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The FINA Sports Medicine Web Pages are designed to provide team physicians and allied medical support staff with up to date medical and scientific information to guide their daily care of the aquatic athlete.

Coaches, athletes and parents can also use these pages to answer their questions regarding aquatic health issues.

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Maintaining Health - “The Best Prevention of Chronic Injuries”

The key to treating chronic injuries is in their prevention. Medical science dedicates enormous resources to the diagnosis and treatment of illness and injury, yet the optimal answer lies in prevention. When addressing prevention, several basic considerations are important and yet are quite simple.

Training, competition and regular everyday life can be difficult to balance. Today’s athlete has the added complexity of a nearly never-ending competition season. There is little down time, where the focus is on high quality training and stroke technique, between major international events. For some elite athletes, the media quickly focuses on performances that are less than astounding. There was a time when the traditional cycles of training accounted for a more balanced approach, but now there is always a need for heavy training and high quality performances… and then there is life! This new fast paced regime is a formula conducive to creating long term, nagging injuries – physically and emotionally.

So how can chronic injuries be prevented when the athlete is confronted with so many demands and so little time for restoration? The principle to remember is that the more the demands on the athlete and the athlete’s body, the more attention needs to be paid to the basics.

The Basics

The basics are frequently forgotten when considering more exciting topics such as training strategy and the materials used in the racing suit. However, without a sound foundation underlying training and performance, the best efforts of the most gifted athletes will suffer.

Nutrition

The first basic principle is nutrition. The pattern of nutrition is critical to success. To fuel muscle that is undergoing the stresses of training, a quality fuel source has to be made available at the correct times. Training muscle requires simple sources of carbohydrates to refuel that muscle. Refueling begins during the workout. A simple source, such as diluted juice or a sports drink with electrolytes and carbohydrates taken in half strength during the practice provides the energy to complete the training session. It also helps to prevent muscle breakdown, which will occur without proper nutrition. Once the training session is complete, the athlete has 30 minutes to take in a fuel source. This can be as simple as fruit. While more complex energy bars and gels may make this process easier, the added cost is not necessary. Some even say that chocolate milk is a good, quick and easy source of fuel. The point is that something - preferably a low fat carbohydrate (perhaps with some protein) -- should be ingested soon following an energy burn. Muscle fibers are openly receptive to refueling within the first half hour of completing a training session. If the athlete succeeds in meeting this time deadline, those same fibers will remain open for another two hours. Those two hours will allow the athlete to have a full meal with balanced proteins, carbohydrates, and fats. Remember that concentrated fat or protein alone will not meet these refueling needs. The suggested amount of calories and the exact balance of fuel types will vary athlete to athlete and sport to sport. Remember that fast food does not make a fast athlete. An extreme example is the nutritional requirements of just one athlete during the 25-kilometer swim, as shown in the picture below.

Hydration

The second basic principle is hydration. Hydration sounds simple, but the explosion of soft drinks and caffeine have made this much more difficult than it should be. The human body is comprised of over 50% water and the effects of the by-products of training build up without sufficient fluid. A simple rule to gauge the adequacy of hydration: the color of urine should be clear by mid-day. If it is not, the athlete needs to take more fluids. 

Sleep

Sleep is the third and final basic principle. As with nutrition, the amount needed also varies somewhat athlete to athlete, but it is incorrect to believe that older athletes need less sleep. Sleep studies indicate that the low end of the requirement is probably 8 hours! The restorative requirements of sleep approach 10 hours in many athletes.

The heavier the training, the more important hydration, sleep and attention to nutrition become. An argument can be made that a significant percentage of “over-trained” athletes are suffering from a combination of lack of quality sleep, dehydration or lack of attention to nutrition. These three basic components also have a tremendous effect on the ability of the athlete to cope psychologically with the demands of training and stresses of performance.

Medical Support

Hopefully, by practicing these basic principles, athletes can avoid injury, illness and fatigue. However, injuries and illnesses may still occur in spite of the basics. To prevent those situations from leading to chronic injury, there is another tenet to be followed: the earlier an illness or injury is addressed, the quicker the recovery and the less training is affected. To accomplish an effective early intervention, the health care practitioner, whether a trainer, massage therapist, physiotherapist or physician; need to become a partner with the athlete and coach. Athletes and coaches come to those whom they trust much more quickly than those who are unfamiliar to them. So it makes sense that continuity and ongoing communication is critical to successfully getting athletes to come in early for any injury or disease process.

Sport-specific injury prevention is a unique opportunity to complete the task of quality athlete support. Each of the aquatic sports has unique needs and injuries that are problematic for the athletes. The injuries can be overuse or traumatic in nature. Dry land programs designed for each sport to meet these needs and decrease injury rate. As an example, survey data from the FINA World Championships in Rome shows that shoulder injuries are the most prevalent problems facing most aquatic athletes. To expand upon this further, other research indicates that as many as 85% of all swimmers have a shoulder injury some time in their careers to the point that there is time lost from training or performance is affected. 

 
Taking this concept one step further, it makes sense that the medical experts review the characteristics of each sport that lead to injury prevalence. Once those characteristics are identified, the challenge is to design exercises to decrease the injury rate and improve performance. The key to success will be to design a preventative program that is simple and takes little time to perform. If designed correctly, entry-level athletes would start with prevention programs and carry them throughout their competitive careers. 

An Example

An example from my sports medicine practice highlights the principles I have described as well as approaches to therapy.

A university student who was ranked in the top 10% in his events nationally came to see me. He was expected to qualify for the final heat in at least four events in his university championships. As you would guess, there was a delicate balance between his training, university studies and life. The university held a weekend that featured social events and concerts. The athlete decided that he had been training hard for many months and was entitled to a weekend with his friends. He felt that he had not really been able to enjoy his university experience due to the heavy demands that he faced daily. Since there was only one Saturday practice, he went out with his friends on Friday night, missed Saturday practice, and stayed out late into the night on Saturday. Between Friday and Saturday nights he got a total of 9 hours sleep. His diet was far from ideal during these two days. He caught up on his studies on Sunday, got 6 hours of sleep and went to Monday morning training. He felt tired and this feeling worsened as the practice continued. Each day was worse and worse. By the end of two weeks, he came to see me to ask what was happening to him. 

He underwent an extensive history (including the facts you see above) and a physical examination. Laboratory studies were performed to look for anemia, metabolic deficiencies and chemical markers to suggest an overtraining state. His history showed poor sleep patterns had developed with the failing performances and heightened anxiety. His resting heart rates were higher than expected and his response to exercise showed a disproportionately high heart rate for even warm-up. An echocardiogram was performed due to his heighted heart rate combined with sudden onset of fatigue. The echocardiogram and EKG heart tracing were normal. Everything was negative except for his markers for overtraining. His coach kept records of his training. There had been no sudden change in his training routine. The conclusion was that his weekend of fun had taken a highly trained athlete who was barely in balance and tossed him physically into an over-trained state. Was he really over-trained? He was actually out of balance with his physical demands. He was under-rested, under-hydrated, and his nutrition had suffered significantly, even though only for a brief time.

The treatment consisted of a very regimented program of rest, hydration, nutrition (in and out of practice), as well as a training program that allowed him to refuel between demand sets and clear his training byproducts. The trainers kept meticulous records of his resting heart rates and recovery heart rates as well as his hydration and his scholastic performances. The scholastic records served as one more measure of concentration and focus. His swimming performances were easy to monitor. He completely recovered 6 weeks later and went on to have a great season, surpassing his pre-season expectations.  

In summary, both illnesses and injuries can become chronic if not addressed early. Prevention is the best medicine both as far as expense and time lost to the athlete. Without attention to the basics, the success of the athlete is in jeopardy. Identification of medical practitioners who understand your aquatic discipline and with whom the athletes are comfortable is a key step to helping athletes seek treatment early. 

Key Points

- Prevention is the best “treatment” for chronic injuries. Prevention - especially during times of high training stress - can be accomplished by following basic principles:

Nutrition - the body should be re-fueled both during training and immediately after training.
Hydration - proper hydration allows the body to maintain the proper level of fluids to counteract by-products of training.
Sleep - Sufficiently restorative sleep is necessary to allow the athlete to recover from training and to be sharp mentally and physically.

- Early recognition of illness and injury - the early stages of any medical problem is easier to correct than the more advanced stages.

- Sport specific injury prevention - each aquatic sport is unique, requiring design of exercises to address injury prevention. These exercises need to be simple and take little time to complete at all levels of ability


*Jim Miller, MD
Family Practice, Sports Medicine
Associate Clinical Professor University of Virginia, Virginia Commonwealth University
FINA Sports Medicine Committee
Chair, FINA World Sports Medicine Congress 2004
National Team Physician, USA Swimming
President, United States Masters Swimming 2001-2005

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