The Pain Clinic, Vol. 14, No. 3, pp.

229– 234 (2002)

Ó 2002 VSP
Also available online - www.vsppub.com

Research paper

Musculoskeletal pain in elite competitive

male swimmers
K. CAPACI 1;¤ , B. OZCALDIRAN 2 and B. DURMAZ 1
1 Ege University, School of Medicine, Department of Physical Medicine and Rehabilitation,
Izmir, Turkey
2 Ege University, School of Physical Education and Sports, Department of Kinesiology and
Training Sciences, Izmir, Turkey

summary Musculoskeletal problems that interfere with effective training is serious and may result in
decreased performance in the swimming athlete. The aims of this study were to estimate the
prevalence of musculoskeletal pain in our competitive male swimmers, and to investigate the
relationship between stroke style and musculoskeletal pain. It was found that 23 of the 38
competitive male swimmers examined reported musculoskeletal pain in this study: 13 had
shoulder pain, 7 had low back pain, and 3 had knee pain. Ten swimmers with pain never
stopped training, and only one swimmer had to stop swimming for a period of one month.
Knee pain was observed only in breaststrokers, but back pain from all strokes. Shoulder pain
was not seen in breaststrokers; this pain instead occurred frequently in free-stylers. Injuries
leading to pain may be acute or caused by repeated microtraumas, eventually leading to an
overuse injury. Corrections of factors contributing to overuse injuries should be properly
treated so that the swimmers may return rapidly to swim safely.

Key words: Shoulder pain; knee pain; back pain; competitive swimming.

introduction As opposed to contact sports, most musculoskeletal complaints related to

swimming result from repetitive use of the extremities, which leads to
overuse injuries. Competitive swimmers perform highly repetitive move-
ments; therefore, characteristic overuse injuries of the shoulder, back, and
knee can occur.1,2 Muscle imbalance, weakness, and poor  exibility are some
of the factors that may lead to athletic injuries of overstressed tissues. 3 – 7
Another important factor of overuse injuries is poor technique.8 This is a
common cause of injury in swimming. Shoulder pain is the most common
complaint among swimmers. 1,9,10 Occurrence of knee pain among competi-
tive swimmers is approximately 25%. Repeated  exion and extension of the
knee in all four strokes (and especially in breaststroke) can result in knee
pain.1,2,11 Strain of the low back muscles, particularly during backstroke and
butter y swimming, is the most common cause of back pain in swimmers. 1,12
Musculoskeletal problems in the swimming athlete that interfere with effec-
tive training are serious and may result in decreased performance.
In this study, the musculoskeletal problems seen in our competitive swim-
mers are presented and relationships between stroke style and musculoskele-
tal problems are discussed. Furthermore, the proŽ les of musculoskeletal pain
and the differences of physical characteristics between injured and healthy
swimmers were also investigated.

¤ To whom correspondence should be addressed at Ege Universitesi Tõ p Fakultesi,

Fiziksel Tõ p ve Rehabilitasyon Anabilim Dalõ , 35100 Bornova, Izmir, Turkey. E-mail:
capaci@med.ege.edu.tr
230 K. Capaci et al.

material and Thirty-eight competitive male swimmers (9 breaststrokers, 6 butter yers, 13

methods free-stylers and 10 backstrokers) were evaluated by means of a questionnaire.
The procedures of the study were fully explained to each subject and
then they signed an informed consent which was approved by the ethical
committee.
The questionnaire included items related to previous and current medical
status, and lifetime incidence of skeletal injury. Subjects were asked to
identify whether they had musculoskeletal pain. If they had musculoskeletal
problems, they were asked to identify the location of pain. Demographic data
were recorded in the questionnaires.
In this study, the musculoskeletal pain was classiŽ ed into Ž ve categories:
1 — no pain, 2 — pain only after heavy workouts, 3 — pain during and
after workouts, 4 — pain interfering with performance, 5 — pain preventing
competitive swimming. All subjects were asked to identify the movement
that caused pain. In uence on training (1 — no, 2 — mild, 3 — moderate,
4 — severe) and period of suspended training because of pain (1 — never,
2 — < 1 week, 3 — > 1 week < 1 month, 4 — > 1 month) were also
evaluated.
The statistical analyses were performed using SPSS (9.0 version) for Win-
dows. The results of variables were reported as means § standard deviations,
and 95% conŽ dence intervals were calculated for means of differences. Chi-
squared tests were used to evaluate the distribution of musculoskeletal prob-
lems among the swimmers. Differences between injured and healthy swim-
mers were evaluated with the Mann– Whitney U tests for unpaired observa-
tions. Spearman’s correlations were used to determine whether a relationship
existed among the variables. A nonparametric t-test for independent samples
(Kruskal– Wallis) was used to test differences in age, height, weight, body
mass index (BMI), training hours per week, and years of training.

results Twenty-three of the 38 competitive swimmers reported musculoskeletal pain.

Thirteen swimmers (38.2%) had shoulder pain, 7 swimmers (18.4%) had
low back pain, and 3 swimmers (7.9%) had knee pain. The physical
characteristics and years of training are shown in Table I. The swimmers
suffering from musculoskeletal pain had a longer history of training and
spent more time in training (p < 0:05/. A statistically signiŽ cant positive
correlation was observed between the pain score and age, years of training
and weekly training time (p < 0:05/. The proŽ les of musculoskeletal pain
are presented in Table II. Arm propulsion and leg propulsion were the major
causative activities for shoulder and knee pain. Two of seven swimmers with
back pain said that they felt back pain during pike dive; two butter yers
reported that the dolphin kick caused back pain; one backstroker and two
freestylers reported that they felt back pain while kicking. Pain only after
heavy workouts (8=23) and pain during and after workouts (11=23) were the
most frequent associations (p < 0:001/. More than half of these swimmers
(16=23) reported a mild in uence on training and the others never stopped
their training, with the exception of one swimmer who had to stop swimming
for a period of one month.
Physical characteristics and years of training of stroke specialist swimmers
are shown in Table III. There was no statistically signiŽ cant difference be-
tween groups as regards anthropometric characteristics and years of training.
Table IV shows the distribution of the musculoskeletal problems according
to four strokes. While knee pain was seen only in breaststrokers, back pain
was associated with all strokes. Shoulder pain was seen in all strokes except
breaststroke. Most shoulder pain occurred in free-stylers (6=13) (p < 0:05/.
 Musculoskeletal pain in competitive swimming 231

Table I.
Anthropometric characteristics and years of training

With pain Without pain

Number 23 15
Age 14:78 § 1:56 13:93 § 1:43
Body height (cm) 169:78 § 10:41 164:00 § 7:60
Body weight (kg) 61:08 § 10:44 54:26 § 11:27
Body Mass Index 21:04 § 2:04 20:05 § 3:16
Training history (years) 6:34 § 1:82 5:13 § 0:99*
Average training hours per week 8:86 § 1:25 8:00 § 1:06*
* p < 0:05.

Table II.
The proŽ les of musculoskeletal pain

Question Movement which Pain classiŽ cation In uence of Training stopped
causes pain pain on training because of pain
Arm propulsion (13) a) No pain (15) a) No (1) a) Never (10)
Leg propulsion (3) b) Pain only after heavy b) Mild (16) b) < 1 week (9)
workouts (8)
Flutter kick (3) c) Pain during and after c) Moderate (5) c) 1 week <
workouts (11) 1 month (3)
Dolphin kick (2) d) Pain which interferes d) Severe (1) d) 1 month (1)
with performance (3)
Pike dive (2) e) Pain preventing
competitive swimming (1)
Total 23 38 23 23

Table III.
Anthropometric characteristics and years of training of stroke specialist swimmers

Breaststroker Butter yer Freestyler Backstroker

Number 9 6 13 10
Age 14:11 § 1:90 15:16 § 1:32 14:46 § 1:39 14:30 § 1:63
Body height (cm) 167:00 § 13:79 175:50 § 7:17 166:53 § 6:74 164:40 § 8:69
Body weight (kg) 54:88 § 16:0 62:32 § 6:86 60:30 § 8:90 56:70 § 10:97
Body Mass Index 19:30 § 3:23 20:17 § 0:69 21:63 § 2:04 20:86 § 2:87
Training (yr) 5:55 § 1:94 5:83 § 1:47 5:84 § 1:51 6:20 § 1:81
Average training 8:55 § 1:13 8:83 § 0:98 8:53 § 1:45 8:30 § 1:33
hours per week

discussion The prevalence of musculoskeletal problems was 60.52% (23=38). The

prevalence of shoulder pain in this study (13=38) was lower than that
observed generally.1,4,9 Rodeo11 pointed out that knee pain ranked second to
shoulder pain as a common complaint in competitive swimmers. In our study,
back pain ranked second to shoulder pain with an incidence of 18.4%. Mutoh
et al.13 reported an incidence of 37% of low back pain among swimmers. In
another study, Drori et al.14 reported that 50% of butter y swimmers and 47%
of breaststroke swimmers complained of back pain compared to 8% and 27%
of swimmers in the past, respectively. It was found in our study that 33.3%
of butter y swimmers and 22.2% of breaststroke swimmers had back pain.
Anthropometric characteristics, such as age, body height, body weight
and BMI seem not to be risk factors which in uence the potential for
musculoskeletal injuries because there was no signiŽ cant difference between
the swimmers who had musculoskeletal problems and the healthy swimmers.
Injured swimmers were trained for more years and more hours per week
232 K. Capaci et al.

Table IV.
Distribution of the musculoskeletal problems according to the four strokes

Stroke style Shoulder pain Knee pain Back pain

Breaststroke N — 3 2
% within stroke style 60 40
% within musculoskeletal site 100 28.2
% within all musculaskeletal pain 13 8.7
Butter y N 3 — 2
% within stroke style 60 40
% within musculoskeletal site 23.1 28.6
% within all musculaskeletal pain 13 8.7
Freestyle N 6 — 2
% within stroke style 75 25
% within musculoskeletal site 46.2 28.6
% within all musculaskeletal pain 26.1 8.7
Backstroke N 4 — 1
% within stroke style 80 20
% within musculoskeletal site 30 14.3
% within all musculaskeletal pain 17.4 4.3
Total N 13 3 7
% within all musculoskeletal pain 56.5 13 30.4
% within all group (N D 38) 38.2 7.9 18.4

than healthy swimmers. Also, a statistically signiŽ cant positive correlation

was found between pain scores, years of training, and weekly training time.
This may mean that a longer period of training will increase the chance of
suffering from musculoskeletal injury and pain. A longer period of training
may be included in the potential risk factors for musculoskeletal pain in
swimmers.
According to the results of this study, we can say that only the knee pain
was stroke speciŽ c. Knee pain occurs most commonly in breaststroke swim-
mers. The most common cause of knee pain in swimming is patellar com-
pression; the second is damage of the medial collateral ligament (swimmer’s
or breaststroker’s knee) due to excessive valgus and rotatory stress of the
knee during breaststroke kicking, which stretches the medial collateral liga-
ment. Finally, also, improper technique for the whip-kick has been reported
to cause knee pain in breaststrokers.1,2,11,15
We have found in this study that shoulder pain occurs mostly in free-stylers
(6=13). It is well known that the average competitive swimmer may do as
many as 750,000 strokes per arm per year over a career of 8– 12 years.1 In
competitive swimmers, males perform over 400,000 overhead strokes in a
season.16 Over 50 percent of world class swimmers complain of shoulder
pain, mostly due to overuse.17 Shoulder motion in free-style, backstroke and
butter y strokes is mechanically very similar, so that shoulder pain occurring
in any of these three strokes usually originates from the same source.1 This
supported our Ž ndings that we found shoulder pain in these three stroke
specialist swimmers.
The sources of low back pain are multiple but the most common causes
are strains of the lower back muscles, particularly during breaststroke and
butter y.1 Low back pain has recently become a common complaint in
swimmers. Swimmers in recent years have signiŽ cantly increased the amount
of time spent in the water. They start swimming training at a very young age,
and they may spend over 10 hours a week at such training. Also, swimmers
spend many hours on trunk strengthening exercises as dry land exercises
which, if performed incorrectly, can harm the spine. In recent years, most
 Musculoskeletal pain in competitive swimming 233

swimming training is performed with special devices. For example, lower

body workout is usually performed with a kicking board. Thus, the lower
back is put in continuous hyperextension which can lead to low back pain.
It was found that 33.3% of butter y swimmers and 22.2% of breaststroke
swimmers had back pain in our study. These Ž ndings supported the general
knowledge about low back pain in competitive swimmers.
The majority of injured swimmers in our study reported mild pain which
interfered with training but only one swimmer had to stop swimming for
one month. The most important goal for the medical managers of the
swimming athlete is to maintain training capacity. Even short absences from
effective training have been shown to result in signiŽ cant detraining. This
is often followed by psychological problems from falling behind the team.
Trainers, physicians and physical therapists should therefore make early
diagnosis and apply appropriate treatment rapidly. The physician, coach,
trainer, and athlete should cooperate to determine a training program which
will allow the swimmer to remain in good physical condition. It was found
that the propulsion phase of stroke and kicking were the major causes of
musculoskeletal pain in our swimmers. Rest of the injured part protects it
while the swimmer continues with activities to maintain as high a level of
Ž tness as possible without aggravating the injury. For example, when an
injury occurs to lower extremities, a pull-buoy may be employed to relieve
stress on the legs, while still exercising the upper extremities. Similarly,
kicking and dry-land cycle ergometry may be used for exercise to relieve
stress of an injured upper extremity.
Rehabilitation should focus on stabilisation exercises for hypermobile
joints, postural correction, strengthening and  exibility. 2,3,18
Early identiŽ cation and treatment of musculoskeletal problems of swim-
mers by the coach and physician are very important for competitive swim-
mers. Injury prevention is also very important; furthermore, information
must be given to the coaches and swimmers about the importance of injury
prevention. For instance, proper warm-up and stretching before training ses-
sions is very important. Correction of factors contributing to the overuse
injury should be made through appropriate therapy and education.

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