Khodaee et al.

Sports Medicine - Open (2016) 2:27

DOI 10.1186/s40798-016-0051-2

REVIEW ARTICLE Open Access

Medical Care for Swimmers

Morteza Khodaee1*, George T. Edelman2,3, Jack Spittler1, Randall Wilber4, Brian J. Krabak5, Daniel Solomon6,
Scott Riewald7, Alicia Kendig4, Laura M. Borgelt8, Mark Riederer9, Vladimir Puzovic10 and Scott Rodeo11,12

Abstract
Swimming is one of the most popular sports worldwide. Competitive swimming is one of the most watched sports
during the Olympic Games. Swimming has unique medical challenges as a result of a variety of environmental and
chemical exposures. Musculoskeletal overuse injuries, overtraining, respiratory problems, and dermatologic
conditions are among the most common problems swimmers encounter. Although not unique to swimming,
overtraining is a serious condition which can have significant negative impact on swimmers’ health and
performance. This review article is an attempt to discuss various issues that a medical team should consider when
caring for swimmers.

Key Points statement on the definition of injury and illness in Féd-

ération Internationale de Natation (FINA), which is the
 Swimming training often consists of frequent weekly governing body for aquatic sports [1]. In this paper, we
practice sessions with long hours. attempt to discuss medical care guideline for swimmers
 Musculoskeletal overuse injuries, particularly not only at elite level but also in a wide array of different
shoulder injuries, are common among swimmers. competition and age levels [3].
Medical team should be aware of risk of overuse While the focus of this article relates to swimmers,
injuries, nutrition deficits, and overtraining among many principles from the guidelines (e.g., pulmonary
swimmers. issues and dermatoses) should be valuable for other
aquatic athletes. The available scientific literature and an
experienced group of experts on the topic was gathered
Review
to provide practical and sound guidelines.
Introduction
Swimming is one of the most popular sports worldwide
and is the second largest sport based on the number of Physiology of Swimming
athletes at the Olympic Games [1]. More than 219 mil- Compared to other types of exercises, swimming is
lion people watched the 2012 Olympic Games with unique as it takes place in the water, which results in dif-
swimming being one of the most watched events [2]. At ferent gravitational and resistive forces [4]. Horizontal
the Olympics, competitive swimming has pool events body position also alters the gravitational effect on circu-
ranging in distance from 50 to 1500 m (lasting from lation. Environmental factors such as water temperature
under 20 s to over 15 min) and official open-water have deep impacts on peripheral vascular physiology
swimming events that can be as long as 25 km (lasting which ultimately affects the entire cardiovascular system.
more than 5 h). Respiratory physiology is also unique as breathing is
Despite its popularity as a sport, there is a lack of restricted by stroke [4].
large-scale, methodologically sound, comprehensive epi- As in all activities, the body utilizes three main energy
demiological studies on swimming injuries and illness. pathways to produce the ATP that fuels muscle contrac-
Mountjoy et al. have recently published a consensus tion and swimming performance [5, 6]. These systems
are the phosphocreatine system, the anaerobic glycolytic
* Correspondence: [email protected] system, and the aerobic system; details of each are pro-
1
Department of Family Medicine, University of Colorado School of Medicine, vided in Table 1.
Denver, CO, USA
Full list of author information is available at the end of the article While the energy systems are associated with seem-
ingly specific characteristics, in reality, all three systems
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
Khodaee et al. Sports Medicine - Open (2016) 2:27 Page 2 of 15

Table 1 Energy systems and their characteristics. Reproduced from Salo et al. [7] with permission
Characteristics
Anaerobic phosphocreatine • Fuels intense swimming lasting from 0 to 12 s
• ATP production is limited by amount of creatine-phosphate present in the muscles
• Generally associated with high intensity, sprint performance (e.g., 50 m)
Anaerobic glycolysis • Fuels high intensity swimming lasting up to 2–3 min
• Generally associated sprint and middle distance swimming events (e.g., 100- and 200-m swims)
• An end product of anaerobic glycolysis is lactic acid
Aerobic • Fuels performances lasting longer than 3 min
• The percentage of energy derived from fats and carbohydrates is dependent on swimming
intensity—the higher the intensity, the greater the reliance on glucose
• Generally associated with endurance activities (e.g., 400 m and longer)

work in concert to provide a seamless energy continuum processes associated with delivery of oxygen to
that supports all swimming performances, with different working muscle (i.e., improve VO2max).
systems contributing energy at different levels depending
on the event and/or swimming intensity. Table 2 shows An understanding of physiology is not only important
the relative energy contributions of each energy system for understanding training and competition but also re-
for a range of maximal-effort swimming events. lates directly to technique and how an athlete prepares
It is important to note that the basic premise of train- for and recovers from training [7]. In a recent study,
ing is to challenge the energy continuum so the body US-based coaches reported routine use of a variety of
can adapt and enhance the way energy is produced and physiologic and biomechanic monitoring systems (e.g.,
delivered to the muscles. As such, a majority of the heart monitoring, lactate monitor, 2D/3D video-based
training swimmers’ experience is designed to develop system monitor) [8]. Proper swimming mechanics will
the physiological systems that support performance. improve metabolic efficiency as propulsive forces in-
Event-specific training should be designed to achieve the crease and drag forces increase. Conversely, fatigue
following goals [5, 6]: brought on by the depletion of ATP can contribute to
technique breakdown and injury. Athletes must engage
 Sprint training (50 m): Enhance the capacity to in a warm-up that will “prime” the cardiovascular system
produce energy through the phosphocreatine system and prepare the body for intense training or competi-
and optimize the enzymatic processes associated tion. Athletes also need to warm down appropriately to
with this pathway. remove lactate and facilitate recovery. Paradoxically, the
 Middle distance training (100–200 m events): shorter the race (and the greater the reliance on anaer-
Enhance the ability to produce energy anaerobically, obic pathways) the longer the athlete should warm
which involves increasing enzymatic activity down. General guidelines are to warm down for approxi-
associated with anaerobic metabolism and mately 20 min at an intensity that gives a heart rate of
improving the body’s buffering capacity, or about 130 beats/min [7].
tolerance, for lactate.
 Distance training (400 m events and longer): Nutrition
Enhance lactate removal and improve the myriad Elite swimmers train on average 2–4 h per day but can
cardio-respiratory functions and biochemical often exceed 5–6 h. Due to this often variable, high level
Table 2 Relative energy system contributions to maximal performance in a range of swimming events. Reproduced from Rodrigues
et al. [5] with permission
Distance (m) Phosphocreatine (%) Anaerobic glycolytic (%) Aerobic (%)
50 15–80 2–80 2–26
100 5–28 15–65 5–54
200 2–30 25–65 5–65
400 0–20 10–55 25–83
800 0–5 25–30 65–83
1500 0–10 15–20 78–90
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of energy expenditure, attention to fueling and dietary for convenience products often found in the dietary sup-
intake is crucial to maximize the desired adaption from plement form. Decreased regulation of manufacturing
training and to enhance recovery. A periodized nutrition standards and quality assurance in dietary supplements
plan that reflects changes in training volume and inten- (DSHEA Act, 1994) has increased the risk for anti‐dop-
sity will support the energy and nutrient needs of the ing rule violations and health concerns as potential side
athlete. Increased attention and education is needed to effects when athletes are choosing which products to
ensure the swimmer achieves appropriate energy balance take [14]. Athletes should consult with qualified health
to prevent Relative Energy Deficiency in Sport (RED-S) and performance professionals before taking any sports
which many swimmers are susceptible to, due to their nutrition or supplement to confirm safety and efficacy.
high training volumes and limited recovery times [9]. Table 3 summarizes the three categories of available
Common signs and symptoms of RED-S are frequent in dietary supplements used in sport.
swimmers: increased injury risk, impaired immune sys-
tem functioning, and decreased training response.
Swimmers training in the water two times per day can Common Medical Issues
easily reach total calorie needs of 4000–5000 kcal/day, Musculoskeletal
despite their highly efficient stroke techniques [10]. Ma- Acute Injuries Although most musculoskeletal prob-
nipulation of dietary carbohydrate intake easily adjusts lems in swimming are overuse injuries due to chronic
for the changes in training volume and thus energy de- overload, there are several acute types of injury that can
mands, throughout the season [11]. For sprint swim- occur in swimmers. Most truly acute injuries occur due
mers, carbohydrate needs may only be 5–7 g of to contact or direct trauma and are thus uncommon in a
carbohydrate per kg of body weight, but a distance non-contact sport such as swimming. However, this can
swimmer may need as high as 10–12 g of carbohydrate happen in swimming due to striking the hand on the
per kg body weight daily due to their heavy training wall at the finish of a sprint. Metacarpal fractures requir-
loads [11, 12]. Protein needs for most swimmers are ing surgery have occurred in elite-level swimmers. Hand
often ~1.4–1.8 g protein per kg body weight, with intakes and finger contusions and fractures may also occur by
exceeding this amount taking the place of other macronu- striking the hand on the lane line or by striking the hand
trients (mainly carbohydrates and often essential fatty of another swimmer. Foot injuries can occur from strik-
acids when caloric intake is limited). The balance of ing the foot on the wall during a flip turn. These mecha-
energy needs must then be met from essential fatty acid nisms of injury can also lead to lacerations.
intake, preferably from plant- and fish-based sources Shoulder pain is common in swimming and is typically
which contain natural anti-inflammatory properties. a chronic injury due to repetitive overuse. However,
Adequate daily consumption of nutrient dense foods acute shoulder subluxation can occur in swimmers with
(whole grains, fresh produce, and lean protein) should be underlying shoulder laxity. For example, the overhead
encouraged for swimmers to resiliently adjust to the stress position of the arm during hand entry in backstroke can
and demands of heavy training. Common micronutrient predispose to shoulder subluxation [16, 17]. Swimmers
deficiencies in swimmers are low vitamin D and iron sta- often have some degree of underlying shoulder laxity,
tus, which can limit training quality and decrease immune and this can predispose to acute subluxation. Patellar
system functioning [9, 13]. subluxation can occur in individuals with underlying
generalized laxity and, although uncommon, can occur
Supplements during breast stroke swimming [17]. Acute meniscus
The use of dietary supplements in the swimming world tears are uncommon in swimming, but symptoms from
continues to grow in popularity. High training volumes, a degenerative meniscus tear in an older athlete may be
limitations of digestion time, and time constraints due exacerbated by breaststroke swimming due to the force-
to travel and fatigue from heavy training create a niche ful rotatory and valgus loads on the knee [17].

Table 3 Available dietary supplements in sport. Reproduced from the Australian Institute of Sport Dietary Supplement [15] with
permission
Category Function Examples
Sport foods Convenient foods used to deliver necessary macronutrients (e.g., carbohydrates and Protein shakes, sports drinks, gummy
protein) before, during, and after exercise chews, chewable tablets
Medical Tablets, capsules, or liquids of essential nutrients needed to treat diagnosed conditions or Iron and vitamin D supplements
supplements deficiencies affecting health and performance
Performance Naturally found dietary ingredients in supplemental form taken to ergogenically aid Beet juice, caffeine, beta alanine,
supplements performance and recovery time creatine, sodium bicarbonate
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Acute onset of back pain can occur in swimmers. The NCAA Division I collegiate swimming program found
repetitive hyperextension that occurs in breaststroke and that 38 % of all injuries occurred during dryland training
butterfly may lead to spondylolysis. Although spondylo- [20]. Attention to technique and careful performance of
lysis is usually a chronic process, the onset of symptoms dryland exercises is critical to prevent injury from these
can be acute [18]. The repetitive trunk motion from flip exercises. Relative rest of the irritated region and a focus
turns may also lead to fatigue of the core stabilizing on core strength and rehabilitation of supporting muscu-
muscles, contributing to back pain [18]. Acute onset of lature is the key to treatment.
back pain is often simply due to fatigue of the lumbar
paraspinal muscles resulting from overload during swim- Overuse Injuries Overuse injury risk in swimmers has
ming or dryland training. Other less common causes of been reported as high as 4.0 injuries per 1000 athletic
acute low back pain include disc herniation and facet exposure (AE) [16, 19–22]. In a study of swimmers at
joint injury. the University of Iowa from 2002 to 2007, the shoulder
It should also be recognized that there may be an and upper arm were the most commonly injured areas
acute exacerbation of an underlying chronic condition. followed by the back and neck [20]. In the NCAA Injury
For example, a swimmer with shoulder tendinopathy Surveillance Program study for a 4-year span, the rate of
(“swimmers shoulder”) may have an acute exacerbation overuse injuries in men was 0.66 per 1000 AE and in
of shoulder pain due to a change in training volume or women was 1.04 per 1000 AE [22]. In a study of the
frequency [16, 17, 19]. A survey of injuries in a NCAA 2009 FINA world championships, 171 injuries were re-
Division I collegiate swimming program reported that ported (incidence of 66.0 per 1000 registered athletes)
freshman had the highest rate of injury, supporting the [23]. The most affected body part was the shoulder and
relationship between a change in training and injury the most common cause of injury was overuse [23].
[20]. A careful history is critical to determine if an appar-
ently acute presentation of pain or injury is actually an ex- Shoulder Shoulder pain is the most common musculo-
acerbation of a pre-existing problem. Acute exacerbation skeletal complaint in swimmers [20]. The vast majority
of a pre-existing, chronic injury is rather common. of shoulder issues in swimmers pertain to overuse rather
Swimmers often do weight lifting and other “dryland than from acute injuries (Fig. 1) [23, 24]. Differential
training” as part of their training program. Acute muscu- diagnosis of swimmer’s shoulder pain is extensive [17].
loskeletal injury can occur during these training activities An appropriate work-up including a detailed history,
[19]. Acute muscle strain injury can occur with forceful and thorough physical examination of the neck, shoulder,
weightlifting or other forms of resistance exercise. Not- and upper back is critical to developing and narrowing
ably, a report of injuries occurring over five seasons in a this differential. The medical practitioner must also be

Fig. 1 Pathway to injury: competitive swimmer. Reproduced from Edelman et al. [25, 26] with permission
Khodaee et al. Sports Medicine - Open (2016) 2:27 Page 5 of 15

aware of physiologic stressors and biomechanics during infraspinatus against the posterior glenoid rim and lab-
the swim stroke similar to how we have come to under- rum—a condition also described as “internal impinge-
stand throwing mechanics in baseball. Poor biomechanics, ment.” Fortunately, most of these cases can be treated
especially with fatigue of scapular stabilizing and rotator with rehabilitation and a proper strengthening routine as
cuff muscles, leads to dynamic instability and impinge- well as improvement in potential stroke flaws [27]. A
ment [19]. A multitude of issues contribute to the “swim- group of strength training exercises for rehabilitation of
mer’s shoulder”: a hypermobile glenohumeral joint the rotator cuff, scapular stabilizers, and abdominal and
combined with technique flaws or fatigue can lead to im- low back core muscles is helpful as either preventative or
pingement of the rotator cuff [17]. Hypermobility can be rehabilitative exercises for the shoulder (Fig. 2) [19].
multifactorial: the swimmer may have a predisposition
with shoulder laxity or may have a traumatic event. Hip and Groin Breaststroke, far more commonly than
Microtears or stretching of the glenohumeral ligaments other competitive swimming strokes, can lead to a var-
exacerbate static instability. Once these athletes fatigue, iety of hip and groin strains and injuries. Adductor
their rotator cuff cannot alone stabilize the humerus and strain, iliopsoas strains, and sports hernias pose difficult
the increased translation, especially upward or superior- diagnostic and treatment challenges. Symptoms can be
posterior leads to overloading the rotator cuff tendon. Ab- quite similar among these entities. Given the repetitive
duction and rotation with humeral head translation can nature of swimming, these can also be notoriously prob-
result in contact of the posterior supraspinatus or anterior lematic over an extended time [28]. Stretching and

Fig. 2 On-deck active warm-up (S start, F finish). Complete 2 sets of 15 for each activity. Active Warm-Up: a Place your arms by your side, bend your
elbows to 90° to assume the start position. Externally rotate your arms to the end range at a comfortable pace and then return to the starting position. As
you externally rotate, pinch your shoulder blades together. Do not force the end range. Complete 2 sets of 15 repetitions. Active Warm-Up: b Place the
back of your hands on your back at the belt line and bring your elbows forward to assume the start position. Squeeze your elbows and shoulder blades
together and then return to the start position. Complete 2 sets of 15 repetitions. Active Warm-up c Forward elevate your arms to 90° and then bend your
elbows to 90° to assume the starting position. Horizontally abduct your arms to a “goal post” position, squeezing your shoulder blades together at the
same time. Then, return to the starting position. Complete 2 sets of 15 repetitions. Active Warm-up: d Abduct your arms to 90° and bend your elbows to
90° to assume the starting position. Then, externally rotate your shoulders to achieve the “goal post” position. Return to the starting position. Complete 2
sets of 15 repetitions. Active Warm-up: e Assume a tight streamline for the start position. Drop your elbows into your “back pockets,” while squeezing your
shoulder blades together and keeping your hands up. Return to the streamline position and complete 2 sets of 15 repetitions
Khodaee et al. Sports Medicine - Open (2016) 2:27 Page 6 of 15

supportive core strengthening will aid in recovery. A swimmers. To date, swimmers have adopted stretches
narrower breaststroke kick will decrease strain on the that target the static stabilizers of the GHJ. In the past,
hip adductor muscles [29]. This can be facilitated using static stretches and pre-race rituals (i.e., ballistic wind-
a number of technique drills in the pool. Prophylactic mill motion) were utilized in hopes of preventing injury
stretching and strengthening is always better than treat- [38]. Recent research on swimmer’s flexibility suggests
ing an issue. there is no indication that extraordinary shoulder joint
motion or flexibility is necessary to achieve a fast, effi-
Knee Up to 75 % of breaststrokers report medial knee cient stroke [39, 40]. In addition, there is no evidence
pain [30]. Medial knee pain can occur from strain on the that static stretching immediately before activity will re-
medial collateral ligament, irritation of a medial plica, or, duce muscle injury rates [41, 42]. Many swimmers are
in unusual cases, medial meniscus tears. Patellar instabil- generally flexible and possess loose connective tissue
ity is another less common differential diagnosis to con- (general joint laxity) [43]. Because of their inherent lax-
sider. Examination of the knee should be focused on ity, swimmers should emphasize preserving the overall
evaluation of knee stability. Knee injuries from cross- stability of the shoulder and less time on general static
training such as weight-lifting, plyometrics, or running stretches [26]. Instead, a dynamic warm-up (Fig. 2) has
can be exacerbated by swimming. Improving hip flexibility been found to produce short-term and long-term per-
and avoidance of an overly wide breaststroke kick will help formance enhancements in power, agility, strength,
decrease strain on these areas of the knee. muscle endurance, and anaerobic capacity [26, 38, 44,
45]. A dynamic warm-up tends to include some form of
Lumbar Spine Dolphin kicking plays an important role dynamic stretching, agility, and plyometric activities and
in modern swimming technique. With an increased em- specific motor pattern movements [46]. Figure 2 demon-
phasis on this facet of swimming comes risk of low back strates dynamic warm-up which is specifically designed
injury, as hyperextension with dolphin kicking can lead for the swimming population. Swimmers should employ
to pars interarticularis pathologies (e.g., spondylolysis). a steady pace with each activity and avoid ballistic type
The L5-S1 disc is another common area of irritation motions.
with overuse. Similar to other areas of overuse in swim-
mers, dryland training, especially weightlifting, can ex- Focused Strengthening Exercises Dryland training has
acerbate or cause back injuries [31, 32]. Also, similar to been an important part of strengthening programs
other areas of overuse, a prevention program with em- among swimmers at different age and skill levels. The
phasis on core abdominal and low back strengthening main focus of these training programs seems to be the
can help prevent chronic low back complaints. spine and core strengthening [47]. Strength deficits can
play an important role in fatigue development. Madsen
Shoulder Rehabilitation Changes in training practices et al. found that the majority of swimmers demonstrated
and improved research allow healthcare providers to signs of scapular dyskinesis in the course of a 100-min
manage shoulder pain in competitive swimmers better swimming session [48]. Through EMG analysis of the
than ever before. In the past, the healthcare providers painful shoulder, Scovazzo et al. discovered muscle activ-
generally attributed shoulder pain to excessive training ity of the serratus anterior is significantly depressed
or too many repetitive overhead strokes leading to laxity through the important pull-through phase in swimmers
and resultant impingement of the rotator cuff [33–37]. with shoulder pain [49]. Batahla revealed in the course
Recently, a new treatment paradigm reveals no single of a swim season the internal rotators of competitive
cause for shoulder pain in swimmers but rather a cluster swimmers become proportionally stronger when com-
of contributing factors that can match the clinical pres- pared to their antagonists, increasing muscle imbalance,
entation to the treatment [27]. Edelman et al. offers a and the risk of an injury process [50, 51]. Fatigue may
subclassification system for shoulder pain identifying a lead to a short-term decrease in acromiohumeral dis-
cluster of etiological factors: (1) predisposition, (2) fa- tance [52]. As a result, a dryland program focusing on
tigue, (3) injury-related (faulty) mechanics, and (4) tendi- the shoulder external rotators and the scapular stabi-
nopathy [27]. This model can guide the selection of lizers would be of benefit and should be recommended
homogenous subgroups for more effective treatment as routine prophylactic measures [53]. Strengthening the
strategies as noted in Fig. 1. Identifying individual causes internal rotators should be de-emphasized.
in the setting of this paradigm should allow targeted and
more effective treatment. Return to Swimming after Injury If the treatment pro-
gram results in removing the swimmer from the water,
Shoulder Stretching and Dynamic Warm-Up The then a careful reintegration back to training is essential
shoulder is the most frequently stretched joint among [54, 55]. During the rehabilitation process, when the
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swimmer is able to reach above shoulder height without Table 4 Recommendations to athletes, coaches, and medical
pain and demonstrate resisted motions from 0° to 90° staff as potential strategies for controlling the negative effects
without pain, then the swimmer is encouraged to return of swimming pool chlorine on general health and performance
to the pool and swim 1000–2000 m slowly and comfort- Schedule training sessions in outdoor pools as much as possible where
natural ventilation helps to reduce surface chlorine levels. If forced to
ably while avoiding antagonizing strokes and sprint sets.
use an indoor pool, avoid older pools that may have low ceilings and
When the swimmer is without pain during resisted mo- poor ventilation systems. In addition, deck-level industrial fans can be
tions in all planes, and during most activities of daily liv- effective in enhancing the clearance of surface chlorine in older, poorly
ventilated pools.
ing and swimming 2000 m, then add 500 m every three
workouts. During this step, it is indicated to avoid Undergo evaluation of pulmonary function by a certified medical professional
for the purpose of determining asthmatic response and/or susceptibility to
double workouts and sprint sets. When swimming airway hyper-reactivity in a chlorinated environment [57, 67].
4000–5000 m without pain, then integrate all four com-
Consider prophylactic use of antioxidant supplementation (beta-carotene,
petitive strokes and add short sprint sets. vitamin C, vitamin E) to reduce the negative effects of chlorine-induced
oxidative stress on pulmonary function [69].
Train in a pool where the professional maintenance staff is conscientious
Pulmonary and precise in their regulation of optimal chlorine levels, as well as water
To ensure the health of swimmers, chlorine-based disin- temperature and ventilation of surface chlorine.
fectants are used to effectively reduce the risk of bacterial Train in a pool where the professional staff ensures that proper swimming
pool behavior, etiquette, and equipment are in place to help reduce the
and viral infection in swimming pool facilities. However,
level of chlorine exposure. Posted requirements should be in place regarding
when chlorine reacts with organic compounds in the pool pre-entry showers, bathroom breaks, suntan lotion, swim caps, goggles, etc.
water (e.g., sweat, urine, soap residues, cosmetics, suntan Encourage swimming pool maintenance staff to stay current on the latest
oil, dirt, and other solid waste material), several volatile information regarding the efficacy of potential substitute disinfectant
chemical compounds are produced in the form of trihalo- methods such as electro-physical systems (electrolytic copper and
electrolytic silver), ozone disinfection, and ultraviolet disinfection [56].
methanes, chloramines, and haloacetic acids [56]. In turn,
exposure to these chemical compounds can occur in
swimmers via three direct avenues: (a) ingestion of pool related to the endurance nature of swimming and not
water, (b) inhalation of airborne chlorine and chlorine an- necessarily due to chlorines [68].
alogs in the air space located immediately above the pool Exercise-induced bronchospasm (EIB) is more common
surface, and (c) direct skin contact with the pool water among swimmers in comparison to general population
[57]. Exposure to trihalomethanes, chloramines, and [68, 69]. This may be partially due to more participation
haloacetic acids can have a negative impact on general as a result of a belief that breathing the warm and humidi-
health and athletic performance. Specifically, there is fied air benefits swimmers with asthma and EIB [17].
strong evidence suggesting that acute and/or chronic However, exposure to aerosol chemicals may trigger these
exposure to these chlorine-based chemical compounds conditions [17]. Management of swimmers with asthma
can manifest as clinical symptoms of upper respiratory and EIB is similar to other athletes [17, 70]. Finally, along
dysfunction (chronic rhinitis, sneezing, irritated nasal si- with EIB, assessment of exercise-induced laryngeal ob-
nuses, runny nose, nasal obstruction, and sinusitis) [58, 59] struction (EILO) should also be included in the medical
and lower respiratory dysfunction (breathing difficulty, workup of swimmers who present with chronic pulmon-
wheezing, cough, chest tightness, and abnormal spirometry) ary issues [71].
[58, 60, 61], as well as eye irritation and headache [62]. The
negative effects of exposure to chlorine-based chemical Ear, Nose, and Throat
compounds on pulmonary function appear to be due to Allergic and non-allergic rhinosinusitis is common
pathophysiological mechanisms related to lung epithelial among swimmers [72]. Due to easy spread and possible
tissue perturbation [63–65] and airway remodeling [66, 67]. other factors (e.g., suppressed immune system), viral
Thus, swimmers face a tough balancing act between the upper respiratory infection (URI) is more common
positive effects of a contaminant-free pool and the negative among swimmers than other athletes [17, 70]. Swimmers
aspects of over-exposure to chlorine and chlorine analogs. with symptoms and signs of more serious infections
Table 4 summarizes the recommendations for potential (e.g., pneumonia, fevers, and hypoxia) should not be
strategies to control the negative effects of swimming pool allowed to practice.
chlorine on general health and performance. Prolonged exposure to water and frequent attempt to
One study reported that about 20 % of elite swimmers clean the ear canal predispose swimmers to develop
(FINA world championships and Olympic Games) had acute otitis externa (swimmer’s ear). Gram-negative bac-
asthma/airway hyperresponsiveness [68]. In this study, teria, most commonly pseudomonas, are the major patho-
swimmers in comparison to other aquatic athletes had gens. Treatment with otic anesthetic/anti-inflammatory/
higher prevalence of asthma. This seems to be more antibiotic/acidifier agents is usually adequate [73]. In rare
Khodaee et al. Sports Medicine - Open (2016) 2:27 Page 8 of 15

cases with systemic signs (e.g., fever), oral antibiotics may Ophthalmologic
be necessary [73]. Other less common ear problems in The most common ophthalmologic issue encountered
swimmers include otomycosis, exostoses (“surfer’s ear”), by swimmers is eye irritation and redness related to che-
traumatic tympanic membrane perforation, otitis media, micals contained in swimming pools. This is more com-
and barotraumas of the inner ear. monly experienced in pools containing chlorine or
bromine compared to those using ozone, UV, and salt
Dermatologic electrolysis treatments [84]. Wearing swim goggles sig-
Swimmers are susceptible to different dermatologic con- nificantly decreases the risk of developing eye irritation
ditions given their substantial amount of time spent in [85]. In addition to peri-orbital skin irritation, some
the water and in moist environments [74]. Certain studies have shown a small but significant transient
dermatoses are infection or organism-related. Swimming increase in intraocular pressure (IOP) in individuals
pool granulomas (atypical Mycobacterium infection) wearing certain types of swimming goggles. Goggles with
may occur overlying bony prominences and are often smaller surface areas lead to larger IOP measurements
found in the upper extremities, especially the fingers. [86]. Despite some speculation that repetitive goggle use
Nodules or plaques arise about 6 weeks after exposure over time could consequently lead to development of
[75]. The affected area should soak in warm, clean water glaucoma, one recent study challenges this notion [87].
for 5–10 min, three to four times per day. Antibiotics Another ophthalmologic issue in swimmers is ocular in-
(clarithromycin, minocycline) may also be used [76]. fection. Swimmers wearing soft contact lenses are at risk
“Hot tub” (pseudomonas aeruginosa) folliculitis usually of developing pseudomonas infection and acanthamoeba
appears within 8–48 h of exposure to contaminated keratitis [88, 89]. Acanthamoeba infection is rare but
water. Pale green fluorescence under Wood’s lamp can serious. Symptoms may include eye pain/redness,
aid in diagnosis [77]. Most eruptions self-resolve within blurred vision, light sensitivity, foreign body sensation,
2 weeks, but acetic acid 5 % compresses may provide and excessive tearing. Suspected patients should be re-
symptomatic relief [78]. Deep bacterial folliculitis (“bi- ferred to an ophthalmologist immediately for evaluation,
kini bottom”) may arise in swimmers who wear wet, as early detection is essential [88]. Treatment usually
tight-fitting swimsuits for long periods of time. Macer- consists of topical agents; however, sometimes oral itra-
ation of the skin allows for infection with Streptococcus conazole therapy and/or surgery may be required in ad-
or Staphylococcus aureus. This can be usually treated vanced cases [88]. Prevention consists of contact lens
with a course of cephalexin or appropriate MRSA cover- removal during swimming or thorough disinfection of
age, if suspected [79]. Swimmers are also particularly lenses following swimming.
vulnerable to other common skin infections such as
molluscum contagiosum (“water warts”), tinea pedis Neurologic
(“athlete’s foot”), and plantar warts [74]. The main concerning neurologic condition for swim-
Other swimming-related dermatoses may be caused by mers is epilepsy. Having a seizure in the water could re-
irritants or allergies. Goggles are often an offending sult in serious immersion-related injury and ultimately
agent, caused by reaction to the foam, rubber, or plastic drowning. Therefore, it is widely accepted that swim-
lining [80]. A short course of medium-potency topical mers with epilepsy should always be supervised while
steroid or an oral steroid burst for swimmers with severe swimming [90]. This is especially important in those
symptoms may be used [74]. Chlorinated or brominated athletes with poorly controlled seizure disorders. If an
pool water may cause an allergic or irritant contact athlete does have a seizure in the water, it is important
dermatitis. This can be treated by attempting to avoid to extricate them to land as quickly as possible to
the chemical irritant or by typical contact dermatitis care minimize immersion injury and practice standard seizure
(i.e., moisturizers, topical corticosteroids). care such as body injury prevention and airway manage-
Frictional dermatitis may occur from rubbing the chin ment. Even after apparent full recovery, near drowning
on the shoulder when turning the head to breathe or victims are at risk of major delayed complications, such
with recurrent contact on rough pool surfaces with as secondary drowning [91]. Therefore, all athletes who
hands/feet (“pool palms”) [81, 82]. Lesions generally self- experience a seizure in the water should be evaluated
resolve, but petroleum jelly may help alleviate symptoms. and monitored at a medical facility.
Finally, it is important to note that swimmer’s may be at Often swimmers (more common among synchronized
an increased risk for skin cancers, such as melanoma. This swimmers) will train by holding their breath for ex-
is due to sun exposure with the effects possibly potenti- tended periods of time in effort to increase respiratory
ated by chlorine [83]. Therefore, it is important to counsel capacity. This may be dangerous as it can result in loss
outdoor swimmers on adequate use of water-resistant or of consciousness and potentially anoxic brain injury [92].
water-proof sunscreen. Swimmers should be counseled that these “blackouts”
Khodaee et al. Sports Medicine - Open (2016) 2:27 Page 9 of 15

can be dangerous and possibly result in permanent but not testosterone, were higher than average in swim-
damage. mers compared with controls [96]. Mild hyperandrogen-
ism, rather than hypoestrogenism, was a suggested
Concussion mechanism for reproductive dysfunction in swimmers.
Though uncommon, the recognition and appropriate Furthermore, the prevalence of amenorrhea in runners
treatment of the concussed athlete is essential in pre- is 24–26 % compared with swimmers at 12 % [99]. This
venting long-term sequelae. The incidence of concus- may be related to the emphasis of leanness in running
sions vary for high school (men = 0.1 per 10,000 AE/ compared with swimming.
women 0.2 per 10,000 AE) [93], collegiate (men = 0.6 per Sports performance during various phases of the
10,000 AE/women 0.1 per 10,000 AE) [22, 94], and inter- menstrual cycle has been researched for many years.
national levels (0.04 per 10,000 athletes). Concussion Evidence-based conclusions have been extremely difficult
may occur from a variety of reasons (e.g., when a back- to reach due to methodological issues (e.g., inappropriate
stroke swimmer strikes the wall, runs into another verification of menstrual cycle phase, timing of hormone
swimmer while entering in the water or collision with samples), inter- and intraindividual variability in hormone
the ground) [93]. Symptoms are similar to other sports concentrations, pulsatile secretion of hormones, and small
(i.e., headache, nausea, vomiting, and dizziness), and any numbers of subjects. Research has not consistently dem-
athlete suspected of a concussion should be removed onstrated significant differences in aerobic capacity, anaer-
from practice/competition [95]. Successful management obic capacity, aerobic endurance, or muscle strength in
of the concussed swimmer requires coordination of ser- any specific menstrual cycle phase [100, 101]. However,
vices by a sports medicine provider and team experienced very active or highly competitive swimmers are at risk of
in concussion care. Athletes should initiate a return to developing the RED-S (formerly known as female athlete
school program when appropriate and be symptom free triad) which is a syndrome resulting from relative energy
prior to the initiation of a return to swimming/dryland deficiency that affects many aspects of physiological func-
training [95]. All athletes should follow a gradual return to tion including metabolic rate, menstrual function, bone
play program that incorporates progression of swimming health, immunity, protein synthesis, cardiovascular, and
activity while monitoring symptoms [95]. Any athlete ex- psychological health [9]. In athletes with amenorrhea for
periencing prolonged symptoms, specific deficits, or mul- over 6 months, bone mineral density (BMD) should be
tiple concussions may require further cognitive testing measured with dual X-ray absorptiometry (DXA). Weight
prior to returning to swimming. gain, with adequate protein and carbohydrate intake, has
been the strongest predictor for return of normal men-
Endocrine and Metabolic strual function in college athletes [102].
Menstrual Cycle and Contraception The prevalence of The use of contraceptives may be advantageous for
menstrual disorders in sports like swimming ranges swimmers who are negatively affected by their menstrual
from 16 to 82 % [96–98]. Several etiologic factors may cycle, as they can provide a stable and controllable
contribute to menstrual disorders including abnormal hormonal environment for training and competition.
levels of hormones, luteinizing hormone (LH) pulsatility, Furthermore, swimmers may desire minimal or no
inadequate body fat stores, low-energy availability (EA), bleeding/spotting which can be offered with several dif-
and exercise stress [9]. Function hypothalamic amenor- ferent forms of contraception. Examples of long-acting
rhea occurs through reductions in EA which may dis- reversible contraceptives with high (>99 %) efficacy in-
rupt LH pulsatility by impacting the hypothalamic clude intrauterine devices (IUDs) and the implant [103].
hormone gonadotropin-releasing hormone output and Progestin-only IUDs offer the advantage of minimal to
alter the menstrual cycle. During extensive training, no menstrual bleeding. Injectable depot medroxyproges-
rapid or significant fat mass reduction may adversely terone may cause amenorrhea and adversely affect BMD
affect menstrual function. Low EA alters levels of meta- if used long term (>2 years) [104]. Continuous or ex-
bolic hormones and substrates including insulin, cortisol, tended use of combined (containing estrogen and pro-
growth hormone, insulin-like growth factor-I (IGF-I), gestin) hormonal contraceptives can be used for the pill,
3,3,5-triiodothyronine, grehlin, leptin, peptide tyrosine– patch, or ring to avoid menstrual bleeding. Instructions
tyrosine, glucose, fatty acids, and ketones. for this include continuous use of a monophasic (same
In the past studies, female competitive swimmers not amount of estrogen and progestin) contraceptive by
only appeared vulnerable to delayed puberty and men- using only active pill, vaginal ring, or patch and discard-
strual irregularities but the associated hormonal profile ing inactive pills or skipping the ring-free or patch-free
was also very different from the hypothalamic amenor- week. Some combined hormonal contraceptive pills are
rhea described in dancers and runners. Specifically, packaged to allow for a menstrual cycle every 3 months
dehydroepiandrostenedione sulfate and androstenedione, with 84 active pills and 7 inactive pills. Although an oral
Khodaee et al. Sports Medicine - Open (2016) 2:27 Page 10 of 15

contraceptive may be a less desirable form of contracep- parasympathetic and sympathetic activity resulting in car-
tion due to lower efficacy (91 %) and masking low EA diac arrhythmias, pulmonary edema, and potential death.
and menstrual dysfunction, the use of oral contracep- The evaluation, treatment, and prevention of
tives has shown no effects on swimming or endurance environmental-related illnesses require a coordinated ef-
performance. Therefore, combined contraceptives should fort between the athlete, sports medicine providers, and
be recommended only when there is a medical indication venue managers. Symptoms will vary for hyperthermia
or other more effective contraceptives (e.g., IUD, implant) (fatigue, fever, chills, elevated temperature, thirst, confu-
are contraindicated, not tolerated, or unacceptable to the sion, and tachycardia) and hypothermia (chills, fatigue,
swimmer. confusion, and bradycardia). All athletes should undergo
removal of wet or damp clothing and have a rectal
temperature measurement to obtain an accurate core
Diabetes Mellitus Participating in regular physical ac-
temperature [111]. Athletes with a temperature >40 °C
tivity among patients with type 1 and type 2 diabetes
should undergo cold water immersion as soon as pos-
mellitus improves blood glucose control, lipid profile,
sible to normalize core temperature. Athletes with
blood pressure, and fitness [105, 106]. Swimmers with
hypothermia should be warmed with heat blankets/air,
diabetes should be able to compete in endurance events
as appropriate. Any athletes with cardiovascular com-
granted that they have no complications of their diabetes
promise will require transportation to a local hospital.
and are in good glycemic control [105, 107, 108]. When
Preventive strategies include acclimatization, familiarity
planning medical coverage, it is crucial to be aware of
with the race venue, adequate warm-up time, and proper
swimmers with diabetes in advance. Medical teams
hydration [111].
should be prepared to manage unusual but serious
circumstances such as hypoglycemia [107, 108]. Close
Overtraining
glycemic and dietary monitoring before and during long
Overtraining (OT) is a condition experienced by many
practice sessions and races is the key to avoid complica-
swimmers, especially those competing at the Olympic
tions [109]. As insulin is on the prohibited WADA list, a
level [113]. OT is characterized by several physiological,
therapeutic use exemption is required.
biological, and psychological symptoms with the most
obvious ones being (a) a consistent decrement in per-
Cold- and Heat-Related Illness formance, (b) an inability to train and recover effectively,
Cold- and heat-related illness is greatly impacted by a and (c) a loss of determination and mental focus [114].
variety of factors that can affect the swimming athlete. OT can be more accurately portrayed as the end-point
Both occur when there is a thermoregulatory mismatch on a continuum [114], as shown in Fig. 3. Moving from
between heat production from exercise and heat loss. left to right, the first three phases on the OT continuum
Body heat loss in the swimmer primarily occurs through are reflective of “positive” training and good perform-
convection from the interface of the skin and water that ance, analogous to green on a traffic light (“proceed im-
is proportional to speed (heat transfer coefficient) and mediately”). Next on the OT continuum, separated by a
the temperature difference between the skin and water thin line is a phase that typically includes both “positive”
[110]. Other factors impacting heat loss include the and “negative” training/performance, due primarily to a
design and thermal properties of garments, the environ- requisite increase in training load for the purpose of
ment (air temperature, humidity), athlete illness, and advancing the athlete’s fitness level and competitive per-
medications [111, 112]. formance. This block is analogous to yellow/amber on a
Pool and open-water venues offer unique environmen- traffic light (“proceed with caution”). Finally, on the far right
tal challenges for the swimmer. Pool venue environ- of the OT continuum is OT, which is characterized by
ments are often well controlled when in a closed setting “negative” training/performance, analogous to red on a traf-
but can be impacted by weather (temperature, wind, and fic light (“stop”). There are several models that have been
humidity) when in an open setting. Open-water swim- proposed to explain the underlying biological, physiological,
ming venues have greater environmental variability (air and/or psychological mechanisms of OT. Among the more
and water temperature, humidity, and sun exposure) credible is the “elevated pro-inflammatory cytokine”
that can fluctuate during the course of a race leading to hypothesis [115–117]. This model proposes that excessive
hypothermia or hyperthermia. FINA guidelines suggest musculoskeletal stress (two or three training sessions per
open-water swimmers should only compete when the day for several weeks) in combination with insufficient
water temperature is above 16 °C or below 31 °C to recovery (sleep, nutrition, psychological down time) leads
minimize the risk of severe hypothermia or hyperthermia, to chronic musculoskeletal inflammation and the release of
respectively [110]. Additionally, the impact of cold water the following pro-inflammatory cytokines: interleukin-6
immersion and voluntary apnea could result in (IL-6), interleukin-1-beta (IL-1β), and tumor necrosis
Khodaee et al. Sports Medicine - Open (2016) 2:27 Page 11 of 15

Fig. 3 Overtraining continuum. Reproduced from Wilber et al. [114] with permission

factor-alpha (TNF-α). These pro-inflammatory cytokines Child, Adolescent, and Masters Swimmers
act on the central nervous system (CNS), hypothalamic- The young and Masters athlete represent two special
pituitary-adrenal (HPA) axis, and hypothalamic-pituitary- populations of swimmers that present unique conditions
gonadal (HPG) axis, which manifests in several of the in their medical care. Swimming is an excellent activity
clinical symptoms seen in overtrained athletes (e.g., sleep for the young athlete that not only promotes physical ac-
disturbances, elevated stress hormones, perturbed repro- tivity but also helps build psychosocial and academic
ductive function) [115–117]. In terms of the prevention of skills. For the Masters athlete, swimming improves phys-
OT, we offer a medically based and practical treatment ical performance without impact on the weight bearing
algorithm, as shown in Fig. 4 [114]. joints that may contribute to degenerative joint disease.

Fig. 4 Overtraining treatment algorithm. Reproduced from Wilber et al. [114] with permission
Khodaee et al. Sports Medicine - Open (2016) 2:27 Page 12 of 15

In addition, regular physical activity and training regi- and safety for the Masters athlete. Masters athletes are
mens often delay and blunt the aging-related declines in at risk for the same overuse injuries seen in the young
aerobic and anaerobic fitness. However, swimming can athlete; however, the recovery and rehabilitation from
have a negative impact on the health and safety of both these injuries may be prolonged. Thus, it is important to
groups. recognize these injuries early to prevent further progres-
Early sports specialization, OT, and burnout are vari- sion. Rehabilitation from injuries is even more critical
ous conditions that commonly affect the young swim- for the Masters athlete to prevent more rapid loss of
ming athlete. Increasing desires by parents, guardians, flexibility, strength, and endurance than seen in younger
coaches, and young athletes often drive more intensive athletes [121].
and earlier training schedules. Athletes as young as
11 years are swimming >25 h per week in the pool. Near-Drowning and Drowning
Training schedules often include swimming several Drowning is the major cause of death worldwide
hours in the morning, going to school, and then swim- (449,000 in 2000) and the second leading cause of unin-
ming several hours after school. Some young athletes are tentional death in children and adolescents in the USA
swimming 20–30 km per week, which has an aerobic [126, 127]. Children should be taught to swim. Children
equivalent to running 100 km. Many young athletes younger than 5 years of age should be supervised all the
swim all year round, with only 1 day off of swimming time, as instruction in younger children may lead to a
per week. This intensive training schedule, combined false sense of security [127]. Additional counseling tech-
with early sports specialization, can lead to a significant niques include never swimming alone, swimming with
risk for overuse injuries as well as mental and physical adult supervision, the use of an approved personal float-
burnout. Female and male athletes are at risk for the ation device, and the risks of the consumption of alcohol
RED-S if they are not consuming enough calories from and other drugs [127]. A lifeguard or someone familiar
both daily and exercise activities. Young athletes that ex- with cardiopulmonary resuscitation (CPR) should be
hibit decreasing performance emotional or behavior present during each practice and competition [127].
changes, or have prolonged recovery from common
overuse injuries may be experiencing OT or burnout. Open-Water Swimming
Sports medicine physicians are encouraged to counsel The unique environmental conditions of open-water
their young athletes to take at least 1–2 days off from swimming inherently belie the potential injuries. In
sports per week, not to specialize in one sport until late addition, marathon swimming, with some competitions
adolescence, and to spend 2–3 calendar months partici- greater than 25 km, adds interesting physiologic condi-
pating in another sport [118–121]. Additionally, young tions that can affect competitors [11]. With training,
athletes should not spend more hours training than their most open-water swimmers do longer-distance work-
chronological age per week [121]. The IOC recently outs, also increasing potential for overuse injuries.
published recommendations on youth athlete develop- As with pool swimming, the most likely cause of injury
ment [122]. is overuse of the shoulder in training. The highest in-
Participation in swimming by the Masters athlete has competition injury risk of any aquatic discipline at the
become an increasingly popular sport, with the United FINA World Championship was reported to be open-
States Masters Swimming (USMS) as the governing body water swimming [23]. The risk of an in-competition in-
[123]. Swimming offers the Masters athlete the oppor- jury was 57.7/1000 starts of female athletes with most of
tunity to improve their physical conditioning and delay those being contact injuries with another athlete result-
the most common chronic diseases of the aging popula- ing in contusion.
tion which include arthritis, hypertension, and heart dis- Environmental conditions such as water/air temperature,
ease. The physiology of aging puts the Masters athlete at water quality, and aquatic fauna and flora create the most
a unique disadvantage in comparison to the younger unique aspect of open-water swimming [125]. Poor water
athlete [121, 124]. Most importantly are the changes in quality can result in gastrointestinal illness. This can cause
the cardiovascular (decreased maximal heart rate, de- dehydration especially given the inability of athletes to fre-
creased cardiac output), pulmonary (decreased total lung quently hydrate during races. Animal exposure (e.g., jelly-
capacity, decreased maximal oxygen uptake), and mus- fish, rays, fish, sharks, dolphin, seals, snakes) can all be
culoskeletal (decreased strength and bulk, decreased problematic [128]. Because swimmers will be in the water
flexibility) system. Sex-related performance differences for such long periods, prevention of chaffing and rubbing
are less significant among female elite swimmers with of the skin is important [128]. Exhaustion and fatigue can
advanced age in comparison to counterpart marathon possibly exacerbate pre-existing medical conditions. This
runners [125]. Medications that interfere with blood can be notable in both recreational as well as elite
pressure and heart rate may also influence performance swimmers.
Khodaee et al. Sports Medicine - Open (2016) 2:27 Page 13 of 15

Lastly, the team and swimmer are reliant on training Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA. 10Faculty of
and race support. On most open-water courses, the Medical Sciences, University of Kragujevac, Kragujevac, Serbia. 11Sports
Medicine and Shoulder Service, Orthopaedic Surgery, The Hospital for Special
swimmer is some distance from coaches and land-based Surgery, Weill Medical College of Cornell University, New York, NY, USA.
medical personnel, relying on lifeguards and other, usu- 12
Tissue Engineering, Regeneration, and Repair Program, The Hospital for
ally boat-based, observers. However, boats, including Special Surgery, Weill Medical College of Cornell University, New York, NY,
USA.
those of support crew and media covering events can
unintentionally injure swimmers if in proximity. Com- Received: 12 May 2016 Accepted: 7 July 2016
munication between the athlete, coach, and support
crew is usually minimal.
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