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Swimming Injuries and Illnesses

LT C. Scott Kammer, MD, USNR; Craig C. Young, MD; Mark W. Niedfeldt, MD


In Brief: Swimming has a distinct profile of injuries and medical conditions. Common problems seen among swimmers include 'swimmer's shoulder,' an overuse injury that causes inflammation of the supraspinatus and/or the biceps tendon; overuse injuries of the elbow, knee, ankle, and back; medical conditions such as asthma, folliculitis, and otitis externa; and problems associated with overtraining. Swimmers are more likely to comply with treatment plans that minimize time spent out of the water. Prevention and treatment of musculoskeletal injuries often focus on proper stroke mechanics.

Swimming is one of the most popular participation sports. People are drawn to the sport for leisure, cardiovascular workouts, or competition. Therefore, physicians can expect to encounter patients often who have certain musculoskeletal problems or medical conditions related to the sport.

Training Demands

Young athletes often begin their competitive careers as early as age 7. Most competitive swimmers train and compete year-round, frequently on several swim teams. College swimmers train and compete during most of the school year, from September to March. The increasing popularity of organized masters teams, whose members range in age from 20 to 95, and improved financial compensation for elite swimmers have extended the competitive careers of many participants.

Competitive swimmers train intensely. Elite swimmers often swim up to 11 two-hour workouts per week. In addition, 80% of these athletes also participate in weight training, which generally consists of three 30- to 50-minute sessions per week (1). The typical daily training distance averages 10,000 to 15,000 yd. Regardless of the swimmers' specialty stroke, 75% to 90% of training is done freestyle (front crawl). This intense regimen continues throughout the season, often with no breaks, from October to February. In a unique taper period spanning 2 to 6 weeks before season-ending championship meets, swimmers decrease yardage by 50% to 90% and drastically lower workout intensity.

Success in swimming is judged primarily on performance at the championship meets; however, most swim coaches believe that a swimmer's success relies heavily on strength and endurance established over many months of heavy training (2,3). Costill et al (4) have shown that a 4-week interruption in training dramatically changes the metabolic characteristics of a swimmer's muscle. Further work has shown that although aerobic capacity and muscle strength are maintained despite 4 weeks of reduced training, the ability to generate power during swimming is significantly reduced, and complete inactivity leads to decreased aerobic capacity (3).

Because of these factors, swimmers are reluctant to take time off, making injury rehabilitation difficult. When designing a rehabilitation program, physicians and coaches should keep in mind that extended time out of the water quickly results in detraining and may be detrimental to the whole season (2,3). Physicians and coaches need to realize the long-term effects of rest and attempt to work with the swimmers' reluctance to take time off (1).

The Shoulder Under Stress

In 1 year a swimmer may move the shoulder to its extreme range of motion in about 2 million arm strokes (1). Swimmers' shoulder injuries usually result from long-term overuse and repetitive microtrauma (5). McMaster and Troup (2) found that 10% of 13- to 14-year-olds, 13% of 15- to 16-year-olds, and 26% of elite college swimmers reported current interfering shoulder pain. When surveyed for past shoulder pain, 47% of 13- to 14-year-olds, 66% of 15- to 16-year-olds, and 73% of elite college swimmers had positive histories (2). Despite the high incidence of shoulder pain in the younger age-groups, the average age of initial presentation to a physician is 18 (1). Almost half of masters swimmers, who participate in much less intense training, report pain episodes that last at least 3 weeks and interfere with swimming (6). Specialty strokes, with the possible exception of the butterfly, and competition distances do not appear to influence the incidence of swimmers' shoulder pain (7).

"Swimmer's shoulder," the most common swimming injury, is an overuse injury involving inflammation in the supraspinatus and/or biceps tendons usually caused by glenohumeral instability (figure 1) (8,9). Additional degenerative changes in the supraspinatus tendon may result from repeated "wringing out" of its blood supply during adduction with the finish, or late pull phase, of the stroke (10). The repetitive irritation of supraspinatus tendinosis may lead to acute local inflammation that further decreases the subacromial space, causing secondary impingement and possibly subacromial bursitis. A new trend in competitive swimming is to modify the finish of the stroke so that the arm exits the water at the iliac crest (figure 2). This technique change is intended to reduce irritation of the supraspinatus tendon.

[Figure 1]

Proper stroke technique greatly improves a swimmer's ability to train intensely without injury. Technical flaws lead to increased shoulder stress and become more frequent and severe with fatigue (11). Most competitive swimmers receive ample technique instruction at younger ages, but stroke work drops considerably after age 12.

Some specific freestyle technical flaws heavily stress the shoulders and can lead to overuse injuries. In properly performed freestyle, the elbow remains well above the hand during the out-of-the-water recovery phase and the catch phase of the stroke (figure 2). Dropping the elbow during these phases may irritate the rotator cuff muscles (1). This high elbow position on the recovery is achieved by rolling the body 70° to 100° per stroke cycle. Failure to sufficiently roll the body from side to side promotes impingement of the shoulders (10).

[Figure 2]

In the entry and catch phase of the stroke, the hand should be in front and at a position just outside the line of the shoulder. Entering too far to the side and overreaching toward the midline are common mistakes in tired swimmers. These positions are less efficient and force the shoulder to bear a greater load when the arm is straightened during the pull phase. Other fatigue-related errors in competitive swimmers, such as breathing only to one side (breathing every other stroke) (10) or kicking poorly and losing a buoyant body position, may add to overuse stress.

Use of hand paddles, which increase surface area and water resistance, and use of kickboards also can exacerbate shoulder pain (12). Weight training, excessive stretching exercises, improper stretching, and partner stretching may also irritate the injured shoulder (6,7). On the other hand, poor flexibility predisposes the swimmer to injury (13). To prevent stretching of the rhomboids instead of the posterior capsule, the swimmer must actively control scapular motion and passively stretch the capsule. The swimmer may be instructed in these techniques by a physical therapist or athletic trainer. Anterior inflexibility correlates with increased shoulder pain (7).

Swimmers may have increased shoulder laxity when compared with nonswimmers, especially in the anterior and inferior directions, though some laxity may be inherently genetic (14). To stabilize the humeral head in the glenoid fossa, swimmers who have greater shoulder laxity increase stress on their rotator cuff muscles, which increases the risk of tendinitis (15). The freestyle arm stroke naturally strengthens the internal rotators; thus, most swimmers' internal rotators are significantly stronger than their external rotators (12).

Addressing Shoulder Injuries

Diagnosis. When evaluating a swimmer's shoulder pain, identifying the painful phases of the stroke may aid diagnosis and treatment. Frequently, irritation is worst during the catch or early to middle pull portion of the stroke, though arm abduction during the recovery phase sometimes contributes to it (16). The "painful arc" syndrome—pain on active abduction between 45° and 120°—suggests supraspinatus tendinitis (figure 3). The physician should also evaluate for:
  • impingement,
  • internal or external rotator muscle weakness,
  • anterior, posterior, inferior, or multidirectional laxity and instability, and
  • point tenderness over the supraspinatus and/or biceps tendons.

[Figure 3]

Treatment. Though management of swimmer's shoulder requires rest, it is important to minimize a swimmer's time out of the water (5). When possible, relative rest should include pool-based training alternatives such as nonaggravating strokes or one-arm butterfly. Kicking drills can be emphasized, but care must be taken not to irritate the shoulder further with kickboard use (13).

Studying the swimmer's stroke mechanics is essential because alteration may be needed to prevent reinjury. Nonsteroidal anti-inflammatory drugs (NSAIDs) and ice are part of the standard treatment. Massaging the shoulder with a frozen paper cup of water for 15 minutes works very well in the shower after workouts (13).

Physical therapy should include internal and external rotator strengthening in arm abduction and adduction and supraspinatus strengthening (9,16). Steroid injections must be used with caution in all athletes; for swimmers, training load should be decreased for 3 to 4 weeks after injection (15). (See "Subacromial Space Injection: Pain Reliever, Diagnostic Tool," page 119.) If necessary, complete rest from swimming often will allow the injury to heal.

Surgery is rarely needed in young swimmers (9). However, surgery is sometimes considered for athletes with chronic shoulder pain that does not respond to conservative treatment. A capsule-tightening procedure may be considered for athletes with instability. Subacromial decompression should be considered only for swimmers who have a type 3 (hooked) acromion, and then only as a last resort (9).

Preventing Shoulder Injury

Appropriate prevention of swimmer's shoulder is critical in all intense training programs. Routine icing and, in some cases, prophylactic NSAIDs may be needed during heavy training. Continual reinforcement of proper stroke mechanics and adequate flexibility is essential. Yardage and intensity must be increased gradually at the start of each season, and warm-up and cool-down periods should be lengthy. After long kicking-only sets, a swimmer needs additional warm-up before using arm strokes at normal speed (15).

Weight training should emphasize the same goals as rehabilitation, including consistent rotator cuff strengthening exercises (9,16). Hand paddle use should be minimized. These simple modifications can greatly decrease a swimmer's chances of shoulder overuse but are frequently overlooked when intense training is the priority.

Elbow Injuries

Although coaches often encourage swimmers to use a high elbow position during the pull phase, this position may predispose the swimmer to high medial elbow stresses that may overload the medial tendon and place the elbow at risk for injury (17). A swimmer may compensate for the sore elbow by dropping it throughout the pull phase. This position is much less efficient and can increase stress on the shoulder and common extensor muscles and tendons. The increased stress increases the risk of tennis elbow (inflammation of the extensor carpi radialis brevis and extensor communis aponeurosis at the lateral epicondyle) and shoulder injuries (13,15). Other overuse injuries of the elbow, such as triceps strain and synovitis, may occur with full elbow extension during the backstroke (17). Thus, analysis and alteration of stroke technique are especially important in long-term management of elbow injuries.

Knee Injuries

Almost all knee injuries in swimmers are related to the use of the whip kick in the breaststroke (11). "Breaststroker's knee" is a chronic medial collateral ligament (MCL) sprain that results from repetitive stress on the MCL (15,18). Symptoms of breaststroker's knee are point tenderness along the MCL and pain on valgus external rotation. Though breaststroker's knee arises more from stress than from technical errors, aligning the knee with the hip (allowing the knees to separate only to hip width) will minimize stress and maximize kick efficiency.

Management includes minimizing breaststroke distance by cross-training with other strokes, ensuring adequate warm-up, and increasing training distance gradually (13).

Less common breaststroke-related knee injuries include patellofemoral pain, medial synovitis, and medial plica syndrome (10). Patients who have patellofemoral pain syndrome commonly present with anterior knee pain beneath the patella, whereas anteromedial pain suggests medial synovitis or medial plica syndrome. These syndromes are usually treated with correction of stroke mechanics, relative rest, anti-inflammatory medication, strengthening, and stretching.

Foot and Ankle Injuries

The most common foot and ankle injury is tendinitis of the extensor tendons at the extensor retinaculum, caused by repeated extreme plantar flexion in flutter and dolphin kicking (11). On examination, crepitus can be felt and heard when the foot is passively dorsiflexed. Treatment includes stretching and rest in the form of increased pull-buoy use (13). (Styrofoam pull buoys placed between the thighs allow arm-only propulsion while the body is buoyant and in proper position.)

Uncommon problems include foot contusions or "swimmer's heel" from improper flip-turn technique and mild ankle sprains from improper flip-turn technique or slipping on the wet pool deck.

Back Injuries

Causes of low-back pain in swimmers include mechanical low-back stress, spondylolysis, spondylolisthesis, and Scheuermann's kyphosis (13,15). Low-back injuries in swimmers most often are caused by repetitive stress during turns and the strain of poor head and body position in the water (11). Treatment should include avoiding diving and flip turns, abdominal strengthening, and improving hamstring and back flexibility (10).

The adolescent "swimmer's back" is Scheuermann's kyphosis from repetitive flexion of the thoracic spine. Usually only the butterfly stroke aggravates this injury, so it is relieved by avoiding that stroke (13). The butterfly also involves repetitive hyperextension of the back, which may predispose the swimmer to spondylolysis. Spinal trauma from diving accidents is now infrequent because starting blocks are routinely located in the deep end.

Medical Problems

Asthma. Asthma is more common among swimmers than among other athletes because many youngsters were encouraged to begin swimming as exercise treatment for their breathing troubles (19). Other athletes with asthma gravitate to swimming after they notice that the warm, humid environment makes breathing easier than the cold, dry environments often found in other sports. However, the enclosed environment may exacerbate asthma, especially at poorly ventilated pools where heavy chlorine odors may build (20). Asthmatic swimmers should inform their coaches and medical staff about their condition and have their inhalers easily accessible at the pool.

Dermatologic problems. Several dermatologic problems are seen in swimmers. Many shave all their body hair to increase their "feel for the water" before championship meets. Repetitive shaving exposes the lower epidermal layers and may predispose them to folliculitis from Pseudomonas or Staphylococcus organisms. Mild cases of folliculitis may be treated with topical antibiotics, whereas more extensive cases may require oral antibiotics.

Green-hair syndrome in blonde swimmers may be caused by copper-based algaecides used in some pools. Using a swim cap, shampooing regularly, and applying 3% hydrogen peroxide lotion helps prevent this syndrome (19). Darker-haired swimmers may have problems with bleaching of their hair from repeated exposure to chlorine. Bleaching may be minimized by using a swim cap and shampooing regularly.

Foot infections. Athlete's foot and plantar warts, both transmitted from pool decks and locker room floors, can be prevented by wearing sandals or other foot protection (11). Most cases of athlete's foot can be treated with topical antifungal agents. Warts can be treated with topical agents, cryotherapy, laser vaporization, or surgical excision.

Swimmer's ear. Otitis externa, or swimmer's ear, is usually caused by Pseudomonas aeruginosa or, occasionally, Aspergillus organisms. Presenting symptoms are often pain and/or itching. Tragal tenderness and pain on auricle manipulation are noted on exam, along with inflammation and erythema of the ear canal. Treatment should include either colistin sulfate or polymyxin B-neomycin-hydrocortisone. The suspension forms of these medications are usually preferred since they have a more neutral pH than the solution forms and thus are less harmful to a perforated eardrum (21). Occasionally the pain may be severe enough to warrant pain medications.

Ideally, the swimmer should remain out of the water for 7 to 10 days, but a return in 2 to 3 days may be allowed if the pain has resolved and the patient can tolerate alcohol ear drops used after swimming. Recurrences are common, so swimmers should routinely use ear drops of isopropanol and vinegar solution for prevention after swimming and showering (21). Over-the-counter ear drops containing boric acid should be avoided because they may remove protective cerumen.

Swimming in an "away" pool often triggers swimmer's ear (21). When doing so, swimmers must be especially scrupulous about preventive measures. Wax ear plugs should be avoided; instead, a tight-fitting swim cap is the best method of keeping water out of the ear. Self-manipulation of any sort, including cotton swab use and scratching, should be strictly avoided (22).

Conjunctivitis. Conjunctivitis is often caused by chlorine irritation (11) but can also result from anti-fogging agents for goggles (23). Spreading of adenovirus types 3 and 4 in pool water has been reported as well (24). Properly fitting goggles are essential for treatment and prevention, and over-the-counter eye drops or ophthalmic cromolyn sodium often works well to resolve the patient's infection (11).

Mononucleosis. Swimmers who are recovering from mononucleosis may resume training when they feel able. Diving, including racing dives, must be avoided until all signs and symptoms of splenomegaly have resolved.

Overtraining Syndrome

Swimmers are at risk for overtraining because they participate in long, intense, twice-daily practices through most of the season, and many swim with more than one team, competing year-round. Overtraining has been observed in 10% to 21% of swimmers during the course of a competitive season (25-27).

Staleness and overtraining syndrome can develop when exercise outpaces recovery or when athletes fail to adapt to the stress of sustained, high-intensity training. Swimmers' tolerance varies; a workout that increases performance in some swimmers may cause others to become stale or overtrained. As few as 10 days of increased training without adequate rest may decrease performance (25).

The primary feature of overtraining syndrome is an unexpected drop in performance during practice or competition that cannot be attributed to illness or injury. This decline in performance may be preceded by a period when greater effort is needed to maintain the same performance (26). Overtrained athletes will often have a multitude of physical and psychological complaints (table 1). Mood disturbances are common, along with fatigue and feelings of heaviness or soreness in the limbs (26,27). Often athletes will have sleep and appetite disturbances (26). One way to monitor athletes for overtraining is to have them check their resting heart rate upon awakening; a rising resting pulse may indicate early overtraining.

Table 1. Signs and Symptoms of Overtraining in Swimmers

Altered sleep pattern
Appetite changes
Inability to concentrate
Loss of motivation

Change in bowel habits
Chronic muscle soreness
Frequent illnesses
Frequent musculoskeletal injuries
Increased resting heart rate
Weight change

If overtraining is suspected, the patient should be examined to rule out illness or other diseases. Athletes should be questioned about sleep patterns, fatigue, stress, and muscle soreness. If no medical cause for the swimmer's condition is found and the swimmer is showing symptoms of overtraining, a training break is necessary. The length of the break may range from a few days to several weeks, depending on the severity of the overtraining syndrome. Athletes can usually return to activity as soon as they feel ready. Overtraining syndrome can be prevented if coaches allow adequate rest and recovery, especially during the heaviest training periods and following injury.

Communication Smooths Compliance

While many injuries and illnesses in competitive swimmers require adjustments in the athlete's training plan, arrangements with the swimmer and coach can often allow for these adjustments to keep the swimmer in the water, a crucial component to a successful season and the key to compliance with a treatment program. Good communication among the swimmer, coach, athletic trainer, physical therapist, and physician is the key to successfully rehabilitating the injured swimmer.


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The authors thank Chris McLaughlin for her editorial assistance with the preparation of this manuscript.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the United States government.

Dr Kammer is in the US Naval Reserve and is a family practice resident at Iowa Lutheran Hospital in Des Moines. He was a 4-year varsity swimmer at Duke University. Drs Young and Niedfeldt are assistant professors in the departments of Community and Family Medicine and Orthopedic Surgery at the Medical College of Wisconsin in Milwaukee and members of the American Medical Society for Sports Medicine and the American College of Sports Medicine. Address correspondence to Craig C. Young, MD, MCW Sports Medicine Center, 9200 W Wisconsin Ave, Box 26099, Milwaukee, WI 53226-3596.


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