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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.

FINA Soprts Medicine Committee

Sports Medicine Congress



Knee problems in Aquatics

For the aquatic athlete, knee problems can seriously interfere with training and competing. In this article, the different types of knee pain are discussed as well as the predisposing factors. The many causes & mechanisms are reviewed. The signs & symptoms are described and various treatment options to facilitate recovery are outlined. Prevention strategies that can be utilized to decrease the occurrence of knee problems in the aquatic athlete are also discussed.

Maybe you have heard that when somebody suffers from knee pain, their doctor will advise him/her to exercise in the water for their rehabilitation. It may be a bit surprising for people to learn that some swimmers, water polo players and synchronized swimmers have knee problems resulting from their sport.

Knee pain in aquatic athletes has several causes. It is more common in breaststroke swimmers and as a result of this frequency, is often termed BREAST STROKER'S KNEE. Aquatic athletes that use the eggbeater kick are also at risk for developing knee problems as a result. There many causes of knee pain in the aquatic athlete will be discussed below.

Frequency in Aquatic Sports

By far, the majority of swimmers have no problem with their knees. Twenty five percent of all aquatic athletes will have knee pain at some time during their competitive career. It is well known that knee problems are more common in breaststroke swimmers, water polo players and synchronized swimmers. The majority (86%) of breaststroke swimmers will have experienced knee pain at one point in their career and 47.2% of them will have had this problem at least one time every week.

Predisposing Factors

It is more common to see knee problems in the older athlete than in the younger athlete. The longer the competitive career, the more likely that knee pain will develop. Likewise, the longer the distance trained predisposes to the development of knee pain. All of these three factors suggest a chronic overuse origin to the knee pain. Training errors such as inadequate warm up is another predisposing factor. Strength and flexibility imbalance in the abductor and adductor muscle groups of the hip also predispose the athlete to knee pain.

The predisposing factors for the development of knee pain in aquatic athletes are outlined in Table 1 below.

Table 1 - Predisposing Factors

Increasing age of the athlete
Increasing length of competitive career
Increasing length of event
Inadequate warm up
Strength imbalance of hip abductors/adductors
Flexibility imbalance of hip abductors/adductors

Causes and Mechanisms

There are several causes and mechanisms of knee pain in aquatic sports. The following list reviews many of the possible causes:

1. Chondromalacia (irritation of the cartilage under the patella) and patellofemoral pain often due to the dolphin kick.

2. Medial Patella stress because of:

• Technique errors:

- At the time of hip and knee flexion, keeping both of lower extremities very far from each other.
- Extreme flexion of hip joint in recovery phase of whip kicking.
- Upward flexion ankle and leg external rotation at the time of knee and hip flexion.
- Abduction of both hip joints at the end of push up phase of whip kick in breaststroke.
- Not bringing legs close together at the end of kicking.

• Deviation of patella to lateral side due to anatomical problems.

3. Medial Collateral Ligament Sprain that is often made by overuse and repeated valgus stress on the knee (position in whip kick and eggbeater)

4. Medial Synovial Plica Syndrome where the synovial membrane of the knee wrinkles and folds causing knee pain.

5. Pes anserinus Tendinopathy and Bursitis. The pes anserinus is the combined tendinous insertion of 3 muscles at their attachment to the shinbone. The bursa lies between this insertion and the bone which as result of overuse may become inflamed.

6. Patellar Tendonitis or inflammation of the tendon of the patella (knee cap).

7. Medial Meniscus (internal cartilage) problems such as tears and degenerative changes or cysts.

8. Osteoarthritis of the medial compartment of the knee

Signs and Symptoms

The breaststroker’s knee pain is typically located in the medial side of knee. Lateral knee pain is rarely seen in aquatic athletes. The pain becomes more apparent in stress valgus position which is the position of the knee when in the whip kick and eggbeater kick. The location of pain can be different depending on the specific cause as outlined above. Swelling is not a common symptom.

Prevention

Prevention of knee pain is preferable to prevent time lost from injury. There are several effective preventative strategies that can be instituted by the coach to prevent the development of knee pain. These strategies should be incorporated into the training program throughout the training cycle to reduce the risk of knee pain. Various prevention strategies are outlined in Table 2.

Table 2 - Prevention Strategies

Balanced training program
Gradual and progressive build up of breaststroke distance
Prevention of over-use
Correct kick biomechanics
Balance in strength of hip and knee musculature
Adequate warm-up
Provision for adequate recovery
Well-designed strength & stretching program

Treatment

Relative Rest

The treatment of knee pain in swimmers is easier than shoulder pain. As with all sport injuries, treatment should include the protection of the injured part from subsequent injury. This does not mean complete cessation of athletic training. The term “relative rest” refers to resting the affected injured joint while maintaining fitness and strength in the rest of the body. Relative rest as be prescribed by the team physician in the treatment of knee pain may include the following:

- reducing the length of breaststroke/eggbeater training
- reducing the intensity of  training
- cross training with other strokes to reduce valgus stress on knee
- cross training with other sports for cardiovascular fitness such as cycling

Stroke Correction

Correction of the breaststroker’s technique is an important part of the treatment of knee pain. The breaststroke swimmer should be instructed to keep the knee in the alignment with the hip allowing the knees to separate only to the width of the hips. This will decrease the lever arm toward a valgus stress at the knee as the legs are brought toward midline.

Other Treatment Options

The application of ice (15 minutes every 3 hours) for the first few days to help reduce swelling may be prescribed. Elevation of the injured limb is also useful for the treatment of knee swelling. Strengthening and stretching exercise of the surrounding knee soft tissues in combination with the other physiotherapy modalities have an important role in treatment. The team physician may prescribe a knee brace. Sometimes physicians use corticosteroid injection as an adjunct treatment if indicated. (Please note the Therapeutic Use Exemption requirements in the case of intra-articular steroid injection.) Surgical intervention is rarely required. Table 3 summarizes these treatment options.

Table 3 - Treatment options for Aquatic knee pain

Icing
Elevation of limb
Strengthening
Stretching
Physiotherapy
Knee brace
Cortisone injection
Surgical Intervention is rarely needed

Return to Sport

It is important that the athlete returns to full training only when adequate recovery has occurred. Returning too early to full training may result in the return of symptoms requiring more treatment and time away from active training.

Returning to sport is possible when the swimmer can flex and extend the knee pain-free. It is also important that the injured knee is no longer swollen and that pain or tenderness does not occur while hopping on the affected leg.

Returning the swimmer to breaststroke should include the minimization of breaststroke distance by cross training with other strokes. Adequate warm up is essential. A training program of gradual and step-wise increases in training distance should be designed in co-operation with the team physician and the coach. All swimming distances should be pain-free.     

Conclusion

Knee pain may be found in swimmers, water polo players and synchronized swimmers. In swimmers, it is most common in breaststrokers. Although most aquatic athletes will not have knee problems, knee pain may occur with increasing competitive career and distance. This article summarizes the common causes, signs & symptoms, prevention strategies and treatment options.

Key Points

• knee pain in the aquatic athlete occurs in swimming, water polo & synchronized swimming

• breaststrokers are more likely to have knee pain

• there are many causes of knee pain in the swimmer

• prevention strategies are successful in decreasing knee pain

• there are many treatment options for knee pain

• a graduated return to sport is recommended

References:

1. H.Fu, Freddie. A. Stone, David. : SPORTS INJURIES .2nd Edition, 2001 by LIPPINCOTT WILLIAMS &WILKINS. Philadelphia, USA.
2. Shamus, Eric. Shamus, Jennifer. Sports Injury Prevention and Rehabilitation.1st Edition, 2002 by Mc Graw- Hill. Australia
3. Brukner, Peter. Khan, Karim : CLINICAL SPORTS MEDICINE .2nd Edition, 2001 by Mc Graw- Hill. Australia
4. Huston, Michael. : SPORTS INJURIES recognition & management.3rd Edition, 2001 by Oxford University press. G.B.
5. Mellion, Morris. Et al: TEAM PHYSICIAN’S HANDBOOK. 3rd Edition, 2002 by Hanley & Belfus Inc. Philadelphia, USA.
6. Prentice, William E.: Arnheim’s principles of Athletic Training. 11th Edition, 2003 by Mc Graw- Hill. USA.

Internet Resources:

1.  www.physsportmed.com
2.  www.medformation.com
3.  www.sportmed.buffalo.edu
4.  www.gsv1.de
5.  www.ncbi.nlm.nih.gov
6.  www.ajsm.org

*Dr. Farhad Moradi is a member of the FINA Sports Medicine Committee. He is a Sports Medicine Physician from Iran. He also practices Emergency Medicine. He is a swimming judge.

Ask the Doc

Swim Coach: My athlete is having a cortisone injection in their knee by the team doctor. What forms should the doctor complete for anti-doping purposes?

This is a good question!  I encourage you to refer to the FINA website (www.fina.org) where you can find the 2007 Prohibited List.  In the section entitled “Substances & Methods Prohibited in-competition” you will find # S9 (Glucocorticosteroids). This point states that “…other routes of administration (intraarticular….) require an Abbreviated Therapeutic Use Exemption…” The abbreviated Therapeutic Use Exemption document can be downloaded from the FINA website and taken by the athlete to the doctor for completion. This completed document should then be forwarded immediately to the FINA office.

Synchro Coach: My swimmer has been diagnosed with patellar femoral syndrome in her knees. I notice that when she walks on the deck, her foot prints show that her feet are flat compared to her team mates. Is this important?

Yes! Very good observation! This flattening of her feet and the ‘rolling in’ while walking may very well have an influence on the knee cap (patella). Her doctor may prescribe orthotics or shoe inserts to provide support to her foot arch and correct the biomechanics of the lower leg. This will help in the healing of the knee problem and prevent recurrence.

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