ultra-short Race-Pace Training (Revised), Swimming Science Bulletin, 40b http://coachsci.sdsu.edu/swim/bullets/ultra40b.pdf

Rushall BS (1998). Basic Training Principles For Pre-Pubertal Swimmers, Swimming Science Bulletin, 23

Tovin BJ (2006). Prevention and Treatment of Swimmer's Shoulder. North American Journal of Sports Physical Therapy, 1(4): 166-175.

Wanivenhaus F, Fox AJS, Chaudhury S, Rodeo SA (2012). Epidemiology of Injuries and Prevention Strategies in Competitive Swimmers. Sports Health. May 2012; 4(3): 246–251.

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