ExRx.net : Swim Injuries

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

Injury Prevention

Stroke-specific mechanics instruction, monitoring, and timely feedback
- Also see Skill Acquisition and Proficiency
Carefully program and monitor training volume, intensity, and duration
- Minimize overuse injuries and identify athletes at risk
- Do not subject swimmers to irrelevant/incorrect training principles
  - See Problems with Traditional Training and Ultra-short Race-pace Training
- Understand dose-response relationship of fitness and risk of injury
  - See Running Example
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.
- Functional / ROM
- Posture
  - Common postural problems with swimmers include
    - forward head, thoracic kyphosis, decreased cervical lordosis
    - rounded shoulder posture
      - protracted scapulae, and internally rotated/anterior humeral head
    - Issues associated with this posture include
      - restricted anterior shoulder musculature
      - lengthened and weak medial scapular stabilizers
      - tight glenohumeral posterior capsule
      - weak anterior cervical flexors
- Potential Common Impairments
  - Postural deviations
  - Tight anterior chest musculature
  - Hypomobility of the thoracic spine
  - Loss of joint mobility or excessive joint mobility
  - Tight posterior capsule
  - Impaired strength and endurance of the rotator cuff and scapular stabilizers
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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Swim Injuries