Con1petitive Swin1n1ing Illness and
Injury: Con1n1on Conditions
Lin1iting Participation
]ames N. johnson, MD
Address
USA Swimming National Team Physician, Southern Sports Medicine,
2021 Church Street, Suite 200, Nashville, TN 37203, USA
E-mail: jjohnson@southernsportsmed.com
Current Sports Medicine Reports 2003, 2:267-271
Current Science Inc. ISSN 1537-890x
Copyright © 2003 by Current Science Inc.
Illness and injury can significantly limit a swimmer's participa-
tion in training and competition. Catastrophic injuries to the
neck and risk of drowning are life threatening. Infectious illness
can cause significant time out of the water and an even longer
convalescence. When injuries to the shoulder, back, and knee
become chronic, these overuse injuries can affect perfor-
mance despite continued cross-training. By identifying the risks
for swimming injury and illness, and implementing prevention
strategies, the physician can help keep swimmers in the water.
Introduction
Competitive swimming at the highest levels requires 20 to 30
hours of training each week. Even at the masters level and age-
group level, a minimum of 5 to 10 hours are spent each week
swimming laps. Up to 1 million shoulder revolutions per year
are possible; thus, shoulder injury is the most common cause
of missed training and has been well documented in the med-
icalliterature [1• • ,2-5]. Other causes of missed training that
have not been explored in as much depth range from devas-
tating neck injuries and drowning to less serious illness, such
as upper respiratory infections (URis). Acute and overuse
musculoskeletal injuries can also result from dry-land train-
ing that includes weight lifting, plyometrics, running, and var-
ious calisthenics. The culture of competitive swimming is
such that coaches and teammates do not tolerate missed
training due to the mix of myth and fact about how quickly
swimmers decondition. Furthermore, swimmers can usually
perform some kind of dry-land cross-training or kick in the
water if they have an upper extremity injury, and can usually
continue to do modified swimming while rehabilitating a
lower extremity injury. So, total restriction from training is
unusual, and thus is not well-tolerated within the swimming
world. The physician must be aware of the common risks in a
competitive swimming environment and be able to help pre-
vent and treat the associated injuries or illness. The focus of
this review is the injuries and illness that are the most signifi-
cant in limiting a swimmer's ability to participate in training
and competition.
Catastrophic Injuries
The two most catastrophic injuries in competitive swim-
ming are neck injury resulting in paralysis and drowning,
and sudden death. Neck injury can result from too deep a
dive into a shallow pool or colliding head first into the wall
while swimming backstroke. Safety precautions in the sport
include minimum depth requirements of 5 feet for competi-
tive starting block dives, which is mandated by USA Swim-
ming (Colorado Springs, CO). For backstroke, overhead
flags are placed 5 meters from a wall to help prevent head-
first collisions. All coaches are required to be trained by the
American Red Cross in first aid, cardiopulmonary resuscita-
tion, and a special coaches' safety training, which teaches
back-boarding. Coaches must renew those certifications
every 1 to 2 years [6]. Coaches should also teach low-entry
angle dives and steering-up techniques to minimize high-
risk dives [7]; steering-up techniques involve angling the
hands toward the surface after reaching a safe depth.
Drowning has resulted from breath-holding and under-
water swimming. One recent case of a collegiate swimmer
drowning resulted from a breath-holding attempt of 75
meters while swimming unsupervised in an uncoached set-
ting [8]. Hypoxia results when the Pao2 drops rapidly before
the rising PaC02 stimulates the drive to breathe, thus leading
to unconsciousness and drowning. A case of sudden death
occurred during practice in a collegiate swimmer and was
later revealed to be hypertrophic cardiomyopathy on autopsy
[9]. A recent case offatal arrhythmia was reported in a swim-
mer with prolonged QT syndrome after diving into cold water
resulted in an irregular rhythm that further prolonged the QT
interval [10]. All governing bodies of competitive swimming
now highly discourage breath-holding training techniques
and encourage preparticipation cardiac screening [6].
268 Sport-specific Illness and Injury
Fatigue Illness
A second group of illnesses that are not as devastating but
can have long-term detrimental effects are associated with
the training demands placed on competitive swimmers.
Chronic fatigue-type illnesses related to overtraining can
affect the mood and performance of high-level swimmers.
Costill et al. [11] found that not ingesting sufficient carbo-
hydrate may cause chronic muscle fatigue. Mackinnon et
al. [12] showed that neuroendocrine changes marked by
decreased urinary excretion of norepinephrine preceded
overtraining by 2 to 4 weeks. Increased training volume
can also lead to a depressed mood [13].
Mononucleosis also can cause a chronic fatigue state that
can be debilitating for a swimmer because of the difficulty in
returning to training after a prolonged convalescence [14].
The physician must work very closely with the athlete and
coach in devising a gradual progression of return to training.
Unfortunately, no protocol seems to work in these cases, as
each individual responds differently. In general, however,
increasing volume by 5% to 10% per week over a 10- to 12-
week period, followed by a more gradual reintroduction to
higher-quality (faster) training may prove effective. The dry-
land portions of training need to be reinitiated in a stepwise
manner as well [15]. Educating coaches and athletes on the
important concepts of periodization, progression, adaptation
and recovery, and the signs and symptoms of overtraining,
may help prevent future recurrences [16].
Upper Respiratory Illness and Infection
Upper respiratory illness and infection is also a common
cause of missed training. Although URI is no more common
in swimmers than in the general population, it can be very
limiting for the swimmer because of the necessity of con-
trolled breathing while training in water. Another added
problem is that chlorine is a strong upper respiratory irri-
tant. An Australian study has shown that competitive swim-
mers are no more at risk of developing URis than a group of
untrained controls; however, URis do result in poorer per-
formance [17 •]. Other studies also show no relationship of
plasma glutamine levels to the risk of URI, although levels
of glutamine have been shown to be depressed in athletes
during long bouts of intense training [18]. But some data
have shown that low preseason levels of salivary IgA may
predict risk of URI in swimmers [19]. More recent theories
have proposed that low levels of plasma glutamine, immu-
noglobulins, and cytokines combined with decreased func-
tion of neutrophils and natural killer cells may decrease
resistance to minor infection during intense training periods
[20]. Prevention of illness thus becomes of paramount
importance to both coaches and athletes. Other important
illness prevention strategies include vaccination, especially
meningococcus, for those living in a herd-type environment
(dorm or frequent team travel trips), and instructing athletes
on the universal precautions of close contact avoidance and
hand washing. Many teams employ the use of a sick room to
prevent spread of illness.
An interesting phenomenon of herd illness that I have
observed is mononucleosis with an unusual number of reac-
tivations. In a single swim season, I diagnosed 10 cases of
mononucleosis confirmed by Epstein-Barr virus serologies
from one team of 24 athletes. All but two of those cases were
freshman athletes, and there were four recurrences among
the group of 10. Interestingly, a recent study from Gleeson et
al. [21] has shown that the reactivation and viral shedding
may be a reflection of the altered immune control mecha-
nisms that occur in response to intensive exercise. My
approach to those illnesses and their recurrences was to com-
municate contact precautions and hand washing instructions
to those athletes who spent 6 hours each day in close contact,
and then to devise a much more gradual return to training.
Subsequently, there was no more spread of illness and no
more recurrence, and the following season the group of
incoming athletes remained illness-free. The six swimmers
who undertook a more gradual 6-month progression to
return to training performed much better than the early
returnees (3 months or less).
Asthma
Upper respiratory illness causes even more significant limi-
tations of training in asthmatic swimmers. Asthmatics tend
to migrate toward swimming, as the humid environment
was thought to be more asthma friendly, due to the anec-
dotal evidence of Olympic swimmers having succeeded with
asthma [22]. Yet conversely, the chlorine in indoor pools
irritates the respiratory tract and can cause asthma [22,23]. A
recent report by Bernard et al. [24] concluded that exposure
of children to chlorinated pools increases lung epithelium
permeability and thus increases the risk of developing
asthma, especially in indoor pools. But in support of the
assumption that swimming helps asthmatics, a 2000 Austra-
lian study demonstrated that the 1964 Australian Asthma
Children's Swimming Program has achieved its intended
purpose of improving quality of life and asthma manage-
ment by reducing medications, doctor visits, and hospital-
izations in swimming participants [25]. Thus, swimming in
indoor chlorinated pools may be a risk factor for developing
asthma, and some data suggest eosinophilic inflammation
in elite swimmers in the exercise-induced bronchial hyper-
responsiveness [26]. However, swimming may still benefit
known asthmatics by reducing their frequency of exacerba-
tions and increasing their aerobic capacity [27].
Musculoskeletal Injuries
With the potential for missed training from illness, preventing
musculoskeletal injuries that may lead to significant time out
 Competitive Swimming Illness and Injury • johnson
ofthe water becomes even more important. The independent
data of Johnson et al. [1• •I and Bak et al. [2), examining 1
year of competitive swimming in a broad-based population,
agree that shoulder, back, and knee injuries are the most com-
mon musculoskeletal injuries in swimming. The US studies
of Pink et al. [28•) and the Australian studies of Wadsworth
and Bullock-Saxton [29) thoroughly describe the bio-
mechanics and pathomechanics of the shoulder and scapular
junction using EMG analysis, which provides insight into
important considerations preventing shoulder injury [1• •).
The missing link in the literature review is the back injury,
which accounts for about 20% of all swimming injuries
[ 1• • ,2]. Knee injuries have remained at a constant 10%, and
these result primarily from either dry-land bounding activities
or breaststroke swimming [1••,2,5).
Upper extremity injuries occurred at a three to one ratio to
lower extremity injuries during swimming [30). Knee injuries
in competitive swimming primarily involve the medial joint
line. Women collegiate swimmers were shown to have a four
to one likelihood of injury to their lower extremity during
cross-training as compared with during swimming. A 1980
study of breaststroke swimmers presumed the common inju-
ries to include medial patellar facet arthritis and chronic
medial collateral ligament injury, then videographically corre-
lated both injury types to kick techniques [31). A subsequent
arthroscopic study showed medial synovitis in seven of nine
swimmers with no biomechanical correlate to be identified
cinematographically. The conclusion was that "breaststroker's
knee" was an overuse synovitis [32). A 1985 study of breast-
strokers undergoing knee arthroscopy supported these find-
ings in demonstrating that 47% of breaststroke swimmers
with knee pain had an inflamed medial synovial plica [33).
Prevention should be geared toward preventing overuse by
reducing breaststroke kicking in training and correcting the
hip abduction angle to between 37° and 42° [34). Treatment
initially includes controlling inflammation with ice and anti-
inflammatory drugs, eliminating breaststroke kicking, and
then initiating a gradual build-up in training distance [33).
Meniscal, chondral, and ligamentous injuries can result from
dry-land activities that involve running, lifting, bounding, or
excessive loads, similar to any other land-based sport.
Back injuries in swimming develop from excessive load
to the spine, whether it be a gradual extension load while
swimming with poor posture, or an axial load while lifting
weights. The data from Johnson et al. [1• •I describe a 23%
incidence of spine injury in a single season. The data from
Bak et al. [2) report a similar 22% incidence. A comparison
of spine injury incidence in gymnasts and swimmers dem-
onstrated that 16% of all swimmers had spine abnormalities
[35). Adolescent swimmers with thoracic back pain and
kyphosis may suffer from Scheuermann's disease and
should be imaged. If this diagnosis is confirmed, short-axis
strokes (butterfly and breaststroke) should be avoided [36).
Other spine injuries include stress fractures of the pars inter-
articularis, resulting from either swimming or weight lifting.
269
With the increase in popularity of underwater dolphin kick-
ing off the start and turns, the extension stresses on the lum-
bar spine are increased, and the resulting incidence of pars
defects should be explored. Swimmers with a new pars
defect must be rested for 12 weeks and then returned very
slowly, after initiating a core and pelvic stabilization pro-
gram. A case can be made for bracing these athletes after 3
weeks of rest if they are not yet pain free. But no data have
shown a definitive benefit to bracing over rest alone [37). An
association of swimming with disc disease has not been
shown [38). A link between back injury and shoulder injury
has also been postulated, and exploring that link may help
to develop preventive rehabilitation strategies that could sig-
nificantly decrease missed training [39).
The incidence of significant shoulder injury has been
reported from 30% of swimmers in a single season, up to
48% of all swimmers in a competitive career [1• • ,2-5). The
factors involved in interfering shoulder pain have been related
to muscular fatigue and ischemia, biomechanical factors
including abnormal scapulothoracic and glenohumeral
function, and abnormal stroke mechanics. In a 1978 report,
Kennedy et al. [5) ascribed most "swimmer's shoulder" to
anterior subluxation of the humerus on the glenoid and the
resulting impingement of the avascular region of the
supraspinatus and biceps. Bak [40) showed that gleno-
humeral instability and coracoacromial impingement caused
a similar clinical presentation. McMaster [41) reported the
high incidence of labral injuries in swimmers, likely second-
ary to this same subluxation/glenohumeral instability phe-
nomenon. Interestingly, even though the data from McMaster
[41) were published in 1986, labral injury identification is
often significantly delayed in swimmers. The delay phenome-
non may result from a surgeon's reluctance to stabilize a
shoulder joint in an athlete who engages in repetitive over-
head motion. Although there are no published data, many
elite swimmers have successfully returned to high-level
competition after shoulder stabilization and labral repair.
Impingement syndrome responds well to a scapular stabiliza-
tion program closely following the proposed exercises of Pink
et al. [42) in their landmark EMG study. Unfortunately, physi-
cal therapy of swimmer's shoulder remains locked into exter-
nal rotation strengthening exercise. Bak and Magnusson [43)
also showed that prevention and rehabilitation of swimmer's
shoulder might not solely involve strengthening external rota-
tors. Applying the recommended exercises of Pink et al. [42)
and a knowledge of biomechanics and correct stroke tech-
nique, Johnson et al. [1••1 developed a preventive stroke
correction and exercise program that has shown promise in
the swimming teams that have applied the program this past
season. Return to swimming and actual improvement in per-
formance has been observed in swimmers previously very
limited by shoulder pain. The stroke corrections and scapular
stabilization program have also resulted in an observed lower
incidence of back pain, and should be explored further as
more data are collected.
270 Sport-specific Illness and Injury
Conclusions
Illness and injury can severely limit a swimmer's ability to
train and compete. Shoulder injury and URI represent the
most common causes of missed training, and their presen-
tation can be limited if risks are addressed and preventive
strategies are implemented. Return to training from pro-
longed illness or injury must follow a logical, gradual pro-
gression to prevent recurrence. The physician needs to
understand that the culture of swimming mandates year-
round training; therefore, the physician must communicate
clearly to the athlete, coaches, and parents that missed
training now and a gradual return over time will provide a
greater long-term benefit to performance than cutting cor-
ners and doing too much, too soon.
References and Recommended Reading
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
• • Of major importance
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This review presents a comprehensive shoulder injury prevention
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Characteristics of 'low risk' and 'high risk' dives by young
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A good initial study of the relationship of URI to performance in
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classes and infection risk in elite swimmers. Immunol Cell Bioi
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This EMG study represents the best analysis of the freestyle stroke and
the corresponding important exercises necessary to condition the
prime movers.
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scapular rotator muscles in freestyle swimmers with
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 Competitive Swimming Illness and Injury • johnson 271

39. USA Swimming Task Review on Injury Prevention: Shoulder
Injury Prevention: A Series of Exercises for the Uninjured Swimmer.
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