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Objective: The shoulder is the most common injury in swimming, followed by the knee and spine. The repetitive nature of swimming training may predispose a swimmer to injury. Several risk factors have been previously identified, but the level of evidence and level of certainty that these risk factors predispose a swimmer to injury risk has yet to be evaluated critically in a systematic review., Design: Systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines., Data Sources: Data were obtained through PubMed, Cochrane, and Google Scholar. The database search was limited to articles that were published between January 1980 and December 2019., Eligibility Criteria for Selecting Studies: Level I, II, and III studies were included in this review. All studies must have been conducted in swimmers or swimming, a description of the specific pathology and provide at least one identified risk factor with an association (P < 0.05)., Results: A total of 19 critically appraised articles identified 28 potential risk factors for musculoskeletal injuries in swimmers. The risk factors were grouped by the anatomical region: neck and back, pelvis and hip, and the knee. Only 2 risk factors were appraised at a moderate level of certainty, both occurring in the knee. The remaining 26 identified risk factors were appraised at a low level of certainty. There is a clear lack of research surrounding nonshoulder injuries in swimmers., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Reported here is a 20-year-old male suffered a hamstring strain after a prolonged bout of swimming. After ultrasound imaging, the patient's injury was considered to be the result of nearby osteochondromas. Case reports have been previously published concerning anterior cruciate ligament injury, rotator cuff tears, subacromial impingement, or femoroacetabular impingement in multiple osteochondromatosis. However, to the best of our knowledge, this is the first reported case of a hamstring injury secondary to an osteochondroma.

Objective: To examine male-female differences in pediatric overuse sports injuries., Study Design: Cross-sectional epidemiological study., Setting: Tertiary level sports medicine division in a large academic pediatric medical center., Participants: Five percent probability sample of patients 5 to 17 years seen from January 1, 2000 to December 31, 2009. About 3813 charts reviewed. Final study cohort included 1614 patients., Intervention: Nonlinear decomposition analysis of male-female differences in overuse injuries., Main Outcome Measures: Age, body mass index, history of previous injury, and activity type (contact/collision, team vs individual, "high overuse")., Results: Females sustained approximately half of the total injuries. Fifty-two percent of the injuries were overuse, 61% to the lower extremity. A high proportion of tennis players, swimmers, dancers, track athletes, runners, gymnasts, and cheerleaders were seen for overuse injuries. Females sustained more overuse injuries versus males (63% and 40%, respectively). Males playing team sports have a 5.3 times higher likelihood of being seen for an overuse injury compared with males not playing team sports (P < 0.01). High-overuse sport participation increased overuse injury odds by a factor of 10 for males versus 3.6 for females (P ≤ 0.01 for males and females). Forty-six percent of the male-female difference in overuse injuries could be attributed to sport/activity characteristics-contact/collision, team, and high overuse., Conclusions: A large proportion of the sex discrepancy in overuse injuries in this cohort was attributed to compositional differences in sports played. Future research is needed to investigate the independent effect of sex on risk for pediatric sports injuries., Clinical Relevance: This study provides a unique analysis of male-female differences in pediatric sports injuries and is the first study to estimate the impact of the different characteristics (ie, collision, team, high overuse) of sports children play on overuse injuries sustained by young athletes. The findings will help guide future prevention efforts.

Objective: The objective of this study is to describe the practice habits, injury frequency, and attitudes and behaviors concerning shoulder pain in high school-aged competitive swimmers and describe the relationship between attitudes and behaviors., Design: Cross-sectional research design., Setting: Local swimming clubs., Participants: One hundred two swimmers, aged 13-18 years, at the top training level of their club team were included in the study., Assessment of Risk Factors: Participants were given a survey with questions regarding swimming practice and attitudes and behaviors concerning shoulder pain., Main Outcome Measures: Practice habits (yards/week, practice/week, dry-land and weight/week, and months swimming/year) and attitudes and behaviors concerning shoulder pain., Results: Subjects completed an average of 6.89 ± 1.41 swimming practices/wk of 6000 to 7000 yd/practice. The majority of swimmers believe that mild and moderate shoulder pain is normal in swimming and should be tolerated to complete practice, while a majority responded that they swim with shoulder pain. Seventy-three percent of swimmers reported using pain medication to manage their shoulder pain. There was a significant correlation between attitude and behaviors of moderate and severe shoulder pain., Conclusions: Club swimmers have a high frequency of practices, comparable to collegiate and professional swimmers. They believe that shoulder pain is normal and should be tolerated to complete practice. The association between the swimmers' attitudes and behaviors indicates that the interventions that educate the swimmers, coaches, and parents may be effective in changing their attitudes and ultimately their behaviors, decreasing the number of athletes who train with shoulder pain.

Objective: To explore stakeholder perceptions of triathlon competition safety and injury risk., Design: Qualitative focus group study., Setting: Triathlon stakeholders from Melbourne, Australia., Participants: Competition organizers, coaches, and competitors of various skill levels, age, gender, and experience (n = 18)., Interventions: Focus groups were conducted, recorded, and transcribed for analysis., Main Outcome Measures: Key themes were identified using content analysis., Results: The perceived risk of serious injury was highest for cycling. Running was most commonly linked to minor injuries. Physical and environmental factors, including course turning points, funneling of competitors into narrow sections, and the weather, were perceived as contributing to injury. Experience, skill level, feelings of vulnerability, personal awareness, club culture, and gender issues were perceived as the competitor-related factors potentially contributing to injury. The cycling mount/dismount area, cycling, and swim legs were the race sections perceived as the riskiest for competitors. Competition organizers were considered to generally have the competitors' best interest as a priority. Triathlons were acknowledged as risky activities and individual competitors accepted this risk., Conclusions: This study has highlighted the main risks and concerns perceived by triathlon competitors, coaches, and competition organizers, which will help identify potential, context-relevant intervention strategies to reduce injury risk.

The Kona Ironman Triathlon is one of the most difficult endurance races in the world. The medical director of this race has summarized his experience in managing the injuries that these triathletes suffer. The heat, strong winds, and overall length of the event present unique injuries in swimming, cycling, and running. These injuries and their management have evolved over the years, and the change in their treatment is discussed.

Most triathlon overuse injuries occur due to the running and cycling aspects of the sport. By nature of swimming being a non-weight-bearing sport, triathletes have a tendency to use swimming for rehabilitation and recovery. Swimming has a significantly lower injury rate than the other 2 disciplines in a triathlon. Most triathletes use the freestyle stroke, because it is typically the first stroke learned, it is for many the fastest stroke, and by lifting the head the freestyle stroke allows triathletes to sight their direction, which is important in open water swimming. During the freestyle stroke, the shoulder undergoes repetitive overhead motion, and shoulder pain is the most common and well-documented site of musculoskeletal pain in competitive swimmers. It is felt that the pathologic process is attributable to repetitive overhead motion causing microtrauma in the shoulder from either mechanical impingement or generalized laxity or both. Without sufficient rest and recovery, the development of inflammation and pain may result. Depending on the age of the triathlete and the exact etiology of the shoulder pain, treatment options range from nonsurgical to surgical in nature.

The sport of triathlon offers athletes the chance to build and/or maintain cardiovascular fitness across 3 endurance disciplines. Swimming, biking, and running each have a host of overuse injuries that can occur as a result of overtraining. High running mileage, a history of previous injury, inadequate warm up or cool down, and an increase in the years of triathlon experience are a few of the factors that have been linked to triathlon overuse injuries. Early identification of overtraining symptoms and a corresponding reallocation of balance between each discipline, perhaps with an emphasis on increasing swimming, may help prevent many overuse injuries.

Objective: To (1) classify types and severity of injuries, (2) establish a temporal model for both the incidence and prevalence of injuries, and (3) identify the most appropriate medical manpower needed for nonelite triathlon competition., Design: Prospective observational study., Setting: Oklahoma City Redman Triathlon., Participants: One hundred four triathletes seeking medical care (575 race starters)., Main Outcome Measures: Prevalence and diagnoses of athletes seeking medical care, 15-minute injury incidence reports with severity classification, and duration of treatment., Results: The prevalence of injuries sustained was 37.7% and 10.8% in the Ironman and half Ironman events, respectively. 72.2% of half Ironman injuries were sustained during hours 6 and 7, with a presentation rate of 78 per 1000 race starters during this time interval. The Ironman had a much higher rate of severe injuries at 38.2% ± 6.0% (95% confidence interval) and a longer average duration of treatment culminating in hour 14 at 62.3 minutes., Conclusions: Triathlon medical support should be modified to fit the temporal flow of injuries sustained throughout nonelite Ironman events. Previous studies have made recommendations from data collected from elite competitions that may not be ideal for nonelite races due to the higher rate of injuries, injury severity, and longer duration competition. Therefore, we recommend increasing support by 20% during the latter stages of triathlons, starting at hour 14, to 3 physicians and 9 nurses and other medical volunteers per 100 competitors. Further research into the implementation of these strategies should be performed before these data should be applied as common practice.

Shoulder pain is the most common musculoskeletal complaint in competitive swimmers. Problems with the shoulders of swimmers resemble that of the disabled thrower's shoulder, but the clinical findings and associated dysfunctions are not quite the same. Therefore, swimmers with shoulder pain should be evaluated and treated as a separate clinical entity, aimed toward underlying pathology and dysfunction. Balanced strength training of the rotator cuff, improvement of core stability, and correction of scapular dysfunction is central in treatment and prevention. Technical and training mistakes are still a major cause of shoulder pain, and intervention studies that focus on this are desirable. Imaging modalities rarely help clarify the diagnosis, their main role being exclusion of other pathology. If nonoperative treatment fails, an arthroscopy with debridement, repair, or reduction of capsular hyperlaxity is indicated. The return rate and performance after surgery is low, except in cases where minor glenohumeral instability is predominant. Overall, the evidence for clinical presentation and management of swimmer's shoulder pain is sparse. Preliminary results of an intervention study show that scapular dyskinesis can be prevented in some swimmers. This may lead to a reduction of swimmer's shoulder problems in the future.

Objective: The objective of this study was to determine whether sodium supplementation 1) influences changes in body weight, serum sodium [Na], and plasma volume (PV), and 2) prevents hyponatremia in Ironman triathletes., Setting: The study was carried out at the South African Ironman triathlon., Participants: Thirty-eight athletes competing in the triathlon were given salt tablets to ingest during the race. Data collected from these athletes [salt intake group (SI)] were compared with data from athletes not given salt [no salt group (NS)]., Interventions: Salt tablets were given to the SI group to provide approximately 700 mg/h of sodium., Main Outcome Measurements: Serum sodium, hemoglobin, and hematocrit were measured at race registration and after the race. Weights were measured before and after the race. Members of SI were retrospectively matched to subjects in NS for 1) weight change and 2) pre-race [Na]., Results: The SI group developed a 3.3-kg weight loss (p < 0.0001) and significantly increased their [Na] (delta[Na] 1.52 mmol/L; p = 0.005). When matched for weight change during the race, SI increased their [Na] compared with NS (mean 1.52 versus 0.04 mmol/L), but this did not reach statistical significance (p = 0.08). When matched for pre-race [Na], SI had a significantly smaller percent body weight loss than NS (-4.3% versus -5.1%; p = 0.04). There was no significant difference in the increase of [Na] in both groups (1.57 versus 0.84 mmol/L). PV increased equally in both groups. None of the subjects finished the race with [Na] < 135 mmol/L., Conclusions: Sodium ingestion was associated with a decrease in the extent of weight loss during the race. There was no evidence that sodium ingestion significantly influenced changes in [Na] or PV more than fluid replacement alone in the Ironman triathletes in this study. Sodium supplementation was not necessary to prevent the development of hyponatremia in these athletes who lost weight, indicating that they had only partially replaced their fluid and other losses during the Ironman triathlon.

Objective: To evaluate a method of medical care at an ultradistance triathlon, with the aim of reducing the incidence of hyponatremia., Design: Descriptive research., Setting: New Zealand Ironman triathlon (3.8 km swim, 180 km cycle, 42.2 km run)., Participants: 117 of 134 athletes seeking medical care after the triathlon (involving 650 race starters)., Interventions: A prerace education program on appropriate fluid intake was undertaken. The number of support stations was decreased to reduce the availability of fluid. A body weight measurement before the race was introduced as a compulsory requirement, so that weight change during the race could be included in the triage assessment. An on-site laboratory was established within the race medical tent., Main Outcome Measures: Numbers of athletes and diagnoses, including the incidence of symptomatic hyponatremia (defined as symptoms of hyponatremia in association with a pretreatment plasma sodium concentration [Na] < 135 mmol/L); weight changes; and changes in [Na]., Results: The common diagnoses in the 117 athletes receiving attention were exercise-associated collapse (27%), musculoskeletal complaints (26%), and dehydration (12%). There was a significant reduction in the number of athletes receiving medical care for hyponatremia, from 25 of the 114 athletes who received care in 1997 (3.8% of race starters) to 4 of the 117 athletes who received care in 1998 (0.6% of race starters). Mean weight change among athletes in the 1998 race was -3.1 kg, compared with -2.6 kg in 1997., Conclusion: A preventive strategy to decrease the incidence of hyponatremia, including education on fluid intake and appropriate placement of support stations, was associated with a decrease in the incidence of symptomatic hyponatremia.

Objective: To identify and compare the nature and frequency of training and cross-training injuries incurred by members of a women's collegiate swim team., Design: A longitudinal survey of training-room and medical records for 7 years, classifying injuries by diagnosis and time lost from participation., Setting: Division I women's collegiate swimming program, United States., Participants: All swimmers in a Division I women's collegiate swimming program over 7 years, for a total of 68 swimmers. ASSESSMENT OF RISK FACTOR: Not applicable., Intervention: Not applicable., Main Outcome Measures: "Injury" was defined as any contact with a trainer or physician that resulted in evaluation or treatment. Each injury was categorized with respect to (a) activity during which injury was incurred; (b) diagnosis, including body part injured; (c) time lost from participation in practice or competition; and (d) severity, i.e., minor (< or = 7 days), moderate (7-21 days), and major (> 21 days). An "Exposure" was defined as participation in one practice session or competition., Main Results: The overall injury rate per 1,000 exposures per athlete was 2.12; 44% of injuries were due to swimming, 44% to cross training, and 11% to activities unrelated to athletics. Cross-training injuries occurred primarily in the lower extremities, while swimming injuries occurred more commonly in the upper extremities. The ratio of upper to lower extremity injuries due to swimming was 3:1, whereas the ratio for cross training was 1:4., Conclusions: Injuries to swimmers occur at a lower rate per exposure than to other collegiate athletic populations. Swimming injuries occurred primarily in the upper extremities, especially the shoulder. Lower extremity injuries occurred primarily due to cross training. We conclude that swimming is relatively safe compared to other collegiate sports, but special care should be used in designing injury-avoiding cross-training programs.

Objective: To investigate whether glenohumeral joint (GHJ) hyperlaxity is related to swimming training volume, we evaluated elite and recreational swimmers for differences in GHJ laxity and general joint hypermobility (GJH)., Participants: Thirty male and female elite swimmers, aged 15-25 years, were compared with 30 recreational swimmers on five clinical GHJ laxity tests. GJH was assessed based on evaluation of hypermobility in four other joints or joint combinations., Outcome Measures: Group differences in both GHJ laxity and GJH were analyzed using chi 2 analysis., Results: Compared with the recreational swimmers, the elite swimmers demonstrated significantly greater GJH, as well as significantly greater GHJ laxity on three of five laxity tests. The specific patterns of greater GHJ laxity demonstrated by the elite swimmers versus the recreational swimmers favour an acquired origin for these laxity differences, while the results of the GJH assessment suggest that these laxity differences are inherent., Conclusions: It was concluded that a combination of acquired and inherent factors contributes to the greater GHJ laxity demonstrated in elite swimmers. We discuss the implications of this study for the prevention of shoulder overuse dysfunction (SOD) in elite swimmers.

We present a case of two consecutive stress fractures in a female swimmer. The diagnosis of the present stress fracture of the ninth rib was based on clinical history and examination and on a new fracture line and callus formation seen in consequent conventional radiographs. Based on the clinical history and radiography, the patient had suffered another rib stress fracture in the fifth rib 15 months earlier. No external trauma had preceded either of the fractures, and no secondary cause of stress fracture was found. Her anatomical and biomechanical characteristics and training errors seem to have been responsible for the stress fractures. Sports physicians should be aware of rib stress fractures. With prompt diagnosis the rest period is short.

The need to investigate shoulder injury in swimmers other than the young and elite is evident, as all ages and levels are represented in the 100 million Americans who classify themselves as swimmers. To investigate the differences between young, highly competitive collegiate swimmers and older, less elite swimmers, a survey questionnaire was distributed to 100 collegiate and 100 master's swim teams. Questions regarding swimming routines, performance standards, and several possible predisposing factors associated with "swimmer's shoulder," as implicated in the literature, were investigated. As expected, the results revealed that the collegiate group swam the higher yardage, with considerably faster times in both the 50- and the 1,000-yd freestyle, and more than double the number of workouts per week. However, the collegiate and master's group reported similar percentages, 47 and 48%, respectively, experiencing shoulder pain lasting 3 weeks or more, despite the lesser distances and intensities associated with the latter group. Chi-square analysis revealed no association between shoulder pain and perceived level of flexibility, hand paddle usage, or breathing side for either group. However, over 50% of the swimmers with shoulder pain in both groups perceived that increased intensities and/or distance provoked shoulder pain, indicating that fatigue may be the issue to avoid and on which to focus. Strengthening the muscles of the shoulder, specifically those shown to have a propensity to fatigue, provides a strong defense against injury, as fatigue of the shoulder muscles may be the initial antecedent to swimmer's shoulder. These results give the swimmer, coach, and medical practitioner feedback to consider for a swimmer of any age or level.

An unusual case of acute axillary vein compression secondary to hypertrophy and intramuscular edema of the subscapularis muscle is described in a competitive swimmer. The signs and symptoms of this condition are similar to those of axillary vein thrombosis, including nonedematous swelling, discoloration, pain, and prominent cutaneous veins of the involved upper limb. Early recognition and diagnosis by means of venography are important to distinguish the condition from axillary vein thrombosis and to alert the practitioner to the potential of future axillary vein thrombosis in such a case. The treatment is primarily conservative.