Millions of people regularly swim in the UK for pleasure, exercise or competition as it is considered a ‘safe sport’. There are relatively few major musculo-skeletal injuries even at elite level. Acute trauma is rare but may be seen in diving, water polo or open water swimming (drowning, neck fractures, head injuries, hypo/hyperthermia etc). Overuse injuries do occur but mainly in competitive athletes where they perform highly repetitive motions. They may also be injured when performing land training just as any other athlete may. Injuries related to the water based strokes are discussed here.

Injuries should be assessed early and adequately. Then in consultation with the swimmer and, with their permission, parents for child swimmers, coach, physiotherapist and doctor (as necessary) a management plan worked out to prevent further injury, treat and rehabilitate the current problem with consideration to current aspirations or refer on as necessary.

The main areas affected in swimming are the shoulder, elbow back, knee, foot and ankle.

Part 1: Shoulder, elbow and back injuries October 2005

Part 2: Knee foot and ankle injuries January 2006

Swimming requires good range of shoulder movement, particularly strong internal rotation (turning inwards) and adduction (pulling towards the body) and lots of training.

‘Swimmer’s shoulder’ occurs when the tendons running across the top of the upper arm are pinched under the overlying bony arch of the shoulder and become irritated. This mainly occurs due to instability depending on the shapes of the bones, the strength and length of the ligaments and rotator cuff muscles and overuse, when the supportive muscles fatigue. Consider this in all four major strokes: butterfly, backstroke, breaststroke and freestyle, as well as the sculling in synchronised swimming.

Some individuals are naturally flexible with large range of movement but when fatigued or overstretched unusual stresses can occur in the shoulder causing injury.

The symptoms are mainly pain, occasionally a snapping-feeling worst at the overhead phase of stroke and nervousness about movement in some directions as if it might ‘go out of joint’.

Treatment requires early accurate assessment. Most cases can be helped by good first aid initially then pain reduction, mobilisation with good posture and strengthening of the shoulder stabilising muscles. Stroke modification may be needed to prevent recurrence. A few cases may require surgery. Chronic overuse can lead to arthritic changes.

Prevention requires a strategy of controlled flexibility with strengthening and avoiding over use.

ELBOW    

Again the ‘elbow up’ pull, although it allows maximal push backwards in the water, may cause ‘tennis elbow’ symptoms on repetitive action. This is mainly seen in butterfly and breaststroke. This can cause tenderness over the bony prominence at the outer elbow, weakened grip and pain at the outer elbow on wrist extension against resistance.

The ulnar nerve as it crosses the elbow sometimes pops out of its groove but only needs attention if it causes significant persistent symptoms.

BACK

Most strokes in swimming require ‘elbow up’ posture that tends to exaggerate the lower curve of the back quite often with rotation and increase the stresses on the interlocking vertebrae and structures that support them (ligaments/muscles/fascia/discs). Sprint diving and butterfly also require back extension. If the load is significant stress fractures can occur.

This may cause low back pain with or without pain going down the legs, local tenderness and sometimes a changed gait or pelvis position.

Accurate assessment is important to help guide appropriate management that is usually conservative with mobilising, strengthening, pain relief and occasionally injections. Only the persistent or severe cases would have surgical intervention.

With any of these conditions a clinician would also be wanting to rule out the relatively rare occurrences of arthritis, congenital deformities, infection or tumour.

References available on request

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