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Musculoskeletal Injuries in Competitive Swimmers PDF
Musculoskeletal Injuries in Competitive Swimmers PDF
Swimming, a popular recreational sport, involves Second, swimming is an inertial sport that is
120 million participants yearly. Of these, more highly dependent on technique. The force neces-
than 165,000 are age-group swimmers registered sary to pull the hand through water is not great;
with United States Swimming, Inc., and almost however, body position, drag, limb surface area
19,000 swimmers 25 years of age or older are for propulsion, buoyancy, endurance, and stroke
registered with United States Masters Swimming. technique are all factors that contribute substan-
In addition, numerous students are in high school tially to swimming ability. Muscle power contrib-
and collegiate competitive swimming programs, utes much less to ability in swimming than in
and an increasing number of people swim regu- many other sports. In fact, improvements in raw
larly for fitness. muscle strength do not necessarily correlate with
1
As a sport, swimming is unique for several an increase in swimming speed.
reasons. First, it is an inefficient method of body Third, swimming provides both upper-body and
propulsion in comparison with running. The lower-body strength training as well as cardiovas-
water in a pool, for example, is a fluid in an open cular fitness. Paradoxically, despite the intensity
system and is thus not easily compressed by of the training, participants have less risk of
the movements of the swimmer. This lack of re- major injuries in swimming than in most other
sistance contrasts with the greater resistance or sports.
"traction" achieved between the runner's shoe Technically, the sport of swimming has im-
and the ground. Therefore, a considerable amount proved greatly during the past 20 years. Innova-
of energy can be expended to swim a short tions such as timed-interval training with use of a
distance. pace clock, longer yardage workouts, weight train-
ing, flexibility exercises, and dietary changes
have all accounted for the continued trend of
*Mayo Graduate School of Medicine, Rochester, Minnesota. establishment of new swimming records each
Address reprint requests to Dr. F. H. Sim, Department of year. During the past 70 years, the world record
Orthopedics, Mayo Clinic, Rochester, MN 55905. times for men have decreased by 47% for
Mayo Clin Proc 62:289-304,1987 289
290 SWIMMING-RELATED INJURIES Mayo Clin Proc, April 1987, Vol 62
swimmers in comparison with only an 11.2% swimmers regardless of cause. Classically, how-
decrease in world record times for runners over the ever, "swimmer's shoulder" refers to the painful
same 1-mile distance. 2 Equipment changes such arc syndrome caused by impingement of the
as goggles, hand paddles, and kick buoys have supraspinatus and biceps tendons against the
also improved the training for swimming. overlying coracoacromial ligament or anterior
Most successful competitive swimmers in the border of the acromion. This "impingement
United States swim for 10 to 11 months each year s y n d r o m e , " described by Neer, 1 0 is also a
in a career that often begins by age 6 years and common cause of shoulder pain in many other
may last continuously for 10 to 15 years. Many overhead-use sports.
swimmers engage in two swim practices daily, 5 to
7 days per week, and often average 8,000 to 20,000
yards per day, depending on the season. Applica-
tion of a four-to-one ratio proposed by Counsil- ANATOMY O F T H E S H O U L D E R
man 3 shows that this distance is equivalent to The shoulder joint, per se, consists of the articula-
running 32,000 to 80,000 yards per day—or more tion between the shallow, concave glenoid cavity
than 45 miles per day. This increased intensity of the scapula and the convex surface of the
has placed the competitive swimmer at a greater humeral head, only a small part of which is in
risk for musculoskeletal injuries. contact with the glenoid cavity at any instant.
Most of the internal and external rotation of the
upper extremity occurs at this joint.
The shoulder girdle also includes articulations
SHOULDER PAIN with the thorax and the distal aspect of the
Shoulder pain is the most common musculoskele- clavicle. Together with the glenohumeral joint,
tal complaint in competitive swimmers. In most these articulations allow a combined shoulder
studies reported in the literature, the incidence of range of motion of 180° of abduction. This coupled
shoulder pain ranged from 40 to 80%.4~8 Richard- motion between the scapulothoracic articulation
son and associates 8 studied three groups of and the glenohumeral joint occurs in a two-to-one
swimmers and reported that the incidence of ratio; for every 3° of abduction, the glenohumeral
shoulder problems increased with the caliber of joint is abducted 2° and the scapulothoracic artic-
the swimmer—the incidence was 57% among the ulation is abducted 1°.11 The wide range of motion
championship group, 52% among the "elite" of the shoulder (primarily abduction) necessary
swimmers, and 27% among the "nonelite" group. for swimming freestyle, backstroke, and butterfly
The incidence of shoulder pain was approximately is therefore dependent on the normal coupled
equal between the sexes, and the average age at motion of the shoulder girdle. What the shoulder
onset was 18 years. Pain was usually located in the joint achieves in range of motion, however, it
anterior or lateral aspect of the shoulder. Almost sacrifices in stability. 12 These characteristics may
all the swimmers studied (92%) swam freestyle, predispose the shoulder to injury, as it is the most
backstroke, or butterfly. With these three strokes, commonly injured joint of the upper extremity in
the arc of shoulder circumduction is wide. In overhead-use sports such as swimming.
contrast, those who swim the breaststroke, which The minimally constrained bony architecture of
involves much less shoulder abduction, are rarely the shoulder joint is stabilized by the surrounding
afflicted with shoulder pain. ligaments and muscles (Fig. 1). The glenohumeral
The most common cause of shoulder pain in fibrous articular capsule and associated liga-
swimmers is subacromial impingement and ten- ments consist of the coracohumeral ligament,
dinitis of the supraspinatus tendon, long head which has primarily a suspensory function, and
of the biceps tendon, or both. 6 Recently, however, the three glenohumeral ligaments (superior, mid-
glenohumeral instability (usually multidirec- dle, and inferior).
tional) has also been associated with shoulder The coracoid process, the coracoacromial liga-
pain in swimmers and may coexist with ment, and the acromion constitute the coraco-
tendinitis. 6,9 acromial arch, beneath which the supraspinatus
The term "swimmer's shoulder" has commonly and biceps tendons lie. The subacromial bursa,
been used to describe pain about the shoulder in which also is located beneath this arch, allows the
Mayo Clin Proc, April 1987, Vol 62 SWIMMING-RELATED INJURIES 291
Coracoacromial lig.
the average swimmer makes approximately 4,000
cycles with each arm through this arc of motion
daily.
IMPINGEMENT SYNDROME
Infraspinatus m.
The space beneath the coracoacromial arch for
long head
movement of the supraspinatus and biceps ten-
{short heac dons is limited. A painful arc syndrome caused by
subacromial impingement of these structures may
Subscapularis m.' occur through one of two mechanisms. 14
First, if the volume of the structures passing
beneath the arch is increased, less space will be
available and the possibility of impingement is
greater. Rathbun and Macnab, 15 with use of a
microinjection technique, studied the vascularity
of the rotator cuff and biceps tendons. They found
that when the shoulder is abducted, such as in the
late recovery and hand entry phases of the free-
style stroke, all the vessels of the tendons are
almost completely filled. When the arm is at the
side, however, in the adducted position (such as in
Fig. 1. Diagram of shoulder anatomy, showing anterior shoul- the late pull-through phase of freestyle, butterfly,
der girdle musculature and coracoacromial arch formed by
coracoid process, coracoacromial ligament, and acromion. or backstroke), a constant area of avascularity in
both the supraspinatus and biceps tendons ex-
tends from their respective points of insertion to 1
cm proximally (Fig. 3). This zone of avascularity
has been found in cadavers of all ages. 15 There-
rotator cuff tendons to glide smoothly through the fore, the supraspinatus and biceps tendons are
range of motion. This relationship is important in subjected to constant pressure from the head of the
the pathogenesis of swimmer's shoulder, as it is in humerus, which tends to "wring out" their blood
other overhead-use sports that may cause an supply when the arm is held in adduction and
impingement syndrome of the shoulder. neutral rotation. 15 Degenerative changes are fre-
quent in these tendons because of the diminished
STROKE MECHANICS blood supply at the watershed area. Repeated
Swimming is an activity that relies on maximal microtrauma in this area results in an inflamma-
propulsive force applied over the extremes in tory response in conjunction with edema and an
motion of the upper extremity. 13 Depending on the increase in the volume of the tendinous structures.
particular stroke, up to 90% of the propulsion is Second, Neer 10 has demonstrated roughness,
generated from the arm pull. The mechanics of the erosion, and formation of osteophytes on the
freestyle stroke illustrate the wide range of motion anterior and inferior aspects of the acromion in
necessary in the shoulder of swimmers (Fig. 2). response to repetitive impingement by the hu-
The stroke is divided into pull-through and recov- meral head. Often, such a response occurs at the
ery phases (Table l). 8 point of insertion of the coracoacromial ligament.
The combined shoulder girdle motions involved Consequently, the available space for movement
in the butterfly stroke and the backstroke are of the supraspinatus and biceps tendons may be
similar to those in freestyle swimming. For all decreased. The functional arc of elevation of the
three strokes, maximal abduction and adduction, shoulder is forward, not lateral; therefore, im-
internal and external rotation, and flexion and pingement occurs against the anterior acromion
extension are necessary. and the coracoacromial ligament during repeti-
If one assumes that a swimmer averages 10,000 tive overhead motions t h a t involve extreme
yards of swimming per day and completes 10 abduction and forward elevation, such as in
freestyle cycles with each arm every 25 yards, then swimming (Fig. 4). Derangements of the aero-
292 SWIMMING-RELATED INJURIES Mayo Clint Proc, April 1987, Vol 62
Table 1.—Mechanics of Freestyle Swimming Stroke brought into abduction and forward flexion.
Phase Description Kennedy and colleages 7 thought that the avascu-
Pull-through (right arm) lar areas of these two tendons were particularly
Hand entry Shoulder is in external rotation vulnerable to mechanical impingement; thus, mi-
and abduction. Body roll begins
Mid pull-through Shoulder is at 90° of abduction and crotears and focal cell death could occur and, in
neutral rotation. Body roll is at turn, produce an inflammatory response consist-
maximum of 40°-60° from ing of edema, tendinitis, and subacromial bursitis.
horizontal
End of pull-through Shoulder is in internal rotation These inflamed, enlarged tendons are more sus-
and full adduction. Body roll has ceptible to mechanical impingement, which
returned to horizontal causes further inflammation and establishes a
Recovery (left arm)
Elbow lift Shoulder begins abduction and
external rotation. Body roll begins
in opposite direction of pull-
through phase
Mid recovery Shoulder is at 90° of abduction and
external rotation beyond neutral.
Body roll is at maximum of 40°-60°
from horizontal. Head is turned to
side for breathing
Hand entry Shoulder is in external rotation
and maximal abduction. Hand is
in neutral position or slightly
pronated
Modified from Richardson and associates. 8 By permission of
the American Journal of Sports Medicine.
Fig. 3. Adduction of arm, as in late pull-through phase of freestyle swimming, is mechanism that
causes "wringing out" of supraspinatus and biceps tendons.
Long head
biceps tendon Acromion
process
Supraspinatus m.
Fig. 4. Impingement of supraspinatus and biceps tendons between humeral head and coracoacro-
mial arch can occur with abduction and internal rotation of humerus, as in recovery phase of
freestyle stroke. Note how serratus anterior muscle rotates scapula into abduction as humerus is
abducted to allow a greater range of shoulder motion. Scapular rotation also delays impingement of
greater tuberosity under coracoacromial arch until humerus is maximally abducted to near 180°.
With fatigue or underdevelopment of serratus, humeral impingement may occur at an earlier point in
recovery stroke at a lower angle of shoulder abduction.
that the swimmer is experiencing. The treatment inflammatory medications may be effective for
for phase 1 and phase 2 swimmer's shoulder short durations.
is multifaceted (Table 2). Absolute rest of the In addition to varying the strokes and decreas-
shoulder is usually not necessary in phases 1 and 2 ing the total yardage of swimming, stroke me-
of the disorder. The training program is altered to chanics also should be examined and corrected, if
decrease total yardage and also to vary strokes applicable. The aim of stroke modification is to
throughout the workout so that one motion is not limit the extremes of abduction and internal rota-
frequently repeated. Thus, the inflamed tendons tion, in which the position of the supraspinatus
are rested. tendon is most likely to impinge against the
Swimmers with painful shoulders can experi- coracoacromial arch. The amount of time the arm
ence night pain while sleeping. Sleeping on the is in adduction should be limited, to spare the
involved shoulder or with the arm elevated over- "wringing out" of the hypovascular area of the
head will often increase the pain. The most com- supraspinatus and biceps tendons. This result can
fortable position is usually lying supine with the be accomplished by earlier arm recovery, greater
head and shoulders slightly elevated and with body roll, and less internal rotation of the arm at
pillows positioned on the posterior and lateral hand entry. 18
aspects of the adducted shoulder and arm. Swim fins are used by some coaches to enable
Physical modalities can usually be beneficial swimmers with phase 1 or 2 swimmer's shoulder to
early in the treatment. Ice massage for 5 to 7 continue training while they are receiving treat-
minutes until the shoulder becomes numb or the ment. The swim fins increase the power and speed
more penetrating use of cold packs for 20 to 30 generated by the kick and thereby reduce strain on
minutes can reduce inflammation and pain. In all the shoulder girdle musculature and enable the
phases of swimmer's shoulder, nonsteroidal anti- swimmer to train at a preinjury pace. When using
Mayo Clin Proc, April 1987, Vol 62 SWIMMING-RELATED INJURIES 295
advance to isotonics and isokinetics as the re- stretching technique; for proper performance of
habilitation program progresses. 22 Once the these exercises, a partner is often necessary.
swimmer has no pain and has adequate range of Muscles that stabilize and elevate the scapula or
motion and strength, a gradual return to swim- externally rotate the shoulder are relatively weak
ming may begin. in competitive swimmers in comparison with the
Therapeutic Exercises.—Therapeutic exer-
cises to correct any muscle strength imbalance or
loss of range of motion should be prescribed for
swimmers with disorders of the shoulder. Greipp 23
reported on the correlation between lack of shoul-
der flexibility and pain. Shoulder-stretching exer-
cises are used to maintain or increase the range of
motion of the shoulder. Such exercises should
involve stretching of all the major muscles that
aid in forward swimming propulsion, such as the
shoulder internal rotators (pectoralis major, latis-
simus dorsi, and subscapularis) (Fig. 8).24 Lack of
shoulder external rotation because of tight inter-
nal rotators predisposes the swimmer to sub-
acromial impingement of the humerus. Stretching
exercises should be done in a gentle, prolonged (up
to 3 to 5 minutes), pain-free manner. Ballistic
(bounce-type) stretching that stimulates the
stretch reflex is not recommended. Contract-relax
Fig. 6. Upper-arm counterforce brace, used as aid in treating
or neuromuscular facilitation is an alternate early phases of "swimmer's shoulder." (Also see Figure 7.)
Mayo Clin Proc, April 1987, Vol 62 SWIMMING-RELATED INJURIES 297
SHOULDER INSTABILITY
Recently, involuntary inferior and multidirec-
Fig. 9. Strengthening exercise for shoulder external rotators. tional instability has been recognized as a cause of
Surgical tubing attached to a stationary object offers resis- shoulder pain in swimmers. 9 ' 12 In fact, Neer (per-
tance for effective strengthening.
sonal communication) currently believes that this
is the most important factor causing shoulder
pain in swimmers. Shoulder instability may be
difficult to diagnose because the symptoms of pain
used with caution by all. Such injections may be may be similar to those caused by impingement
indicated in phase 3 or 4 swimmer's shoulder tendinitis, and the two conditions can coexist. A
when pain persists despite a trial of nonsteroidal prior history of a major shoulder injury may not be
anti-inflammatory drugs, rest, local treatments, elicited. The patient may have discomfort while
exercises, and training modifications. They carrying loads that pull downward on the inferior
should always be used with caution because of the part of the capsule or with overhead arm move-
transient effect of tendon weakening that has ments such as in swimming. Also, a frequent
been associated with this treatment 27 and the complaint is an arm that feels "dead." 30 Emo-
uncertainty of the long-term effects of repeated tional disorders should be ruled out; Neer and
injections. Penny and Smith 18 maintained that Foster 9 found no major emotional problems in
injections of corticosteroids should be reserved for their series of patients with involuntary shoulder
the national or international class swimmer who instability.
is about to participate in a major competition The basic lesion that contributes to shoulder
when it is known that a period of rest will follow. instability is an enlarged joint capsule due to
Surgical excision of the coracoacromial liga- repetitive forceful stretching from the wide range
ment has a controversial role in the treatment of of shoulder circumduction performed during
phase 3 and 4 swimmer's shoulder.4'7,17,28 This swimming (and in other overhead-use sports).
surgical technique is associated with minimal Examination of the shoulder should include
morbidity, and it can be done as an outpatient stress on the glenohumeral joint in three direc-
Mayo Clin Proc, April 1987, Vol 62 SWIMMING-RELATED INJURIES 299
tions—anteriorly, posteriorly, and inferiorly—on ments and inferior capsule in whom a 1-year trial
repeated patient visits. Multidirectional instabil- of conservative therapy has failed. Neer and
ity should be suspected if apprehension is evident Foster 9 described an inferior capsular shift proce-
with inferior stress or stress in more than one dure that tightens the glenohumeral capsule. The
direction. The result of the impingement injection shoulder joint is approached anteriorly or poste-
test is usually negative. Thorough radiographic riorly, depending on the direction of the instabil-
evaluation of the shoulder is important and ity, and a T-shaped incision is made in the capsule.
should include anteroposterior views in internal The two sides are then sutured as flaps over each
and external rotation, an axillary view, and a other to obliterate the capsular redundancy. The
West Point prone axillary view.31 Examination short-term results of this procedure have been
under anesthesia and stress films may also be satisfactory, and some collegiate swimmers have
helpful. Double-contrast arthrography and arthro- reportedly resumed competition postoperatively
tomography may show a Bankart lesion or (Neer CSII: Personal communication). 9 The prog-
an enlarged joint capsule but are often diffi- nosis for returning to a high level of competition,
cult to interpret. Computerized axial arthrotomog- however, should be guarded because by the time
raphy improves resolution and may become the an operation becomes necessary, the changes in
procedure of choice in evaluation of difficult or the soft tissues may be so advanced that repair
occult cases of glenohumeral instability. will allow comfortable daily activities and recrea-
Initially, multidirectional or inferior instability tional sports but not the training intensity neces-
of the shoulder should be treated conservatively— sary for successful competition. 12
the stroke mechanics should be analyzed and
altered, if necessary, and shoulder-strengthening
exercises (Table 2) should be performed.9 The APPREHENSION SHOULDER
objective of the exercises is to enhance dynamic Isolated anterior glenohumeral instability is pri-
stability of the shoulder by increasing the marily seen in backstroke swimmers and is
strength and tone of the rotator cuff and deltoid termed "apprehension shoulder." 7,25 The back-
muscles without causing mechanical irritation of stroke involves maximal abduction and external
the capsule or ligaments. For isolated inferior rotation of the shoulder, particularly during hand
shoulder instability, the emphasis should be on push-off as the backstroker initiates a flip turn.
strengthening the shoulder abductors. Manual This acquired laxity of the anterior capsule is
therapy and stretching exercises should be with- thought to be caused by repetitive stretching of the
held. A balanced strengthening program of all capsule during the initiation of the backstroke flip
rotator cuff muscles is indicated for multidirec- turn 7 and by certain excessive passive shoulder-
tional instability. Cybex testing can be used to stretching exercises that many swimmers do in
determine whether shoulder muscle imbalance is order to improve their flexibility. Cineradio-
present. Strengthening can involve isometric, iso- graphic studies have shown subluxation of the
tonic, and isokinetic training exercises similar humeral head anteriorly onto the rim of the glen-
to those done for the shoulder impingement oid during extreme abduction and external rota-
syndrome. tion of the shoulder, as with initiation of the
Many patients with painful shoulders and de- backstroke flip turn 7 (Fig. 10). This action causes
monstrable shoulder instability will have im- pronounced stress on the anterior shoulder joint
provement with conservative treatment. Conser- ligaments. With the arm in this position, the
vative measures should include an appropriate subscapularis muscle glides superiorly and is
period of rest followed by strengthening exercises unable to help resist the anteriorly directed force
below the level of the shoulder to prevent irritation of the humeral head. With repeated stress, the
of the joint. When the patient returns to swim- anterior shoulder joint capsule may become exces-
ming, stroke modification is important to prevent sively stretched, and anterior shoulder instability
recurrence. Some strokes, particularly the back- may ensue.
stroke and butterfly stroke, may need to be Apprehension shoulder can be diagnosed by
avoided. reproducing pain or the sensation of impending
Surgical treatment may be indicated for the subluxation with the shoulder in abduction and
motivated swimmer with hyperlaxity of the liga- external rotation (positive result of the shoulder
300 SWIMMING-RELATED INJURIES Mayo Clin Proc, April 1987, Vol 62
apprehension test) (Fig. 11). Conservative treat- instability. Ciullo 4 advocated arthroscopic resec-
ment involves strengthening of the shoulder inter- tion of labral interposition and bucket-handle
nal rotator muscles for anterior stability. These tears and debridement of small rotator cuff tears
exercises are usually begun with the shoulder that may be a source of pain, but such procedures
adducted and with limitation of extreme external are not widely performed.
rotation. Isotonic or isokinetic exercises with an Prevention of shoulder pain in swimmers is
emphasis on eccentric strengthening should be perhaps the most important goal. Errors in the
prescribed. In addition, modification of the back- training program should be corrected through
stroke flip turn and avoidance of incorrect ante- proper communication with the coach. Ample
rior shoulder-stretching exercises are important. warm-up and cool-down periods, preventive main-
If swimmers cannot tolerate the subluxation and tenance stretching, strengthening programs, and
if they are unable or unwilling to change the proper stroke mechanics are all components of a
mechanics of their flip turn, surgical treatment training program that will minimize injuries.
may be indicated. Many procedures such as the Coaches and swimmers must be aware of the
Magnuson-Stack procedure, the Bankart repair, difference between adequate muscle flexibility
the Putti-Platt operation, and the Bristow opera- and capsular laxity caused by unusual or repeated
tion have been described for anterior gleno- stretching maneuvers. Switching strokes fre-
humeral subluxation. All these procedures have quently and breathing on alternate sides in free-
the disadvantage of potentially restricting exter- style swimming throughout a workout and early
nal rotation of the humerus. If this motion is and midseason strength training may also be
appreciably limited, the swimmer will probably helpful preventive measures.
have to discontinue backstroke competition. 25 The
inferior capsular shift procedure may provide BREASTSTROKER'S KNEE
anterior stability without substantial loss of exter- Knee pain in swimmers occurs primarily in those
nal rotation. Often, there is no satisfactory ap- who do the breaststroke and thus has been termed
proach to this problem. "breaststroker's knee." Kennedy and colleagues7
Shoulder arthroscopy may be a useful adjunct to surveyed 2,496 competitive swimmers throughout
the physical examination in diagnosing shoulder Canada and found 70 who were affected by knee
Mayo Clin Proc, April 1987, Vol 62 SWIMMING-RELATED INJURIES 301
knee pain during all activities including climbing leg and the supporting ligaments about the ankle
stairs and arising from low chairs. (Fig. 13). This repetitive motion may lead to
The primary treatment of breaststroker's knee inflammation of the extensor tendons. 7
is correction of abnormal kick mechanics, which Although not as frequent a problem as shoulder
will decrease the strain on the medial structures of or knee pain, when foot and ankle pain occurs it
the knee. In the experience of most investigators, may considerably alter performance. Tendinitis
this correction alone has been sufficient to elimi- in this area can be diagnosed when pain and
nate the swimmer's knee pain. 7,32 Most young crepitus are present over the extensor tendons
swimmers incorrectly abduct the thighs during during flexion and extension. Treatment includes
the recovery phase of the kick and rapidly extend local applications of ice and ultrasound, non-
the knees with the legs apart during the propul- steroidal anti-inflammatory medication, and, for
sion phase of the kick. Particular attention should persistent or severe cases, local corticosteroid
be placed on keeping the knees closer together injections around the tendon sheaths. 7 Switching
during the recovery phase and the mid-kicking the flutter kick to a two-beat instead of a six-beat
phase and preventing the knees from being fully kick may also relieve symptoms.
extended until the legs are together at the end of
the kicking phase. In addition, reducing the ante-
rior compression forces on the knee by means of CONCLUSION
hamstring stretching and quadriceps isometric Competitive swimming is a rigorous sport being
strengthening exercises with emphasis on the engaged in by an increasing number of young
vastus medialis may be helpful. athletes, often for prolonged, continued periods
The use of proper warm-up exercises, local appli- that may last for 10 to 12 years. Modern training
cations of ice, and ultrasound can be helpful.7 The techniques are producing steady improvements in
symptomatic breaststroke swimmer should train world record times for competitive swimming but
infrequently with the whip kick and should use may also be placing the competitive swimmer at
other kicks during workouts. The local use of greater risk for injury.
corticosteroids should be avoided. Among competitive swimmers, shoulder pain is
the most common musculoskeletal complaint. It is
usually due to supraspinatus or biceps tendinitis
TENDINITIS ABOUT THE FOOT caused by chronic repetitive impingement be-
A N D ANKLE neath the coracoacromial arch, and it occurs
With the exception of those who do the breast-
stroke, most swimmers strive to develop maximal
ankle plantar flexion, which places the foot in a
better position to push the water in a backward
direction during the propulsive phase of the flutter
or dolphin kick. Expert swimmers often will de-
velop 90° of plantar flexion. Conversely, breast-
strokers need ankle flexibility in the opposite
direction (dorsiflexion). This flexibility enables
the breaststroke swimmer to place his feet in a
good position to push the water backward at a
point earlier in the kick than would otherwise be
possible and thus achieve a more effective kick.
Cureton 33 has shown that expert swimmers with
better kicks have greater flexibility in the ankles
than average swimmers with poorer kicks. Fur-
thermore, Robertson 34 found a significant rela-
tionship between ankle flexibility and propulsive
force. Clearly, the extremes of ankle dorsiflexion
and plantar flexion are achieved through stretch- Fig. 13. The extremes of repetitive ankle dorsiflexion and
plantar flexion may lead to extensor tendinitis in competitive
ing the muscles of the anterior compartment of the swimmers.
Mayo Clin Proc, April 1987, Vol 62 SWIMMING-RELATED INJURIES 303
28. Dominguez RH: Coracoacromial ligament resection for 32. Stulberg SD, Shulman K, Stuart S, Culp P: Breast-
severe swimmer's shoulder. Int Ser Sport Sei 6:110-114, stroker's knee: pathology, etiology, and treatment. Am J
1978 Sports Med 8:164-171,1980
29. Tibone JE, Jobe FW, Kerlan RK, Carter VS, Shields CL, 33. Cureton TK Jr: Mechanics and kinesiology of swimming
Lombardo SJ, Yocum LA: Shoulder impingement syn- (the crawl flutter kick). Res Q 1:87-121, December 1930
drome in athletes treated by an anterior acromioplasty. 34. Robertson DF: Cited by Hay JG: The Biomechanics of
Clin Orthop 198:134-140,1985 Sports Techniques. Third edition. Englewood Cliffs, New
30. Rowe CR, Zarins B: Recurrent transient subluxation of Jersey, Prentice-Hall, 1985, p 363
the shoulder. J Bone Joint Surg [Am] 63:863-872,1981
31. NorrisTR: Diagnostic techniques for shoulder instability.
Instruct Course Lect Am Acad Orthop Surg 34:239-257,
1985