Though we as triathletes may think we’re invincible, swimming-related injuries are common, whatever your level or preferred distance. That’s why what follows is vital to stave off a spell on the poolside or, if you have succumbed to injury, help you come back stronger than before.
What's the difference between a strain and a sprain?
Our first piece of advice is never be tempted to ignore a problem, as continuing to train in the hope of working through it may lead to a chronic predicament. Seek advice from a qualified professional, such as a sports physician, a physiotherapist who specialises in sport, an osteopath or chiropractor. With that in mind, off we go…
Get your blood flowing
As with all injuries, prevention is better than cure, and the best way to do this is to start every swim session with a warm-up. A good swim warm-up is essential to get your cardiovascular system ready to deliver lots of oxygen to your muscles. Once warmed, your muscles are capable of faster contractions, which enable you to swim more powerfully while reducing the risk of muscle and soft tissue injuries. It’s also a good time to mentally prepare yourself for the session or to rehearse what you’ll do in a race.
An efficient warm-up means working at a low intensity – between 30-50% of your VO2 max – and should last for about 15mins.
One example is front-crawl swimming, breathing on both sides over 50, 100, 150m. Then swim down: 150, 100, 50m. Do this at your own pace and rest for 5secs after each interval. Some swimmers then choose to do some light stretching, although there’s no concrete evidence to say you should. If you’re going to stretch, make sure you keep warm while you do it, and focus on stretching all your shoulder muscles and your quads.
Sadly, there’s still a chance you could fall prey to the following physical problems…
Common swim injuries
The four most common injuries that crop up among regular swimmers are: neck pain, lower-back pain, swimmer’s shoulder and fat-pad irritation in the knee. The following preventative advice should help you avoid them…
Lower-back pain in both swimmers and triathletes is often caused by repetitive stress, particularly if you fail to roll your body as a whole unit while swimming. This failure to roll correctly creates torsional strain at the point where the lumbar spine meets your pelvis. Poor body roll may mean that you arch your back to clear your head from the water, leading to stress on the facet joints at the back of your spine.
If you’ve developed excessively tight hip flexor muscles, you may have reduced your ability to fully extend your hip during kicking. This tends to tilt your pelvis in a way that over-arches the small of your back. Again, this can overload the facet joints, causing back pain, as does excessive use of the kickboard.
Poor core stability and weak gluteal muscles are also contributing factors, and it’s important to consider making stability exercises, or pilates-based exercises, a part of your regular training.
Referred nerve-type pain in the leg isn’t commonly caused by swimming, but is a sign that you need to stop training and seek medical advice from a doctor or sports physiotherapist. Sciatica is one such example. Sciatica gets its name from the sciatic nerve that runs down the back of both legs from your pelvis to your feet and controls the feeling and movement in those limbs. It’s caused by pressure, possibly from a ruptured invertebral disk, on the sciatic nerve root in your spine, which in turn leads to a referred pain in your leg or foot.
Any severe back pain associated with difficulty in controlling your bowels or your bladder is something you should consider to be a medical emergency. If you experience this, seek medical attention immediately.
A healthy lower back is not only important for your swimming but will also make your everyday life much more comfortable. Try the two exercises below to keep it in good shape and reduce the chances of swimming-induced lower-back pain.
Knees to chest
Lie on your back on a firm surface, bend one knee and hold on with the hand on the same side. Do the same with the other leg. Gently pull both knees up towards your chest, and hold them there for 10secs, feeling a pleasant stretch in the small of your back . This can be repeated three times, but should be avoided if you have had any disc problems or sciatica.
Lie on your back in a relaxed position. Tighten up your pelvic floor, as if you’re trying to stop yourself passing urine (this may be more familiar to women). Try to draw your belly button inwards, as if pulling it in towards your backbone. Breathe normally and hold this for 10secs. Relax for a few moments and then repeat 10 times.
Problems in your neck can be referred to your shoulder, and even to your hands. It can feel like pins-and-needles and is caused by the nerve roots that supply your arm being pinched where they leave your neck.
The three main causes of swimming neck pain
With good body roll, you should only have to rotate your head a small amount to clear your mouth from the water and breathe. Insufficient body roll forces you to over rotate your neck, which stresses the ligaments, joints and muscles. This can cause neck pain, headache and referred nerve pain in your arm. The problem is compounded by unilateral breathing (only breathing to one side), which leads to muscular imbalances in the neck.
Training excessively with a kickboard may also cause pain and headaches, because it encourages you to hyperextend your neck. (You may also have a tendency to hyperextend your neck on the bike.)
You can prevent these problems by perfecting your body roll and learning to breathe bilaterally (on both sides alternately; try breathing on every third stroke) and avoiding too much kickboard training. Think also about what you do when you’re not training. Are you sitting in front of a computer with poor, round-shouldered posture and your chin jutting forward?
You may gain relief from neck pain with massage, gentle stretching (see Neck-pain exercises box, right) or alternating ice and heat compresses to the sore areas. If your pain persists, stop training and seek treatment from a qualified physiotherapist, osteopath or chiropractor.
The key to preventing neck pain is improving your front-crawl technique, specifically your body roll for breathing. However, the following stretch should help you alleviate any discomfort.
This is a neck movement that counteracts the tendency we all have of allowing our heads to poke forwards in a poor posture. Stand in an upright position but keep your face looking straight ahead. Then draw your head and chin backwards towards your spine, as if you were pulling open a drawer. The end position gives you a ‘Sergeant Major’ exaggerated military neck posture, and you should feel a stretch in the back of the neck.
The ‘fat pad’ is a small, soft-tissue structure on the front of your knee, which has a tendency to be pinched between your kneecap (patella) and the front of your thigh bone (femur). Although it’s only small, it’s highly sensitive, and the pain can be excruciating.
The fat pad tends to get pinched when your knee is in a locked-out position; in swimmers this occurs during a forceful down stroke on the leg kick. You’re also at greater risk if you spend a lot of time standing with your knees locked out.
Get this pain checked by a professional, who’ll guide you on specific treatment. That treatment may consist of muscle training or stretching to correct any biomechanical problems of muscular imbalance. Applying ice can ease your symptoms, but some cases may require a steroid injection. If you seek advice and cut back from swimming, the condition should settle down within two or three weeks. If you don’t, it could last for months. During your recovery, leave the running and enjoy a gentle bike ride instead.
To avoid this problem, cut out long periods of standing with your knees locked out, and concentrate on swim kicking with relaxed knees, instigating the kick from your hips. Specific stretches, like the one below, will also help.
Once again, good swim technique is the key: a relaxed leg kick that starts from your hip is the best way to avoid fat-pad irritation. Whether the kick action is a problem for you, or not, stretching your quads will also help.
Lie face down on a mat. Lift your right leg up towards your buttocks and reach round to grasp your right foot with your right hand. Slowly pull your foot in towards your buttocks so that you feel a comfortable stretch on the front of your thigh. Hold for 30secs and repeat on the other side.
Shoulder pain is prevalent among swimmers; so much so that it’s been given its own name: ‘swimmer’s shoulder’. The name describes the impingement, or pinching, of the tendons of muscles within your shoulder known as the rotator-cuff muscles.
Swimmer's shoulder: what causes it, and three exercises to treat it
Typically, two muscles (supraspinatus and the long head of biceps) are involved. They’re squeezed between a bony arch called the acromion and the head of the humerus (upper arm bone), causing soft-tissue irritation and pain. This squeezing interferes with the delicate blood supply to the tendon, and if the impingement goes on for weeks, the tendons eventually break down, leading to the long-term problem of tendinopathy. This condition can take weeks to recover from, so it’s important not to ignore shoulder pain. Ease back off your training and get yourself along to see a doctor or physio.
Swimmer’s shoulder usually presents itself as an unpleasant ache or sharp sensation felt down the outside (lateral aspect) of your shoulder and down into your upper arm, but also sometimes on the front of your shoulder. It’s often worse at the end of a training session and into the next day, and usually putting your arm above your head is the most uncomfortable position to be in.
You’re most likely to develop swimmer’s shoulder if you have a heavy swim-training workload, though often there’s a predisposing muscle imbalance problem, too. If the muscles that control your shoulder blade (the scapular stabilising muscles) are weak, or if you’re weak in the muscles that externally rotate your arm, then you’re more susceptible.
Your stroke technique is also very important to staving off this condition. If your stroke is too long, if you ‘drop your elbow’ during the stroke’s recovery phase, if you allow your hand to pass far beyond the midline during the pull-through or if you have insufficient body roll, then you’re at risk. There’s also evidence to show that lots of training with hand paddles can put your shoulders under extra stress.
If you suspect you have swimmer’s shoulder, you mustn’t ignore it. Most early cases tend to settle if you rest from swimming for a few days, but if it’s a regular problem seek the advice of a sports physician, physiotherapist, sports osteopath or chiropractor. The treatment involves regaining proper control of your shoulder, by strengthening the scapular stabilisers and the external rotator muscles, but if your shoulder is very painful, then you may be advised to have a corticosteroid injection in the affected area.
It’s fine to train on the bike and go running while you’re recovering, but, above all else, get advice from a swim coach. They’ll be able to help you to correct any stroke technique problems you may have.
Swimmer’s shoulder exercises
The two exercises below focus on your shoulders and the muscles around them. Greater flexibility, control and support here will help ensure your shoulders can cope with the rigours of swim training.
Train the serratus anterior
Attach a piece of theraband or resistance tubing to a heavy object at waist height. Face directly away from the attachment of the band. Gently squeeze your shoulder blades together, then grasp the free end in your hand and position your hand so that your arm is out straight in front of you at shoulder height. Slowly return to starting position. Do 3 x 10 of these exercises each day.
Stretching the back of the shoulder
Lift your arm out in front of you to shoulder height with your elbow bent at 90°. Then using your other arm, gently pull your elbow across your body so that you can feel a gentle stretch at the back of the shoulder. Hold for 30secs and repeat with the other arm.
It’s not just the technique and fitness required to move yourself through the water that causes injury – the water itself can play a part, too…
Swimmer’s ear (aka ‘otitis externa’) is a chronic infection of the external ear canal – the passage leading from the eardrum to the outside world. It usually presents itself as either a pain in your ear (worse when you touch your ear), but often it will cause itching or even a discharge from inside your ear. When your ear canals become regularly water logged, fungi and bacteria can set up home. This can worsen if you damage the soft lining of your ear canal by attempting to dry (or scratch) it with a cotton bud or the corner of a towel.
To remedy the situation you should visit your GP, who’ll examine your ears and may prescribe eardrops containing a combination of steroid and antibiotics or antifungals.
Swimmers who regularly train in cold water can also develop a further problem of a bony overgrowth of the ear canal, known as exotosis. This is a permanent problem that can lead to reduced hearing. The simplest way to prevent both these problems is to wear earplugs.
If you’re lucky enough to train outdoors in warm weather, then you may be at risk of sunburn or even the skin cancer malignant melanoma. That’s why it’s vital you use a water-resistant sun block, and apply it regularly, however overcast it may seem.
Athlete’s foot, the fungal skin condition that affects the webbed spaces between your toes, is common wherever swimmers train. Make sure you thoroughly dry between your toes and avoid sitting around in damp footwear. Consider consulting your doctor if the problem doesn’t settle with an over-the-counter antifungal treatment such as Daktarin or Mycil.
Verrucas are also associated with the usage of swimming pools, although you may be just as likely to pick up the virus that causes these foot warts when walking bare foot around the gym changing room. Verrucas usually present themselves as an uncomfortable wart on the sole of your foot. The treatment generally consists of removing the hard skin that covers the wart with an emery file, and then painting on a wart paint or gel that contains salicyclic acid, such as Bazuka extra-strength gel. Persistent warts can also be treated by freezing them with liquid nitrogen; your GP may be able to perform this in the surgery.
Having a verruca doesn’t mean that you should stop swimming, but until it’s been treated you should wear a verruca sock (available from chemists) to avoid spreading the wart virus around.
This is a rare, but potentially very serious, disease that’s caused by a bacterial infection known as leptospirosis. The bug (leptospira) is transmitted to humans by contact with the urine from rats, cattle, foxes and other wild animals. It usually enters the body through a cut in the skin or via the nose or mouth, and open-water swimmers can be particularly at risk. In most cases it causes flu-like symptoms and bad headaches, but severe infection can lead to ‘Weil’s disease’, when jaundice and liver damage occurs.
Weil’s disease can kill, so if you’ve been open-water swimming and experience fever, muscle pains, headache, vomiting or show signs of jaundice (yellow skin and eyes), you must seek urgent medical advice. Early treatment with powerful antibiotics can be life saving. If you’re in doubt as to whether your symptoms may be due to leptospirosis, you should still seek urgent medical advice and raise the issue of the possibility of Weil’s disease, given your possible exposure to contaminated water.
Good technique = fewer injuries
Most swim-related problems are linked with stroke technique and muscle imbalances, which means that they’re potentially treatable and avoidable. It’s important to get help early on if you’re experiencing symptoms, to reduce the risk of the injury becoming chronic. Coaching advice is also a wise investment.
Finally, as in running and cycling, junk mileage is best avoided because it can lead to overuse injuries.
Dr Catherine Laraman specialises in musculo-skeletal therapy and sports medicine. She is also a keen triathlete.
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