Breaststroker's knee. An analysis of epidemiological and biomechanical factors

The role of the biomechanics analyst in swimming training and competition analysis

Swimming analysts aid coaches and athletes in the decision-making by providing evidence-based recommendations. The aim of this narrative review was to report the best practices of swimming analysts that have been supporting high-performance athletes. It also aims to share how swimming analysts can translate applied research into practice. The role of the swimming analyst, as part of a holistic team supporting high-performance athletes, has been expanding and is needed to be distinguished from the job scope of a swimming researcher. As testing can be time-consuming, analysts must decide what to test and when to conduct the evaluation sessions. Swimming analysts engage in the modelling and forecast of the performance, that in short- and mid-term can help set races target-times, and in the long-term provide insights on talent and career development. Races can be analysed by manual, semi-automatic or fully automatic video analysis with single or multi-cameras set-ups. The qualitative and quantitative analyses of the swim strokes, start, turns, and finish are also part of the analyst job scope and associated with race performance goals. Land-based training is another task that can be assigned to analysts and aims to enhance the performance, prevent musculoskeletal injuries and monitor its risk factors.

Non-shoulder Injuries in Swimming: A Systematic Review

OBJECTIVE

The shoulder is the most common injury in swimming, followed by the knee and spine. The repetitive nature of swimming training may predispose a swimmer to injury. Several risk factors have been previously identified, but the level of evidence and level of certainty that these risk factors predispose a swimmer to injury risk has yet to be evaluated critically in a systematic review.

DESIGN

Systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

DATA SOURCES

Data were obtained through PubMed, Cochrane, and Google Scholar. The database search was limited to articles that were published between January 1980 and December 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Level I, II, and III studies were included in this review. All studies must have been conducted in swimmers or swimming, a description of the specific pathology and provide at least one identified risk factor with an association (P < 0.05).

RESULTS

A total of 19 critically appraised articles identified 28 potential risk factors for musculoskeletal injuries in swimmers. The risk factors were grouped by the anatomical region: neck and back, pelvis and hip, and the knee. Only 2 risk factors were appraised at a moderate level of certainty, both occurring in the knee. The remaining 26 identified risk factors were appraised at a low level of certainty. There is a clear lack of research surrounding nonshoulder injuries in swimmers.

Evidence-Based Musculoskeletal Care for Swimmers: A Critical Analysis Review

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Swimming is a popular activity with numerous health benefits.

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Swimming involves complex biomechanical movements that, especially if performed incorrectly, can lead to musculoskeletal injuries.

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The shoulder is the most commonly affected joint, although lower-extremity and spine injuries have also been reported.

Characterizing Health Events and Return to Sport in Collegiate Swimmers

Background:

There is limited literature characterizing the incidence, variety, and effects of injuries and illnesses observed in elite swimmers.

Purpose:

To describe the epidemiology of injuries and illnesses affecting elite intercollegiate competitive swimmers.

Study Design:

Descriptive epidemiology study.

Methods:

This retrospective study utilized a deidentified injury and illness database of National Collegiate Athletic Association Division I swimmers in the Pacific Coast Conference from the academic years 2016 to 2017 and 2019 to 2020. A health event was defined as an illness or musculoskeletal injury that was identified by an athletic trainer or team physician. Musculoskeletal injuries and nonmusculoskeletal injuries and illnesses were stratified by body location. Injuries were further characterized as career-ending, season-ending, missed time but the athlete returned to sport in the same season, or those that did not cause missed time. Relative risk (RR) was used to compare the percentage of athletes affected between women and men, with statistical significance being defined by a 95% CI not including 1.

Results:

Included were 641 collegiate swimmers (301 male, 340 female). There were 1030 health events among 277 women and 173 men, with 635 (61.7%) occurring in women and 395 (38.3%) in men. There were 540 musculoskeletal injuries reported, most of which involved the shoulder (n = 126; 23.3%), spine (n = 95; 17.6%), foot/ankle/lower leg (n = 81; 15.0%), knee/thigh (n = 67; 12.4%), and hand/wrist/forearm (n = 52; 9.6%). A total of 490 nonmusculoskeletal health events were reported and included events such as respiratory tract infections (n = 119; 24.3%), unspecified medical illness (n = 93; 19.0%), concussions (n = 58; 11.8%), ear infections (n = 25; 5.1%), and gastrointestinal illnesses (n = 24; 4.9%). Compared with male swimmers, female swimmers were at a higher risk of sustaining both musculoskeletal injury (RR, 1.5; 95% CI, 1.22-1.83) and nonmusculoskeletal injury/illness (RR, 1.32; 95% CI, 1.04-1.68). There were 58 documented concussions, with 8 (13.8%) being season-ending, but not career-ending and 14 (24.1%) being career-ending. Women had a higher rate of concussion (9.1% vs 4.3% for men; RR, 2.11; 95% CI, 1.13-3.96).

Conclusion:

This retrospective study identified the most common injuries and illnesses observed among elite collegiate swimmers. Awareness of the incidence and outcome of injuries and illnesses that affect competitive swimmers may allow for more targeted analyses and injury prevention strategies.

Magnetic resonance imaging appearance of breaststroker's knee

Breaststroker's knee is an overuse syndrome resulting from similar repetitive movements in competitive swimmers that has been described in the orthopedic literature. The typical symptoms are medial knee pain with tenderness to palpation at the tibial collateral ligament or inferomedial patella. Despite these localizing symptoms on clinical exam, arthroscopic studies have failed to demonstrate a specific structural abnormality corresponding to this syndrome, although some have reported thickened medial synovial plica, medial-predominant synovitis or patellofemoral cartilage loss in association knee pain with breaststroke swimmers. We present a case of medial knee pain in a young breaststroke swimmer with magnetic resonance imaging (MRI) findings of marrow edema in the anterior aspect of the medial femoral condyle. To our knowledge, this is the first reported case of MRI findings in breaststroker's knee .

Clinical Evaluation Techniques for Injury Risk Assessment in Elite Swimmers: A Systematic Review

CONTEXT

Evidence concerning a systematic, comprehensive injury risk assessment in the elite swimming population is scarce.

OBJECTIVE

To evaluate the quality of current literature regarding clinical assessment techniques used to evaluate the presence and/or development of pain/injury in elite swimmers and to categorize objective clinical assessment tools into relevant predictors (constructs) that should consistently be evaluated in injury risk screens of elite swimmers.

DATA SOURCES

PubMed, Embase, Scopus, CINAHL, SPORTDiscus, PEDro, and the Cochrane Library Reviews were searched through September 2018.

STUDY SELECTION

Studies were included for review if they assessed a correlation between clinic-based objective measures and the presence and/or development of acute or chronic pain/injury in elite swimmers. All body regions were included. Elite swimmers were defined as National Collegiate Athletic Association, collegiate, and junior-, senior-, or national-level swimmers. Only cohort and cross-sectional studies were included (both prospective and retrospective); randomized controlled trials, expert opinion, and case reports were excluded, along with studies that focused on interventions, performance, or specific swim-stroke equipment or technology.

STUDY DESIGN

Systematic review and qualitative analysis.

LEVEL OF EVIDENCE

Level 3.

DATA EXTRACTION

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were utilized at each phase of review by 2 reviewers; a third reviewer was utilized for tie breaking purposes. Qualitative analysis was performed using the Methodological Items for Non-Randomized Studies (MINORS) assessment tool.

RESULTS

A total of 21 studies assessed the presence and/or development of injury/pain in 3 different body regions: upper extremity, lower extremity, and spine. Calculated average MINORS scores for comparative (n = 17) and noncomparative (n = 4) studies were 18.1 of 24 and 10.5 of 16, respectively. Modifiable, objectively measurable injury risk factors in elite swimmers were categorized into 4 constructs: (1) strength/endurance, (2) mobility, (3) static/dynamic posture, and (4) patient-report regardless of body region.

CONCLUSION

Limited evidence exists to draw specific correlations between identified clinical objective measures and the development of pain and/or injury in elite swimmers.

Musculoskeletal Injuries in Master Swimmers: A National Survey in Turkey

Background

This study aimed to determine the frequency of musculoskeletal injuries in master swimmers in Turkey.

Methods

A questionnaire was formed and distributed to all master swimmers registered with the Turkish Swimming Federation. The collected data included age, sex, the age to start swimming (SAS), weekly training time (WTT), weekly training distance (WTD), any painful episode that lasted more than 10 days in any of the body regions within last one year, any confirmed diagnosis of musculoskeletal disease by a physician, and history of musculoskeletal surgical operation. The descriptive data were presented, and multiple comparisons were made according to demographic characteristics.

Results

There were 88 male swimmers with a mean age of 47.1±13.2 years (range, 26-89 years). Of the 88 athletes, 27 (30.7%) had no pain in daily activities, and 61 (69.3%) reported pain in at least one region, with a total of 118 pain zones reported. The shoulder was the most common painful body region (n:37, 42.0%), followed by the lower back (n: 24, 27.3%), neck (n: 19, 21.6%), back (n:12, 13.6%), and knee (n:9, 10.2%). The mean age, SAS, WTT, WTD, and distribution of stroke preference were similar in subjects with or without reported pain and diagnosis (p>0.005). Any painful body region and diagnosis were equally distributed in all swimming styles (p>0.05). The most common surgeries were lumbar disc disease (16.7%) and meniscectomy (16.7%).

Conclusion

Compared to the findings in the current literature, master swimmers do not have as many musculoskeletal problems as their younger counterparts. The problems seen in master swimmers are lower but similar to those in competitive elite swimmers. From the musculoskeletal health perspective, swimming is safe for the master age group. Swimming can be safely offered to elderly patients who underwent even musculoskeletal surgery.

Medical Care of the Aquatics Athlete

Competitive swimmers are affected by several musculoskeletal and medical complaints that are unique to the sport. 'Swimmer's shoulder,' the most common overuse injury, is usually caused by some combination of impingement, rotator cuff tendinopathy, scapular dyskinesis, and instability. The condition may be treated with training modifications, stroke error correction, and strengthening exercises targeting the rotator cuff, scapular stabilizers, and core. Implementation of prevention programs to reduce the prevalence of shoulder pathology is crucial. Knee pain usually results from the breaststroke kick in swimmers, and the 'egg beater' kick in water polo players and synchronized swimmers. Lumbar back pain also is common in aquatics athletes. Among the medical conditions of particular importance in swimmers are exercise-induced bronchoconstriction, respiratory illnesses, and ear problems. Participants in other aquatics sports (water polo, diving, synchronized swimming, and open water swimming) may experience medical ailments specific to the sport.

Epidemiology of injuries and prevention strategies in competitive swimmers

Context:

Competitive swimmers are predisposed to musculoskeletal injuries of the upper limb, knee, and spine. This review discusses the epidemiology of these injuries, in addition to prevention strategies that may assist the physician in formulating rehabilitation programs for the swimmer following an injury.

Evidence Acquisition:

A literature search was performed by a review of Google Scholar, OVID, and PubMed articles published from 1972 to 2011.

Results:

This study highlights the epidemiology of injuries common to competitive swimmers and provides prevention strategies for the sports health professional.

Conclusions:

An understanding of swimming biomechanics and typical injuries in swimming aids in early recognition of injury, initiation of treatment, and design of optimal prevention and rehabilitation strategies.

Soothing suffering swimmers: a systematic review of the epidemiology, diagnosis, treatment and rehabilitation of musculoskeletal injuries in competitive swimmers

BACKGROUND

This review details the examination, diagnosis, treatment and management of injuries encountered by competitive swimmers. Primarily, these involve the shoulder, however, the spine, knee and hip can be involved. Using the Coleman methodology score, we show that the methods used in obtaining and reporting clinical findings and intervention results could be improved. Where possible, we suggest improvements.

SOURCES OF DATA

A literature review was conducted in English, Italian, French and German using PubMed, Google Scholar and Ovid search engines with strict inclusion/exclusion criteria.

AREAS OF AGREEMENT

Poor technique, and high training intensity and distance are the most common cause of missed swim practice and competition through injury.

AREAS OF CONTROVERSY

Few articles agree on a single method of each of clinical examination, diagnosis, treatment and rehabilitation.

GROWING POINTS

Articles are consistently retrospective with few investigating spine, hip and knee injuries.

AREAS TIMELY FOR DEVELOPING RESEARCH

Clinical findings and rehabilitation methods should be reported using a more structured method possibly based on the Coleman methodological scoring system.

Injury patterns in Division I collegiate swimming

BACKGROUND

In the last 25 years, it is estimated that over 42,000 male and female swimmers have competed at the National Collegiate Athletic Association (NCAA) Division I-A level. Despite the magnitude of these numbers, little is known about the epidemiology of collegiate swimming injuries. Purpose To describe the pattern of injuries incurred for one NCAA Division I collegiate men's and women's swimming team over 5 seasons.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Musculoskeletal and head injuries reported in the Sports Injury Management System for a Division I swimming team from 2002-2007 were identified. Gender, body part, year of eligibility, position, stroke specialty, scholarship status, and team activity during which the injury occurred and lost time were recorded. Risk of injury was assessed relative to gender, stroke specialty, and year of eligibility.

RESULTS

From 2002-2007, 44 male and 50 female athletes competed for the University of Iowa swimming and diving team. The overall injury rates were estimated as 4.00 injuries per 1000 exposures for men and 3.78 injuries per 1000 exposures for women. Thirty-seven percent of injuries resulted in missed time. The shoulder/upper arm was the most frequently injured body part followed by the neck/back. Freshman swimmers suffered the most injuries as well as the highest mean number of injuries per swimmer. A significant pattern of fewer injuries in later years of eligibility was also demonstrated. The relative risk (RR) for injury was higher among nonfreestyle stroke specialties (RR, 1.33 [1.00-1.77]). Injury most often occurred as a result of, or during, practice for all swimmers. However, 38% of injuries were the result of team activities outside of practice or competition, such as strength training. No significant relationship was found between occurrence of injury and gender or scholarship status. There was no significant relationship between body part injured and stroke specialty. An increased number of total injuries and an increased risk of injuries in freshman collegiate swimmers were found.

CONCLUSION

Particular attention should be given to swimmers making the transition into collegiate level swimming. These data also suggest that injury surveillance and potential prevention strategies should focus on the shoulder for in-pool activities and the axial spine for cross-training activities.

Exercise and soft tissue injury

Once the almost exclusive domain of the orthopaedic surgeon, sports injuries are now being seen with increasing frequency by other specialists, including rheumatologists. It is therefore important for rheumatologists to be able to diagnose and manage the various musculoskeletal conditions that are associated with physical activity. Soft tissue injuries are a very common cause of morbidity in both competitive and recreational athletes. Most of these conditions are provoked by muscle-tendon overload (or overuse) that is usually the result of excessive training or improper training techniques. However, despite an emerging literature on the natural history of soft tissue overuse syndromes, relatively little is known about the causes, incidence and outcome of many of these injuries. Of the methodologically robust epidemiological studies that have been done, most have focused on habitual distance runners. In this population, it has been reported that the incidence of injury can be as high as 50% or more, and that overtraining and the presence of previous injury are the most significant predictors of future injury. In other popular forms of exercise, such as walking, swimming, cycling, aerobics and racquet sports, injuries are also reported with high frequency but, to date, no prospective studies have examined actual incidences in these populations, and risk factors for injury in these activities remain speculative. Several of the more commonly occurring soft tissue injuries (such as rotator cuff tendinitis, lateral and medial epicondylitis, patellar tendinitis, the iliotibial band friction syndrome, Achilles tendinitis and plantar fasciitis) exemplify the overuse concept and are therefore highlighted in this review. The management of these, and most other, exercise-related soft tissue injuries is directed towards promptly restoring normal function and preventing re-injury.