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Con1petitive Swin1n1ing Illness and

Injury: Con1n1on Conditions

Lin1iting Participation
]ames N. johnson, MD

Address world. The physician must be aware of the common risks in a

USA Swimming National Team Physician, Southern Sports Medicine, competitive swimming environment and be able to help pre-
2021 Church Street, Suite 200, Nashville, TN 37203, USA
vent and treat the associated injuries or illness. The focus of
this review is the injuries and illness that are the most signifi-
Current Sports Medicine Reports 2003, 2:267-271
cant in limiting a swimmer's ability to participate in training
Current Science Inc. ISSN 1537-890x
Copyright © 2003 by Current Science Inc. and competition.

Illness and injury can significantly limit a swimmer's participa-

Catastrophic Injuries
tion in training and competition. Catastrophic injuries to the
The two most catastrophic injuries in competitive swim-
neck and risk of drowning are life threatening. Infectious illness
ming are neck injury resulting in paralysis and drowning,
can cause significant time out of the water and an even longer
and sudden death. Neck injury can result from too deep a
convalescence. When injuries to the shoulder, back, and knee
dive into a shallow pool or colliding head first into the wall
become chronic, these overuse injuries can affect perfor-
while swimming backstroke. Safety precautions in the sport
mance despite continued cross-training. By identifying the risks
include minimum depth requirements of 5 feet for competi-
for swimming injury and illness, and implementing prevention
tive starting block dives, which is mandated by USA Swim-
strategies, the physician can help keep swimmers in the water.
ming (Colorado Springs, CO). For backstroke, overhead
flags are placed 5 meters from a wall to help prevent head-
first collisions. All coaches are required to be trained by the
Introduction American Red Cross in first aid, cardiopulmonary resuscita-
Competitive swimming at the highest levels requires 20 to 30 tion, and a special coaches' safety training, which teaches
hours of training each week. Even at the masters level and age- back-boarding. Coaches must renew those certifications
group level, a minimum of 5 to 10 hours are spent each week every 1 to 2 years [6]. Coaches should also teach low-entry
swimming laps. Up to 1 million shoulder revolutions per year angle dives and steering-up techniques to minimize high-
are possible; thus, shoulder injury is the most common cause risk dives [7]; steering-up techniques involve angling the
of missed training and has been well documented in the med- hands toward the surface after reaching a safe depth.
icalliterature [1• • ,2-5]. Other causes of missed training that Drowning has resulted from breath-holding and under-
have not been explored in as much depth range from devas- water swimming. One recent case of a collegiate swimmer
tating neck injuries and drowning to less serious illness, such drowning resulted from a breath-holding attempt of 75
as upper respiratory infections (URis). Acute and overuse meters while swimming unsupervised in an uncoached set-
musculoskeletal injuries can also result from dry-land train- ting [8]. Hypoxia results when the Pao2 drops rapidly before
ing that includes weight lifting, plyometrics, running, and var- the rising PaC02 stimulates the drive to breathe, thus leading
ious calisthenics. The culture of competitive swimming is to unconsciousness and drowning. A case of sudden death
such that coaches and teammates do not tolerate missed occurred during practice in a collegiate swimmer and was
training due to the mix of myth and fact about how quickly later revealed to be hypertrophic cardiomyopathy on autopsy
swimmers decondition. Furthermore, swimmers can usually [9]. A recent case offatal arrhythmia was reported in a swim-
perform some kind of dry-land cross-training or kick in the mer with prolonged QT syndrome after diving into cold water
water if they have an upper extremity injury, and can usually resulted in an irregular rhythm that further prolonged the QT
continue to do modified swimming while rehabilitating a interval [10]. All governing bodies of competitive swimming
lower extremity injury. So, total restriction from training is now highly discourage breath-holding training techniques
unusual, and thus is not well-tolerated within the swimming and encourage preparticipation cardiac screening [6].
268 Sport-specific Illness and Injury

Fatigue Illness on the universal precautions of close contact avoidance and

A second group of illnesses that are not as devastating but hand washing. Many teams employ the use of a sick room to
can have long-term detrimental effects are associated with prevent spread of illness.
the training demands placed on competitive swimmers. An interesting phenomenon of herd illness that I have
Chronic fatigue-type illnesses related to overtraining can observed is mononucleosis with an unusual number of reac-
affect the mood and performance of high-level swimmers. tivations. In a single swim season, I diagnosed 10 cases of
Costill et al. [11] found that not ingesting sufficient carbo- mononucleosis confirmed by Epstein-Barr virus serologies
hydrate may cause chronic muscle fatigue. Mackinnon et from one team of 24 athletes. All but two of those cases were
al. [12] showed that neuroendocrine changes marked by freshman athletes, and there were four recurrences among
decreased urinary excretion of norepinephrine preceded the group of 10. Interestingly, a recent study from Gleeson et
overtraining by 2 to 4 weeks. Increased training volume al. [21] has shown that the reactivation and viral shedding
can also lead to a depressed mood [13]. may be a reflection of the altered immune control mecha-
Mononucleosis also can cause a chronic fatigue state that nisms that occur in response to intensive exercise. My
can be debilitating for a swimmer because of the difficulty in approach to those illnesses and their recurrences was to com-
returning to training after a prolonged convalescence [14]. municate contact precautions and hand washing instructions
The physician must work very closely with the athlete and to those athletes who spent 6 hours each day in close contact,
coach in devising a gradual progression of return to training. and then to devise a much more gradual return to training.
Unfortunately, no protocol seems to work in these cases, as Subsequently, there was no more spread of illness and no
each individual responds differently. In general, however, more recurrence, and the following season the group of
increasing volume by 5% to 10% per week over a 10- to 12- incoming athletes remained illness-free. The six swimmers
week period, followed by a more gradual reintroduction to who undertook a more gradual 6-month progression to
higher-quality (faster) training may prove effective. The dry- return to training performed much better than the early
land portions of training need to be reinitiated in a stepwise returnees (3 months or less).
manner as well [15]. Educating coaches and athletes on the
important concepts of periodization, progression, adaptation
and recovery, and the signs and symptoms of overtraining, Asthma
may help prevent future recurrences [16]. Upper respiratory illness causes even more significant limi-
tations of training in asthmatic swimmers. Asthmatics tend
to migrate toward swimming, as the humid environment
Upper Respiratory Illness and Infection was thought to be more asthma friendly, due to the anec-
Upper respiratory illness and infection is also a common dotal evidence of Olympic swimmers having succeeded with
cause of missed training. Although URI is no more common asthma [22]. Yet conversely, the chlorine in indoor pools
in swimmers than in the general population, it can be very irritates the respiratory tract and can cause asthma [22,23]. A
limiting for the swimmer because of the necessity of con- recent report by Bernard et al. [24] concluded that exposure
trolled breathing while training in water. Another added of children to chlorinated pools increases lung epithelium
problem is that chlorine is a strong upper respiratory irri- permeability and thus increases the risk of developing
tant. An Australian study has shown that competitive swim- asthma, especially in indoor pools. But in support of the
mers are no more at risk of developing URis than a group of assumption that swimming helps asthmatics, a 2000 Austra-
untrained controls; however, URis do result in poorer per- lian study demonstrated that the 1964 Australian Asthma
formance [17 •]. Other studies also show no relationship of Children's Swimming Program has achieved its intended
plasma glutamine levels to the risk of URI, although levels purpose of improving quality of life and asthma manage-
of glutamine have been shown to be depressed in athletes ment by reducing medications, doctor visits, and hospital-
during long bouts of intense training [18]. But some data izations in swimming participants [25]. Thus, swimming in
have shown that low preseason levels of salivary IgA may indoor chlorinated pools may be a risk factor for developing
predict risk of URI in swimmers [19]. More recent theories asthma, and some data suggest eosinophilic inflammation
have proposed that low levels of plasma glutamine, immu- in elite swimmers in the exercise-induced bronchial hyper-
noglobulins, and cytokines combined with decreased func- responsiveness [26]. However, swimming may still benefit
tion of neutrophils and natural killer cells may decrease known asthmatics by reducing their frequency of exacerba-
resistance to minor infection during intense training periods tions and increasing their aerobic capacity [27].
[20]. Prevention of illness thus becomes of paramount
importance to both coaches and athletes. Other important
illness prevention strategies include vaccination, especially Musculoskeletal Injuries
meningococcus, for those living in a herd-type environment With the potential for missed training from illness, preventing
(dorm or frequent team travel trips), and instructing athletes musculoskeletal injuries that may lead to significant time out
Competitive Swimming Illness and Injury • johnson 269

ofthe water becomes even more important. The independent With the increase in popularity of underwater dolphin kick-
data of Johnson et al. [1• •I and Bak et al. [2), examining 1 ing off the start and turns, the extension stresses on the lum-
year of competitive swimming in a broad-based population, bar spine are increased, and the resulting incidence of pars
agree that shoulder, back, and knee injuries are the most com- defects should be explored. Swimmers with a new pars
mon musculoskeletal injuries in swimming. The US studies defect must be rested for 12 weeks and then returned very
of Pink et al. [28•) and the Australian studies of Wadsworth slowly, after initiating a core and pelvic stabilization pro-
and Bullock-Saxton [29) thoroughly describe the bio- gram. A case can be made for bracing these athletes after 3
mechanics and pathomechanics of the shoulder and scapular weeks of rest if they are not yet pain free. But no data have
junction using EMG analysis, which provides insight into shown a definitive benefit to bracing over rest alone [37). An
important considerations preventing shoulder injury [1• •). association of swimming with disc disease has not been
The missing link in the literature review is the back injury, shown [38). A link between back injury and shoulder injury
which accounts for about 20% of all swimming injuries has also been postulated, and exploring that link may help
[ 1• • ,2]. Knee injuries have remained at a constant 10%, and to develop preventive rehabilitation strategies that could sig-
these result primarily from either dry-land bounding activities nificantly decrease missed training [39).
or breaststroke swimming [1••,2,5). The incidence of significant shoulder injury has been
Upper extremity injuries occurred at a three to one ratio to reported from 30% of swimmers in a single season, up to
lower extremity injuries during swimming [30). Knee injuries 48% of all swimmers in a competitive career [1• • ,2-5). The
in competitive swimming primarily involve the medial joint factors involved in interfering shoulder pain have been related
line. Women collegiate swimmers were shown to have a four to muscular fatigue and ischemia, biomechanical factors
to one likelihood of injury to their lower extremity during including abnormal scapulothoracic and glenohumeral
cross-training as compared with during swimming. A 1980 function, and abnormal stroke mechanics. In a 1978 report,
study of breaststroke swimmers presumed the common inju- Kennedy et al. [5) ascribed most "swimmer's shoulder" to
ries to include medial patellar facet arthritis and chronic anterior subluxation of the humerus on the glenoid and the
medial collateral ligament injury, then videographically corre- resulting impingement of the avascular region of the
lated both injury types to kick techniques [31). A subsequent supraspinatus and biceps. Bak [40) showed that gleno-
arthroscopic study showed medial synovitis in seven of nine humeral instability and coracoacromial impingement caused
swimmers with no biomechanical correlate to be identified a similar clinical presentation. McMaster [41) reported the
cinematographically. The conclusion was that "breaststroker's high incidence of labral injuries in swimmers, likely second-
knee" was an overuse synovitis [32). A 1985 study of breast- ary to this same subluxation/glenohumeral instability phe-
strokers undergoing knee arthroscopy supported these find- nomenon. Interestingly, even though the data from McMaster
ings in demonstrating that 47% of breaststroke swimmers [41) were published in 1986, labral injury identification is
with knee pain had an inflamed medial synovial plica [33). often significantly delayed in swimmers. The delay phenome-
Prevention should be geared toward preventing overuse by non may result from a surgeon's reluctance to stabilize a
reducing breaststroke kicking in training and correcting the shoulder joint in an athlete who engages in repetitive over-
hip abduction angle to between 37° and 42° [34). Treatment head motion. Although there are no published data, many
initially includes controlling inflammation with ice and anti- elite swimmers have successfully returned to high-level
inflammatory drugs, eliminating breaststroke kicking, and competition after shoulder stabilization and labral repair.
then initiating a gradual build-up in training distance [33). Impingement syndrome responds well to a scapular stabiliza-
Meniscal, chondral, and ligamentous injuries can result from tion program closely following the proposed exercises of Pink
dry-land activities that involve running, lifting, bounding, or et al. [42) in their landmark EMG study. Unfortunately, physi-
excessive loads, similar to any other land-based sport. cal therapy of swimmer's shoulder remains locked into exter-
Back injuries in swimming develop from excessive load nal rotation strengthening exercise. Bak and Magnusson [43)
to the spine, whether it be a gradual extension load while also showed that prevention and rehabilitation of swimmer's
swimming with poor posture, or an axial load while lifting shoulder might not solely involve strengthening external rota-
weights. The data from Johnson et al. [1• •I describe a 23% tors. Applying the recommended exercises of Pink et al. [42)
incidence of spine injury in a single season. The data from and a knowledge of biomechanics and correct stroke tech-
Bak et al. [2) report a similar 22% incidence. A comparison nique, Johnson et al. [1••1 developed a preventive stroke
of spine injury incidence in gymnasts and swimmers dem- correction and exercise program that has shown promise in
onstrated that 16% of all swimmers had spine abnormalities the swimming teams that have applied the program this past
[35). Adolescent swimmers with thoracic back pain and season. Return to swimming and actual improvement in per-
kyphosis may suffer from Scheuermann's disease and formance has been observed in swimmers previously very
should be imaged. If this diagnosis is confirmed, short-axis limited by shoulder pain. The stroke corrections and scapular
strokes (butterfly and breaststroke) should be avoided [36). stabilization program have also resulted in an observed lower
Other spine injuries include stress fractures of the pars inter- incidence of back pain, and should be explored further as
articularis, resulting from either swimming or weight lifting. more data are collected.
270 Sport-specific Illness and Injury

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strategies are implemented. Return to training from pro-
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