4 Most Common Injured Body Parts in Swimming

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Is Swimming Safe?

Michael Phelps
Ronald Martinez

The buoyant effect of water lends itself to a reduced risk of injury among those who partake at a recreational level; however, repetitive strains and mirco-trauma injuries have been found among competitive and elite swimmers. Some think swimming is safe, but this may be a misconception due to the low rate of concussions, knee ligament tears, or other big injuries. However, overuse injuries are common within swimming, especially at the shoulder. The other most common known injuries are to the hip, knee, and the low back [learn how to swim through injuries].

Here we discuss these other injuries in more detail.

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The most commonly injured area in swimmers is the shoulder. As I wrote in the shoulder injury rate in swimming:

"Swimming requires copious shoulder motions. In fact, the volume is estimated as ~10 million strokes in a swimming career. This amount of strokes increases the stress at the shoulder. This high volume also increases fatigue, a prerequisite for many shoulder injuries (Stocker 1996). 

The exact prevalence of shoulder pain in swimmers was 3% in a study published in 1974 and has increased in recent publications: 42% in 1980 (Richardson 1980; Neer 1983), 68% in 1986 (McMaster 1987), 73% in 1993 (McMaster 1993), 40 – 60% in 1994 (Allegrucci 1994), 5 – 65% in 1996 (Bak 1996), 38% (Walker 2012)."

The most common injuries occur to the rotator cuff muscles and diagnostic imaging (MRI) show rotator cuff damage in pain-free swimmers. 

Shoulder Injury Risk factors

Dr. Weisenthal suggests two main inherited risk factors:

  1. "Bad bone anatomy. Big or downsloping or spurred acromion (bone you feel when you clap yourself on the shoulder) or else thickened coracoacromial ligament (runs from the lateral tip of the acromion to a little boney knob in the front of the scapula to which the short head tendon of the biceps attaches). Diagnose this with an MRI (14 yr-old. girls can have a poorly ossified acromial head, which can be difficult to see on a plain x-ray).
  2. Lax/hypermobile joint. The humerus is held up against the scapula by ligaments called the joint capsule. Most good swimmers are very flexible (because their joint capsules are loose). Have her hold her arm straight-ahead while standing up (elbow down, palm up). Look at the angle between the (upper) arm and forearm. Is it 180 degrees? Then she is probably NOT hypermobile. Is it more than 180 degrees? Then she very well may be hypermobile. Problem with hypermobility is that the head of the humerus can migrate upwards, smashing the superior rotator cuff (supraspinatus) tendon against the "roof" of the shoulder (acromion and coracoacromial ligament). This is worse during the stroke; usually worst right at the very start of catch and pull through. This is because when downward/rearward pressure is applied, the head of the humerus is forced upward." 

Learn 5 tips for hypermobile swimmers.

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A greater portion of swimmers experience back pain than non-athletes. MRI findings even in healthy swimmers show degenerative or other disc changes. A greater number of elite swimmers had disc degeneration than recreation swimmers. Degenerative disc disease (DDD) of the last low back (lumbar) and first sacral vertebral are the most affected in swimmers.

Spine Injury Risk Factors

Myofascial strains can result from twisting motions (flip turns & body roll errors); Hyperextension of the spine can cause irritation of the spinal joints, often in poor butterfly, dolphin kicking, starts, flip turns, or breaststroke biomechanics. Goldstein et al, Kaneoka et al and Hangai et al suggest hypermobility can cause low back. However, poor pelvis motion (anterior and posterior tilting of the pelvis) can also increase low back pain injury risk.

Ways to Reduce Swimming Low Back Pain

Mullen (2015) suggests the following items for reducing low back pain in swimming:

  1. Swimming “Up Hill”: Swimming with the chest elevated is a common error in swimming. In fact, many swimmers feel they are swimming in a streamline position, when in fact their chest is too high. This is likely from the lungs and prone position in swimming. Unlike other sports, the lungs act as two balloons under the chest of the swimmer. This creates the illusion that the swimmer is in a streamline, when they’re actually swimming up hill. Overall, this position overactives the low back muscles, putting them under higher stress. Solution: Press the chest down, feeling like you’re swimming down hill.
  2. Forward Breathing: Breathing in freestyle should be smooth motion, directly in the horizontal plane towards the side. Unfortunately, many unskilled or young swimmers, and even some elite swimmers, lift their head and breathe forward. Breathing forward increases the stress on the low back. Solution: Smoothly turn the head to the side when breathing, barely bringing it out of the water for the breath. Until this is mastered, consider using a snorkel.
  3. Hyper Undulation During Dolphin Kicks: Although most of the swimming research suggests otherwise, many swimmers and coaches believe dolphin kick should be a full body movement for maximum force production. Disregarding ideal biomechanics for speed, performing a large undulation places excess stress on the low back, from the extra flexion and extension. Solution: Decrease the body motion during the dolphin kick and perform more of a knee oriented kick.
  4. Lifting Chest During Butterfly: Once again, coaches can debate the ideal breathing method in butterfly until the cows come home. However, if a swimmer breathes forward and lifts their chest too high, they will overactive their low back muscles and increase their risk of injury. Solution: If breathing forward, keep your head as low as possible, cutting through the bow wave. Also, consider swimming with a snorkel or using a side breathing if pain persists.
  5. Spinal Flexion Turns: The flip turn undoubtedly causes spinal flexion. However, if a swimmer is having pain during their turn, they can attempt to use more hip flexion than spinal flexion for a simple method of reducing low back pain. Solution: When approaching the turn, bring the knees towards the chest and minimally flex the spine.
  6. Low Back Breath Breaststroke: Many elite breaststrokers keep their hips low and arch their low back as they rise for their breath. Unfortunately, this causes high stress on the low back. Solution: When breathing in breaststroke, move the hips forward for the breath, opposed to arching the low back. 
  7. Rounded Back Start: Like the turn, one must round their spine for a start. However, pressing the hips back and keeping the chest and head in a neutral position can reduce the degree of stress on the low back, making the start more manageable. Solution: Keep the hips high during the start, by extending the front hip. Also, keep the chest and head in a relatively neutral position.
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Jessica Hardy, World Record, 50m Breast, 2008 FINA SC World Championships
Alex Livesey/Getty Images

High incidence of breaststroke swimmers are unable to participate in swimming due to a hip groin (adductor) injuries. A recent study by Andreas Serner found the adductor longus was the most commonly groin muscle. In an interview, he hypothesized the reason in an interview: 

"The anatomical structure of the adductor longus insertion with both tendinous and muscular fibres could be considered weaker than a pure tendinous insertion and potentially more prone to injury thereof. Additionally, the insertional cross sectional area is also relatively small compared to the size of the muscle. However, the injuries that we have seen are more often further distal at the anterior-medial musculotendinous junction, sometimes involving the intramuscular tendon. This would indicate the insertion itself might not be the main problem in the acute injuries. It might rather be that it is the anterior and medial position of the insertion on the pubic bone that increases the stress in the high risk movements with forceful contractions including both hip abduction and hip extension [checkout hip rotation in breaststroke]. For instance, a study on kicking has shown that maximal eccentric adductor longus muscle activation coincides with both maximal rate of adductor longus lengthening and maximal hip extension suggesting a higher risk in this part of the kicking action."

Hip Injury Risk Factors

A wide breaststroke kick is a risk factor for breaststroke knee and hip adductor injury: Weakness and twinge may be an early indicator of adductor strain and reduction in breaststroke training until problem addressed. In the same interview listed above, Serner notes the following risk factors: 

"[a] recently updated review on risk factors for groin injuries sport unfortunately does not find any studies on swimmers, but if we look at the other sports there are a few factors which might be relevant here as well. As with many other injury types previous injury comes out a significant risk factor, and although that might not in itself be an anatomic risk factor, it at least provides ability to detect athletes which might need a bit extra attention. Of the intrinsic risk factors reduced hip abductor and abductor strength is the only factor supported by consistent level 1 and 2 evidence.

In contrast there is consistent level 2 evidence that higher weight, BMI, height, reduced hip ROM, and performance in various fitness test are not associated with increased risk of groin injuries.

Here at Aspetar we are currently conducting a large risk factor study including all football players in the best league. The study is led by Australian physiotherapist Andrea Mosler, and I am feeling fairly confident that if any of the usual suspects in a musculoskeletal screening are relevant, we will be able to give some more info on this in the near future."

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Breaststroke and knee pain.

Knee pain in swimming often occurs during breaststroke kicking. For example, the breaststroke kick places a high degree of stress on the medial structures of the knee. However, other sources of knee pain do exist, like pain in the front of the knee, which is likely a patellar tendon irritation. 

Risk Factors for Knee Pain

Technically poor, wide breaststroke kick leads to additional stress on the inside of the knee. Pain on the front of the knee may be from bending the knee excessively during the downkick or flutter kick.

Hip weakness and a large Q-angle (The Q angle of the knee is a measurement of the angle between the quadriceps muscles and the patella tendon and provides useful information about the alignment of the knee joint) increase the stress at the knee and risk of medial knee pain during breaststroke.

A history of Osgood-Schlatter also increases the risk of knee pain, particularly a patellar tendon injury.