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This paper will look at low back pain and disc disease in the elite athlete swimmer. It will show that the higher the intensity, duration and the distance that an athlete swims, the greater the risk for lumbar disc disease. Since such injuries can not only cause pain, impair performance and end careers, one must use a multidisciplinary health team when facing the low back injury in the aquatic sports. It is imperative to remember that to maintain a healthy back in the aquatic sports and prevent injury, one must do regular strength and flexibility exercises, as well as maintain good cardiovascular health.
As seen in the injury study conducted during the 13th FINA World Championships in Rome 2009, low back, shoulder and knee pain are the most common physical injuries seen in competitive swimmers. Although several studies have reported an increase in low back pain with increasing physical work in competitive sport activities, until recently there has been no specific studies in elite competitive swimmers. Recently, there has been research looking at the relationship between swimming at the elite level and low back pain and lower back injuries conducted in Japan by the Japanese aquatic medical staff.
The spine or backbone is made of thirty three individual bony vertebrae (see figure below). This spinal column provides the main support for the body, allowing one to stand upright, bend, and twist, while protecting the spinal cord, which lies within the boney external structure, from injury. A healthy spine provides strength, is flexible, and allows movement in several planes. Strong bones and muscles, flexible tendons and ligaments, and sensitive nerves contribute to a healthy spine. Yet, any of these structures affected by strain, injury, or disease can cause pain and subsequently interfere with training and performance.Spinal Column with Vertebrae - Oregon Health and Science UniversityThe Lumbar area of the spine (and other areas of the spine) is made up of two parts, including the following:
- Vertebral bodies - the parts that are made of bone.
- Inter-vertebral discs - also known as the discs; the discs are located between the bony parts of the spine and act as "shock absorbers" for the spine.
Oregon Health and Science University
Lower back pain is often caused by lumbar disc disease. What is lumbar disc disease (herniated disc, ruptured disc or bulging disc)? As we age, the inter-vertebral disc may lose water and become dried out. As this happens, the disc compresses. This may lead to the deterioration of the tough outer ring allowing the nucleus, or the inside of the ring, to bulge out. This is considered a bulging disc. There have been several factors proposed for lower back pain and degenerative disc disease, which occurs in the area of the lumbar vertebrae and the sacrum of the spinal column. Proposed risk factors include normal aging, obesity, genetic factors and excessive sports activities with loading to the back in an arched or extended position as seen in diving, synchronised swimming and swimming.
Lower back pain in elite competitive swimmers, can also be caused by overuse syndromes. The term overuse syndrome identifies a large group of conditions that result from using the body in a repetitious way and causing injury by the amount it is done. These conditions are often focused on a joint and usually affect the muscle, bone, tendon or bursa (a small fluid-filled sac which provides a cushion between bones and tendons and/or muscles) of the joint. Usually this pain can be well controlled during competition by decreasing training quantity before the race and appropriate medical support. On the other hand, lower back pain in swimmers caused by lumbar disc disease, which can also cause leg pains, is often difficult to control and can affect competitive performance.
FINA World Championships 2009 in Rome (ITA)
In 2001, the Japanese Institute of Sport Sciences (JISS) was established. A screening study in elite competitive swimmers was completed examining lower back pain and lumbar degenerative disc disease. Two groups of swimmers were used in the study. The first group was elite swimmers, both male and female, that were selected for National Japanese training camps, held at JISS between 2001 and 2002. The second group belonged to a recreational swim club. Both groups included both male and female athletes. Athletes completed a questionnaire that collected information regarding swimming strokes (freestyle, backstroke, breaststroke, butterfly stroke and individual medley) as well as their history of lower back pain and intensity of activity both inside and outside of the pool. Imaging studies were then conducted to look at the spinal column for lumbar spinal disease.
Results showed no significant difference between gender, type of swimming stroke nor self reported low back pain and significant disease of the lower back on medical imaging. Swimmers from the recreational swimming group showed no difference in lower back disease then that of the average population. What was notable in the study was that swimmers from the elite swimming group had significantly higher lumbar disc disease then that of the recreational swimming group. Swimmers in the elite swimming group had a much higher intensity, duration and distance of swimming during practice sessions. Thus, the amount of work and therefore stress on the back was greater for the elite swimmers then for the recreational swimmers. It was also found that the lumbar inter-vertebral disc degeneration (lumbar disc disease) was especially exaggerated at the L5-S1 segment level (see figure below).
The high level of lower back disc disease at the L5-S1 area is occurring at the junction between the lumbar spine and the pelvis. Therefore, it would seem logical that a specific motion occurs during competitive swimming, which causes mechanical stresses. If swimming distance or duration is excessive, such stresses might lead to lower back and leg pain, or lumbar disc disease. Influences such as weight training or dry land training exercises were not included in this study and thus further investigation is needed.
What can we learn from this study?
It is evident that the elite swimmer is at risk for lumbar disc disease most likely due to the repetitive strain from prolonged swimming. It is apparent that prevention exercises and strengthening should occur to prevent the occurrence of this problem. In addition, attention should be placed on evaluating stroke biomechanics to identify the action causing the strain on the lumbar spine and measure to change the biomechanics should be instituted. As lumbar disc disease is painful, can impede performance, and in some cases can be career ending, this is an important injury in swimming that requires the attention and collaboration of the sports medicine physician, the sport scientist, the sport physical therapist and the coach.
Which exercises help maintain a healthy back?
Exercises for a healthy back can be divided into three basic groups:
1. Strengthening: repeated muscle contractions until the muscle becomes tired.
2. Stretching or Flexibility: slow, sustained lengthening of the muscle.
3. Aerobic: steady exercise using large muscle groups.
All of these exercises should be performed slowly and comfortably to avoid injury. When performing strengthening and flexibility exercises, remember to breathe naturally and without holding your breath; exhale during exertion and inhale during relaxation.
1. Strengthening exercises
Strengthening exercises help increase muscle tone and improve the quality of muscles. Muscle strength and endurance provide energy and a feeling of wellness to help you perform daily, routine activities. Adequate strength of abdominal and back muscles helps stabilise the spine, allows proper spinal movement and makes it easier to maintain correct posture. Strong deep trunk muscles, core muscles, hip and leg muscles are important to perform proper lifting techniques and body mechanics. Here are some good strengthening exercises:
- Curl Ups-Upper Abdominal: While lying down, tilt your pelvis to flatten your back. Raise your shoulders and head until your shoulder blades clear the floor. Hold for 5-10 seconds, and repeat 10 times.
Curl Ups-Upper Abdominal
- Prone Bridge (Elbow-Toe): Making a prone bridge on their elbows and toes and then horizontally lifting your left (right) arm and right (left) leg. Hold for 30 seconds.
Prone Bridge (Elbow-Toe)
- Back Bridge: Lifted the pelvis in the supine position until 0° of hip flexion was reached and then extended the right or left leg. Hold for 30 seconds.
2. Stretching/flexibility exercises
Flexibility is the ability to move your arms and legs through their full range of motion. Stretching will help improve your flexibility. Adequate flexibility of tissues around the spine and pelvis allows full, normal spinal movement, prevents abnormal force on the joints and decreases the possibility of injury. Stretching also prepares muscles for activity; stretching should be done before and after each vigorous workout to prevent muscle strain and soreness and to help avoid injuries. When performing flexibility exercises, stretch as far as you can and hold the stretch. Each stretching exercise should be performed slowly, with no sudden jerking or bouncing. Bouncing can injure or strain a muscle or joint. Here are some good stretching exercises:
- Lying Down Hamstring Stretch: Lying down with knees bent, raise one leg, and supporting the back of thigh with your hands, attempt to straighten the knee until a comfortable stretch is felt in back of the thigh. Hold for 20-30 seconds, and repeat 2-3 times. Repeat with other leg.
Lying Down Hamstring Strech
- Double Knee to Chest Stretch: Lie on the floor with your back relaxed and straight. Pull both knees toward your chest until you feel a stretch in your lower back, do not bounce. Hold for 5 seconds. Repeat 5 times.
Double Knee to Chest Stretch
- Backward Bend: Bend backward, arching your back as far as you can comfortably. Hold for 5 seconds. Repeat 5 times. This method is not recommended for those athletes who have low back pain when bending backward (such as Spondylolysis).
- Quadriceps Stretch: Bend one leg, bringing your foot behind your thigh, as shown. Tilt your pelvis until a stretch is felt in front of the thigh. Hold for 20-30 seconds. Repeat 2-3 times for each leg. This method is not recommended for those athletes who have medial knee pain or laxity around the knee joint.
3. Aerobic exercises
Aerobic exercise provides cardiovascular conditioning; it strengthens the heart and lungs and improves the body's ability to use oxygen. Some other benefits of aerobic exercise includes increased energy levels, improved mood, better sleep habits and decreased blood pressure. Aerobic exercise also burns calories and improves your metabolism, helping with weight loss. Obviously synchronised swimming, water polo, open water swimming and swimming are excellent aerobic exercises.
This paper has looked at low back pain and disc disease in the elite athlete swimmer. It has shown that the higher the intensity, duration and the distance that an athlete swims, the greater the risk for lumbar disc disease, especially at the L5-S1 segment level. Since such injuries can not only cause pain, impair performance and end careers, one must use a multidisciplinary health team when facing the low back injury. It is imperative to remember that to maintain a healthy back in the aquatic sports; one must do regular strength and flexibility exercises, as well as maintain good cardiovascular health.
Key Points of Article:
1. Low back pain and injuries are common in the elite athlete swimmer.
2. Elite swimmers with a higher intensity, duration and distance of swimming during practice sessions have a higher rate of low back pain and lumbar disc disease, especially at the junction of the lumbar spine and the pelvis.
3. When an aquatic athlete has a low back injury, a multidisciplinary health care team is needed.
4. Strengthening, flexibility and aerobic exercises can help maintain a healthy back and prevent injury.
* Dr. Koji Kaneoka works at Wasada University in the Faculty of Sports Sciences, in Japan. An Orthopedic Surgeon, his major research interests are sports medicine, lumbar stabilisation exercise and spinal surgery. He has been the Team Doctor for the Japanese Swimming Team from 1997 to the present.
* Dr. Saul Marks works at North York General Hospital, University of Toronto in the Faculty of Medicine, in Canada. He has a special interest in Sport Psychiatry and Health and Disease in Psychiatry. He was Team Doctor for the Canadian Diving Team at the 2007 and 2009 FINA World Championships. He is presently the Honorary Secretary of the FINA Sports Medicine Committee.
Acknowledgement: We appreciate Mr. Keisuke Koizumi (Japanese Institute of Sports Sciences), Mr. Ken Terauchi (former Olympic Diver), Dr. Jim Miller (FINA Sports Medicine Committee) and Dr. Margo Mountjoy (FINA Bureau, Liaison for the FINA Sports Medicine Committee) for their kind cooperation.