Muzna Ali, BS, and Arun J. Ramappa, MD
Swimming– it’s taught as a life-saving skill, enjoyed as a leisurely activity, and competed in at an Olympic-level. From children with asthma to adults looking to stay healthy, swimming has been ranked as one of the most useful exercises for a range of ages, body types, and conditions due to its function as an upper and lower body exercise.1,2,3 However, swimming is a unique activity because it depends primarily on the upper body for propulsion, which can lead to a number of musculoskeletal (MSK) injuries.4
As with other sports, the severity of injury depends on the level of activity. Therefore, recreational swimmers are less likely to experience severe damage, with their injuries ranging from sprains and strains to cuts and bruises.5 Elite swimmers on the other hand – who usually log 60,000-80,000 meters per week, or 30,000 strokes per arm – are a different story.4 The four strokes of competitive swimming are freestyle, butterfly, backstroke, and breaststroke, and all are a test of endurance for the swimmer. The athletes rely on repetitive motions of the arms to generate a forward thrust and this can predispose them to MSK injuries of the shoulder, knee, and spine.6 Injuries can be separated into two broad categories: macrotraumas, which result from external forces, and microtraumas, which are multifactorial and may be due or internal or external factors.7
Swimming injuries to the shoulder fall under the term Swimmer’s Shoulder – which is most often associated with the butterfly, backstroke, and freestyle.5 The term was created to describe front shoulder pain during and after workouts.6 While the shoulder provides the greatest range of motion of all joints in the body, it is an inherently unstable joint.4 Repetitive arm movements and overuse can lead to muscle fatigue of the shoulder joint, upper back, and pecs resulting in microtrauma due to decreased stabilization of the humerus bone.6,8 One of the early signs of Swimmer’s Shoulder is a dropped elbow where, as a result of painful internal rotation, the swimmer may swing their arm wider to reduce pain.4 A 2010 study found that 91% of the 80 young, elite swimmers studied reported an episode of shoulder pain, illustrating the prevalence of this issue in the world of competitive swimming.6 Female swimmers are also at greater risk of suffering an overuse injury as a result of more arm revolutions per lap, because on average they have shorter strokes than their male counterparts.6
Knee injuries are the second-most reported source of pain in competitive swimmers and are most often attributed to the breaststroke.5,6 Overuse is the primary cause of pain and injuries, with rapid knee extension and the repetitive flow of water combining to increase the risk of soft tissue injuries.6 This pain predominantly affects the inside of the knee; however, frontal pain is also common.6
Spine injuries can become the most involved traumas to deal with, but are reported less often than shoulder and knee injuries. All four swimming strokes maintain extension beyond the normal limits of the lower back to achieve a streamlined position. This can amplify degeneration of the discs that separate the vertebrae of the spine and also result in a stress fracture.6 The main variables affecting spine pain and injuries are training intensity, duration, and distance. Additional risk factors include long-term use of training devices such as fins, kick boards, or pull buoys, which also produce excessive extension of the lower back.6
As soon as the swimmer experiences pain, they should increase the duration of their warm-ups and temporarily avoid the painful strokes or positions.6 Treatment can begin with a combination of ice, stretching, and anti-inflammatory medication; however, focused rehabilitation offers a better chance of success.4 Evaluation by a sports medicine physician can determine whether the injury is due to overuse, misuse, or abuse. Overuse refers to performing a task with a frequency that does not allow the tissues to recover, misuse encompasses using improper form or equipment, which may put abnormal stress on the tissue structures, and disuse is when a swimmer has taken time off without training, resulting in wasting away of muscle.7 While surgery is appropriate for structural causes and is an important tool for managing certain sources of pain, it is not the best approach for functional causes.4
Prevention is always better than treatment and studies have found that teaching swimming safety is best started at a young age, for recreational and elite swimmers alike. Instruction in swimming skills and water safety in pre-school age children is associated with improved swimming ability and water safety behavior later in life.5 Additionally, lengthy warm-ups, flexibility exercises, correct technique, and frequent changes of stroke have been recommended as preventative measures.5 While the nature of this sport may not allow for the halting of all injuries, taking appropriate measures can save one from experiencing more severe shoulder, knee, and spine injuries in the future.
- Lazar, J., Khanna, N., Chesler, R., Salciccioli, L. Swimming and the heart. International Journal of Cardiology. 2013. 168: 19-26.
- Lahart, I., Metsios, G. Chronic physiological effects of swim training interventions in non-elite swimmers: a systematic review and meta-analysis. Sports Med. 2018. 48 (2): 337-359.
- Cox, K., Burke, V., Beilin, L., Puddey, I. A comparison of the effects of swimming and walking on body weight, fat distribution, lipids, glucose, and insulin in older women. Metabolism Clinical and Experimental. 2010. 59: 1562-1573.
- Matzkin, E., Suslavich, K., Wes, D. Swimmer’s shoulder: painful shoulder in the competitive swimmer. Journal of the American Academy of Orthopaedic Surgeons. 2016. 24 (8): 527-536.
- Chalmers, D., Morrison, L. Epidemiology of non-submersion injuries in aquatic sporting and recreational activities. Sports Med. 2003. 33 (10): 745-770.
- Wanivenhaus, F., Fox, A., Chaudhury, S., Rodeo, S. Epidemiology of injuries and prevention strategies in competitive swimmers. Sports Health. 2012. 4 (3): 246-251.
- Tovin, B. Prevention and treatment of swimmer’s shoulder. North American Journal of Sports Physical Therapy. 2006. 1 (4): 166-175.
- Tate, A., Turner, G., Knab, S., Jorgensen, C., Strittmatter, A., Michener, L. Risk factors associated with shoulder pain and disability across the lifespan of competitive swimmers. Journal of Athletic Training. 2012. 47 (2): 149-158.