Swimming injuries can actually be quite common, and typically have to do with having poor stroke technique.

Swimming is my least favourite of the three triathlon disciplines, which may be why this article is coming a bit later than it should. Triathletes in general tend to overlook the importance of swimming technique and stroke improvement, as it is the shortest discipline and less time is spent swimming than running or cycling. As well any preventative or maintenance for the muscles and body parts involved in swimming is disregarded in favour of focusing on the main muscle groups for the other disciplines. This can cause lots of trouble because persistent injuries that are caused by poor swim technique can eventually creep into performance of cycling and running, never mind daily activities, and start to impede any progress in those.

Many swimming related injuries are commonly found in the upper body, though sometimes we can actually injure our lower bodies while swimming. With upper quadrant injuries, pain will exist at some point during the swim stroke, whether it is the recovery phase, reaching and gliding phase or the pulling phase. Sometimes this can indicate which structure is injured or causing the pain because of the mechanics involved in each of those phases. With lower quadrant injuries or pain the main cause is typically kicking technique, and can also be a result of an injury from running or cycling. 

Most often swimmers will present with a nagging shoulder pain, which may or may not refer down the arm. As the pain continues the person will become more uncomfortable during activities that aren’t swim related such as sleeping on it, sitting at a desk, driving, and even cycling. There are many muscles that control the shoulder and any of these can eventually become impinged in the bony structures around the shoulder with poor biomechanics  or movements of the shoulder. As well, many athletes have day jobs and also do a considerable amount of commuting, which will cause poor postural habits putting the shoulder at a mechanical disadvantage to start. Then with the added stress that swimming requires of the shoulder it leads to a larger predisposition for shoulder impingement problems. The most common muscles to get impinged in the shoulder are the rotator cuff muscles, a group of muscles that surround the shoulder joint and aid in its ability to rotate the arm at various angles. Most of these muscles attachments, or tendons, have to travel through a small bony canal under the acriomoclavicular joint (AC joint) to attach to the arm. Any time the arm is elevated, or the shoulder blade is in a forward position this causes that space or canal to be decreased, thus pinching on those tendons. For example, most of us have what is referred to as forward shoulder posture, meaning our shoulder blades are coming forward around our trunks, contributing to slouching. This is instead of them being on our backs close together, with nice open chests. Try this: slouch forward with your shoulders and upper back. Now try to reach up and as far back as you can. Now sit straight, shoulders squeezed gently together on your back and do the same. There is a considerable difference in the mobility of your shoulder. This is a key point, because when swimming we need as much range of motion in our shoulders to maximize our strokes, and therefore prevent injury. So in typical physical therapy fashion my first and very important piece of advice is to be conscious of your posture throughout your day to help put your shoulders at a strong mechanical advantage for swimming.

Of course sometimes we still get pain in the shoulder when swimming, so I will outline the possible causes of pain during specific stroke phases and how to potentially alleviate it. I will also go into detail about how to stretch and treat those areas in following articles. Most commonly people will complain of pain, usually sharp pain, in the tip of their shoulder while stretching, reaching, or gliding during their stroke. This is commonly the supraspinatus, and sometimes the infraspinatus tendons being pinched under the AC joint as the arm reaches up but the shoulder blade doesn’t stay back allowing for that movement. Common mistakes during this phase of the stroke are reaching up to the surface of the water instead of reaching perpendicular to the position of the body underwater. This arm isn’t at the surface of the water, so reaching up is going beyond a mechanically advantageous angle for the shoulder. It has been said to reach approximately 20degrees down from the surface, or if you think of it as a clock and the surface being 3 o’clock, reach towards 5o’clock. This will allow for maximum range of motion of the arm without compromising the structures in the shoulder. The other stroke fault could be a lack of rolling the body from side to side which allows for greater reach, and instead trying to reach far while being flat and gaining that range of motion from the shoulder blade. This puts it much further forward on the body and decreases that tendon space again. Treatment of this type of injury depends on a few factors. Usually if it is recent some anti-inflammatory modalaties such as ultrasound, interferential and ice will help, along with postural exercises and stroke improvement to decrease the stress on the tendons during activity. If it has become chronic and is affecting muscle strength and function then a period of rest, usually treatment consisting of intramuscular stimulation (IMS) to deal with the changes in the muscle, and of course postural training and strengthening to help restore function. This is commonly seen as athletes will put up with pain and discomfort until it starts to impede function, and then want immediate help to fix it. It is always best to seek help sooner than later to prevent unwanted complications.

Pain during the pulling phase of swimming is different and not caused by the rotator cuff muscles alone, but typically can involve the lattisimus dorsi muscle, as well as the flexor muscles of the forearm.  These are strong muscles and usually the act of swimming doesn’t cause injury, but if they are already affected by being tight and short due to repetitive use or posture problems you will see issues while swimming as these muscles become a bit more isolated. Again, if a recent or acute injury treatment will involve relieving the inflammation and gaining function back. However these injuries typically are chronic overuse and require a comprehensive look at the entire upper quadrant in order to determine the cause of the overuse. Treatment in this case will involve a cervical spine assessment and typically treatment, as well as large focus on the postural muscles and strengthening and maintaining a biomechanically strong base.

Recovery stroke pain is a bit rarer, and does involve the rotator cuff and shoulder blade a bit more again. This is because the arm is coming up the side of the body to prepare for the reaching phase. If the shoulder blade is in a poor position, those tendons will be impinged as the space between the bones for the tendons to travel becomes minimized. In order to prevent or alleviate this, it is important for the shoulder to remain relaxed as the arm comes up, allowing the shoulder blade to remain down as long as possible. Again rolling on the side during this phase allows the shoulder to remain at a more beneficial position. Treatment for these problems is the same as above depending on the structure at fault.

Lower extremity injuries during swimming are less common though can be restrictive when they do occur. The most common swimming injury is medial knee pain during kicking. This is usually due to whip kicking and providing extra stress to the medial meniscus and medial collateral ligament, causing a strain. This isn’t a common kick, and if pain is experienced during it, it is recommended to flutter kick instead. Other hip and knee pain can be exacerbated during the kicking phase of swimming. It is important to be kicking properly, from the hip and not the knee, and if problems persist swim with pull buoys while having your medical professional figure out the cause of the knee pain and treat it accordingly.