Overuse Injuries from Swimming

Overuse injuries are common among swimmers, especially those competing at the sport’s highest level. The demands of the sport help explain why.

Eric Berkson, MD, a Mass General Brigham sports medicine doctor, says an elite swimmer can practice between 2 to 5 hours a day. They may swim up to 20,000 yards on a given day.

The heavy load placed on small muscle groups, tendons, ligaments, and bones during these workouts can then lead to bone stress injuries, joint sprains, muscle strains, and fatigue.

“Those are injuries that can completely derail your training and limit your ability to compete at your highest level,” says Dr. Berkson, a team physician for the Boston Red Sox and New England Revolution who swam competitively in college. “But, if you give these injuries the respect they deserve, you will find better success and have a longer career than if you tried to rush back too quickly.”

Dr. Berkson explains how and why swimmers develop overuse injuries. He reviews treatment options and shares prevention tips.

How are overuse injuries unique to swimmers?

Overuse injuries in any sport occur from too much of the same exercise at too high of an intensity.  

However, swimmers often experience these injuries in different ways than other athletes. It’s usually not a single traumatic event that causes a swimmer to have pain. Rather, swimmers develop pain from the repeated stress and strain of the activity.  

A swimmer’s body floats atop the water, minimizing the force on the inside of their joints. Their movement, though, redirects force to soft tissue on the outside of joints. With high-level training, repetitive motion can lead to imbalances that load the muscles and tendons, potentially causing workout pain or injury.

What are common swimming overuse injuries?

According to Dr. Berkson, swimmers rely on two parts of their body most: their shoulder muscles and the hip, abdominal, and back muscles of their torso.  

While shoulder muscles generate most of a swimmer’s power, muscles along the torso and spine allow that power to propel a swimmer’s body through water. Forces even travel through the legs, where the knees can experience overuse, too.

Swimmer’s shoulder

The shoulder is one of the most flexible joints in the body. It is also one of the least stable. The collarbone, shoulder blade, and upper arm bone meet at the shoulder, where muscles, tendons, and ligaments hold the joint together. Large chest muscles, such as the pectorals, and back muscles, like the trapezius, power the reach and pull of a swimmer’s stroke.  

Meanwhile, smaller muscles, such as those in the rotator cuff, balance the shoulder. These muscles keep the shoulder in place when the larger muscles lunge a swimmer’s arms through a pool.  

Asking too much of these smaller muscles can lead to muscle imbalances, strains, tears, and irritation. It often leads to a pain commonly referred to as “swimmer’s shoulder,” which can vary in severity. Reports of disabling shoulder pain range between 27% to 87% of competitive swimmers.  

Swimmer’s back

Force from the shoulders propels a swimmer in a wave-like motion. If the abdominal and hip muscles can’t absorb and control those forces, the body may compensate with smaller muscles in the back. If those muscles cannot withstand those forces, bodyweight may transfer along vertebrae — the bones along the spine — leading to back pain.  

The stronger a swimmer’s hips and core, the more power they can transfer from their shoulders to the rest of their body without injuring themselves.

Swimmer’s knee

To a much lesser degree than their shoulders, swimmers also rely on their knees to propel their bodies through water. The repetitive kicking motion can lead to overuse injuries of the tendons around the knees.  

The patellar tendon and kneecap and other tissues surrounding the front of the knee absorb most of these forces, prompting knee pain.

Risk factors for swimming overuse injuries 

Dr. Berkson says several factors can put unnecessary stress on the bones, joints, muscles, ligaments, and tendons of swimmers:

• Too much equipment: When used too often, training fins, footwear designed to help swim faster, can lead to overuse injuries in the knees. Fins add extra weight to a swimmer’s legs and lengthen their feet. The extra weight and longer feet forces swimmers to exert more force to move their legs. Likewise, kickboards — equipment used to keep swimmers afloat — can force a swimmer to hyperextend their back. This may add discomfort to joints along the spine.
  
• Repetitive motions: Swimmers mainly practice four strokes — the butterfly, breaststroke, backstroke, and front crawl. Each one requires different shoulder rotations. Swimmers who spend too much time practicing one stroke often rely too much on the same small muscle groups. 
• Muscle imbalances: Swimmers with underdeveloped muscles in their back, shoulders, knees, abdomen, and torso may not withstand the force exerted on their own body, which can heighten their risk for injury.  

Prevention tips for swimming overuse injuries

Dr. Berkson offers several tips for preventing swimmer’s shoulder, back, neck, and knee. He encourages swimmers to:

• Correct your posture: A nice, straight posture balances back muscles. Outside the pool, remember to sit up straight and keep your shoulders rolled back. A correct posture makes it easier for the shoulders to coordinate movements. 
• Warm up before competitions: Remember to dynamically warm-up the muscles in your shoulders, knees, neck, and back prior to a high-intensity workout. Stretching can help improve the range of motion in joints. This makes it easier for swimmers to fully extend their torso, arms, and legs in sudden, rapid motions without injury. 
• Practice strength training: Dr. Berkson cautions swimmers not to neglect strength training on dry land. Strength training exercises, including weightlifting, can stabilize the shoulders and improve the endurance of key core, hip, and back muscles.
• Alternate strokes: Alternating between the four main strokes helps spread the forces of the shoulder throughout the body in a balanced manner. It also offers a break to muscle groups of a specific stroke.
• Refine your technique: Alternating between different strokes makes little difference if a swimmer does not perform a stroke the correct way. The right technique allows the body to maximize the amount of force it generates without overworking smaller muscles. When performing a breaststroke, for example, a swimmer who keeps their chin closer to the water when breathing may minimize pressure on the back.  

“The closer you get to optimal technique, the less stress you put on your shoulders, back, and knees,” says Dr. Berkson.

Treatment for swimming overuse injuries

Injury treatment and recovery depends on the source of pain. Rushing an athlete back to competition without treating the source may worsen the injury. That said, Dr. Berkson wants to see swimmers stay in the pool as much as possible.

“Pain and injury from swimming are overuse injuries that often improve just by reducing the load on the shoulder and body,” he adds. “Sometimes all it takes is to find the delicate balance of the right amount of training.” 

Consider:

• Rest, but not too much rest: Although resting sore muscles can help, Dr. Berkson does not want to see swimmers completely halt their training. He recommends lightening the intensity of workouts in the pool before ramping up the intensity again.
• Short-term, pain-relief options: Ibuprofen, topical gels, and ice packs can help reduce inflammation — the immune system’s response to tissue damage — in joints and muscles.
  
• See a physical therapist or a sports medicine doctor: A physical therapist can help identify and improve muscle imbalances. A sports medicine doctor can help pinpoint the source of discomfort and identify any underlying structural damage to tendons, muscles, or joints. Understanding the source of pain often leads to faster treatment.

How to talk to your swimming coach about an overuse injury

Dr. Berkson knows how hard it can feel for athletes to ask for help. Too many athletes, he notices, choose not to tell their coach about pain in their shoulder or back. They confide in him that they do not want to appear weak or lose time in the water. 

“There’s normal shoulder stiffness and pain and normal soreness after a workout,” says Dr. Berkson. “Then, there’s pain that rises above that. Being honest with yourself about what those injuries are and how bad it truly affects you can help you recognize important swimming injuries.” 

 He urges athletes to:

• Report any unusual pain to their coach.
• Reach out to an athletic trainer if a coach is not available.
• Seek help from a sports medicine specialist, who can make a final diagnosis.

A diagnosis and rehab plan from a sports medicine doctor makes the conversation with a coach much easier.  

“There’s a lot less pressure when you go to coach with a plan saying, ‘This is what’s going on, this is how I’m going to fix it, and this is why I’m working through this just as hard as I’m working through everything else,’ instead of just saying, ‘My shoulder feels a little sore.’” Dr. Berkson adds, “Most swimming injuries improve by finding the right balance of training and by addressing the underlying muscle imbalances.”