The Common Injuries of Swimming
What they are and how to avoid them
Taylor Millican, PT, DPT, ART-Cert.
Sports Medicine Physical Therapist
Endurance Sports Medicine Specialist
Swimming is a fantastic cardiovascular and total body conditioning activity and sport for all ages. It is one of the few activities that can be participated in for a lifetime! While swimming is non-impact and non-traumatic activity, many injuries can occur due to overtraining/overuse and stroke compensations.
The most affected joint from swimming is fairly obvious: the shoulder. The shoulder is the most complex joint in the body. It has the most range of movement and can move in all planes of motion. However, it is poorly stabilized by bone. Soft tissue (muscle, tendon, ligament, capsule) is what keeps the arm (humerus) in the socket (glenoid). The rotator cuff, made of four muscles, is designed to help stabilize the humerus in the glenoid but often is weak because of a lack of focus on strength and stability in dry land. This can then lead to impingement with overhead activities due to lack of downward control on the arm, as well as poor posture common in adolescent swimmers. Tightness through the front of the shoulder and chest can also further pull the humerus forwarding the glenoid predisposing impingement issues overhead. An imbalance in strength between the posterior scapular (shoulder blade) muscles and anterior chest muscles often cause anterior/forward predisposition as well.
True “Swimmer’s Shoulder” (SS) is a condition that occurs from mechanical (physical) impingement between the soft tissues and the bony coracoacromial arch (the bone bridge formed from the shoulder blade). It is as if a rope is being "pinched" as it travels under a bridge, wearing it down and/or "pinching" it to the bone. It’s the chronic inflammation of soft tissue structures including: Supraspinatus muscle of the rotator cuff, the long head of the Bicep, and the Subacromial bursae (which is a fluid filled sac). Pain is usually deep in the front of the shoulder and is increased with overhead positions and at night with various sleeping positions. Its cause is purely repetitive in nature. While there are factors that can predispose athletes to this condition such as, hypermobile, unstable or "lax” joints, as well as rounded-forward posture, most of the factors are very preventable.
The most controllable factor in shoulder injuries is posture and scapular-thoracic positioning. Weak scapular stabilizers (Serratus Anterior and Middle and Lower Trapezius) lead to the forward “slouch" that is seen in most adolescents and majority of adults who spend excessive time on the computer. The problem is this position brings the delicate soft tissues into contact with the bony acromion and can irritate and inflame the tissue.
Without proper scapular positioning, overhead shoulder motion is compromised. Overhead motion with reaching of the shoulder with the elbow straight is made up of 180 degrees; 120 degrees from the glenohumeral joint (shoulder) and 60 from the scapulothoracic joint (shoulder blade and rib cage joint). If the scapular rotators are not strong enough to rotate the scapula up the only available motion will be from the shoulder itself and be limited by a significant amount. This will lead to altered strategies to force the arm overhead and possible injury. Neck (upper trapezius) strains are common due to compensation to help force the shoulder overhead due with weak scapular stabilization.
Injuries and pain to the low back with swimmers are common as well. These come often from either a decrease in strength or lower than needed flexibility in the shoulders and hips. Typically the deeper core muscles, such as Transverse Abdominus that support the spine, are under utilized with poor posture and frequent growth spurts. Long duration sets and pull sets can lead to lumbar (low back) hyperextension due to poor abdominal control and can lead to lumbar spasms and facet syndromes. Lumbar disc injuries can be seen as well from repetitive flexion with flip turns and again, poor abdominal control to support the spine. Strength programs for dryland training should include plank exercises and low abdominal training to help avoid low back issues. Flexibility can challenge low back health as well. If shoulder flexibility (as discussed earlier) is limited, a swimmer may end up “arching” their low back in order to help get their arms/elbows high enough out the water in recovery phase. In addition, tight hip flexors also allow the back to arch. In all strokes, hip flexors are required to “work” for both stabilization as well as kicking, but when the body needs to be lengthened, the hip flexors have to stretch.
Knee pain and meniscus damage is relatively frequent with swimmers but specifically with those who specialize in breaststroke and IM’s. Medial meniscus injury and patellofemoral pain syndrome (PFPS) is extremely common due to the strain placed on the knee during the end phase of the kick. PFPS is simply a description of any pain that happens due to the knee cap (patella) not being aligned right, or pulled evenly, when the quad (front of the thigh) muscles activate. Deep squatting with flip turns that are too close to the wall can also place excessive strain on the meniscus. Overall, good technique, a balance of hip rotator muscles, hamstrings and quad strength, and flexibility will keep the knee as healthy as possible.
When dealing with younger swimmers it is important to monitor athletes for changes in their strokes to avoid over fatigue and stroke compensations. Slow increases in training loads and intensities are critical. This is why it is so important for coaches to make training sets in advance, keep track of them, and total distance in days, weeks, and months as well. Training paddles and extensive pulling sets are not typically suggested for younger athletes as this puts to much stress on the underdeveloped adolescent scapular and deep core muscles, leading to lumbar and shoulder strain. Avoiding unbalanced strength development with overtraining of a single stroke can also be helpful by mixing in strokes other than freestyle to aid in over development of anterior structures.
A dryland program that incorporates scapular and core strength, pectoral stretching, and thoracic (mid back) mobility is crucial for swimmers. Good form with strength programs is important to avoid injury unto the water. Often it is a hard to find time or even space to fit this into a busy practice schedule but even at a 2-3 times a week it is a great prevention strategy for avoiding these injuries. Lastly, making sure that dry land programs are monitored for form will make the most success out of the athlete’s time!