Injury Patterns in Danish Competitive Swimming
Injury Patterns in Danish Competitive Swimming
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
39. USA Swimming Task Review on Injury Prevention: Shoulder 42. Pink M, Perry j, Browne A, et al.: The normal shoulder during free-
Injury Prevention: A Series of Exercises for the Uninjured Swimmer. style swimming. An electromyographic and cinematographic
Colorado Springs: USA Swimming; 2002. analysis of twelve muscles. Am] Sports Med 1991, 19:569-576.
40. Bak K: Nontraumatic glenohumeral instability and 43. Bak K, Magnusson SP: Shoulder strength and range of motion
coracoacromial impingement in swimmers. Scand] Med Sci in symptomatic and pain-free elite swimmers. Am] Sports Med
Sports 1996, 6:132-144. 1997, 25:454-459.
41. McMaster WC: Anterior glenoid labrum damage: a painful
lesion in swimmers. Am] Sports Med 1986, 14:383-387.