Training Paralympic Swimmers

Take Home Points on Training Paralympic Swimmers

Paralympic swimming grows in stature with each Olympiad Training modifications may be required based on disability classification Balance and kicking may be affected by individual characteristics

The recent conclusion of the Winter Games signals the fast approach of the 2016 Summer

Games.  While most attention is focused on the “regular” Olympics, the Paralympics conducted shortly after have garnered more attention in recent years.  With greater attention comes greater depth and competition.  Though coaching Paralympic athletes is often more art than science, it is worthy to review what the literature has shown in this area.

Basics

Paralympic classifications are based on various degrees of paralysis, mobility impairment, amputation, visual impairment, and intellectual impairment.  Athletes are placed into classification based on a medical exam, though the category into which an athlete is placed may have implications for placing (more on that below). 

Not surprisingly, different classifications may have different training needs.  Anecdotally, lifestyle demands outside the water are sometimes more difficult to manage than those at the pool, particularly for seasoned athletes who are most at home in an aquatic environment and who may have recently acquired their physical impairment.  Learning to swim in a straight line and having a precise stroke count are both crucial in this population, though tactile warnings are given as the swimmer approaches each wall in the visual classifications.    

Training

Visual classifications range from total blindness to partial blindness and are divided into three categories (S11 for total blindness and S12 and S13 for partial blindess).  In analysis of male and female Paralympic swimmers at the 1996 Summer Games, Malone (2001) noted the following:

• The men showed no significant differences between S12 and S13 in clean swimming speed (CSS), stroke rate (SR), stroke length (SL), and stroke index or between all three classes on SL and SI.
• The S11 swimmers demonstrated a significantly slower total race time and CSS in both events. In the women,
• An increase in class was associated with a decrease in total race time, faster CSS, and increase in SI.
• No differences were observed in SR by gender

Injuries remain a constant for both Paralympic and able bodied swimmers.   Magno e Silva (2013) studied elite Paralympic swimmers and noted that eighteen athletes in their sample of 41 reported injuries in the study period, with clinical incidence of 1.5 injuries per athlete, and an incidence rate of 0.3 injuries per athlete per competition.  Additionally, 

• The highest proportion of injuries was in the trunk (46.34%), followed by the upper limbs (34.15%). The shoulders (29.27%) were most affected, followed by the thoracic (21.95%) and lumbar spine (17.07%). Spasm (36.59%) was the most frequent diagnosis, followed by tendinopathy (26.83%).
• No differences observed by class or gender

Not surprisingly, classification may also affect body position.  In a study of Paralympic swimmers in the entire range of classes, Oh (2013) found a significant correlation between the lowest and highest swimming classes with passive drag: lowest swimming classes experienced highest drag, while highest classes had the least drag.  But also note the differences in passive drag between the middle classes were non-linear, such that some lower classes had reduced drag compared to the adjacent higher class.

Changes to body position may also require kicking modifications to optimize balance.  Though direct comparisons between able bodied and Paralympic swimmers are lacking in the literature, kicking has been studied in detail in the Paralympic population.  In a combined sample of different class Paralympians, Fulton (2009) found, “When peak speed was increased by 5%, the active force increased 24.2 ± 5.3%), while kick rate remained at approximately 150 kicks per minute. Larger amplitude kicking increased the net active force by 25.1, although kick rate decreased substantially by 13.6.”

Conclusion

Though Paralympic swimming has been around for several years, competition seems to have accelerated in the previous Olympic quad.  Fulton (2009) notes from the 2004-2006 meets, that international level swimmers improved an average of 0.5% per year in all levels, while improving one’s standing at the Paralympic games may require a 1-2% annual improvement.  To help facilitate such improvements, coaches must understand and integrate the art and science with these unique populations.   

References

1. Malone LA1, Sanders RH, Schiltz JH, Steadward RD.  Effects of visual impairment on stroke parameters in Paralympic swimmers.  Med Sci Sports Exerc. 2001 Dec;33(12):2098-103.
2. Oh YT1, Burkett B, Osborough C, Formosa D, Payton C.  London 2012 Paralympic swimming: passive drag and the classification system.  Br J Sports Med. 2013 Sep;47(13):838-43. doi: 10.1136/bjsports-2013-092192.
3. Magno e Silva M1, Bilzon J, Duarte E, Gorla J, Vital R.  Sport injuries in elite paralympic swimmers with visual impairment.  J Athl Train. 2013 Jul-Aug;48(4):493-8. doi: 10.4085/1062-6050-48.4.07. Epub 2013 Jun 14.
4. Fulton SK1, Pyne D, Burkett B.  Optimizing kick rate and amplitude for Paralympic swimmers via net force measures.  J Sports Sci. 2011 Feb;29(4):381-7. doi: 10.1080/02640414.2010.536247.
5. Fulton SK1, Pyne D, Hopkins W, Burkett B.  Variability and progression in competitive performance of Paralympic swimmers.  J Sports Sci. 2009 Mar;27(5):535-9. doi: 10.1080/02640410802641418. 

Written by Allan Phillips is a certified strength and conditioning specialist (CSCS) and owner of Pike Athletics. He is also an ASCA Level II coach and USA Triathlon coach. Allan is a co-author of the Troubleshooting System and was selected by Dr. Mullen as an assistant editor of the Swimming Science Research Review. He is currently pursuing a Doctorate in Physical Therapy at US Army-Baylor University.

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Weekly Round-up

Each week we aggregate recent swimming journals and blog posts relating to swimming

biomechanics, physiology, nutrition, psychology, etc. If you wish to add, please add an article in the comments section.

Journal Round-up

1. Disordered Eating and Eating Disorders in Aquatic Sports.
2. The effects of high intensity short rest resistance exercise on muscle damage markers in men and women.
3. Caffeine-Containing Energy Drink Enhances Physical Performance in Male Volleyball Players.
4. Effects of fatigue from resistance training on barbell back squat biomechanics.

Blog Round-up

1. Race Analysis and Video: Emma Reaney 2:04.06 200 SCY Breaststroke NCAA Record
2. Swimmer's Guide to Knee Pain
3. History of Swimming Goggles
4. Female Coaching Opportunities in Swimming
5. Three Elements of 400m Freestyle Strategy
6. The Myth about Children Lifting Weights
7. Sleeping for Performance Enhancement
8. Swimming Streamline
9. A Novel Rehabilitation Program To Improve Patellofemoral Pain Syndrome Outcomes

Swimming Streamline

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Race Analysis and Video: Emma Reaney 2:04.06 200 SCY Breaststroke NCAA Record

First and foremost, this analysis was based off a streaming video, since the race is not downloaded yet [as far as I know], so some hand times were used [which  has inherent errors]. 

For new comers to the website, we have done numerous race and world record analyses, which are purely meant for enjoyment and discussion. Below is the video of Reaney's swim and showdown with former NCAA record holder and Olympian Breeja Larson:

[Thanks to Rhys Brennan on YouTube]

Emma Reaney 2:04.06 200 SCY Breaststroke NCAA Record

Emma Reaney was not well known before breaking the NCAA in this event at her conference championship meet a few weekends ago. As you'll see stroke rate consistency and her pullouts helped her turn in the fastest time every in the 200 breaststroke SCY.

First 50

Emma had an excellent start, gracefully reaching 15-m and taking 4 strokes over the entire lap. These four strokes are an important feature, as she used ~4 strokes from the 15-m mark into the wall for the first 125 yards. Her velocity to 15-m was 1.63 on the second 25, which was consistently faster than her competition. She also had a faster stroke rate than Larson, potentially giving her more speed and her lead at the first 50.

Second 50

Emma extended her lead on the second 50, maintaining a stroke pull out (~1.55 m/s to 15-m) on the 3rd and 4th 25, while maintaining her stroke length and tempo. She held six strokes per lap, with excellent turn timing, as noted in the photo below.

Third 50

Emma extended her lead on the third 50, maintaining 15-m under 10 seconds with her velocity around~1.55 m/s to 15-m [note her 15-m distance compared to Katie Olsen below her]. She continued to maintain her stroke count, as her competitors increased their tempo.

Fourth 50

Over the last 50, Emma began showing signs of fatigue, most notably by a shorter and slower breakout. However, she keep her strong long, keeping her stroke count at 6 strokes per lap. This consistent stroke count gave her excellent timing on her turns.

Swimmer Advice

The swimmer demonstrates excellent swimming stroke count consistency. Emma may benefit from maintaining her pull out distance and velocity on the last two laps. This may be improved with proper "hypoxic" training [more correctly hypercapnic training] training (Friday Interview: Dr. Chia-Hua Kuo and Dr. Futoshi Ogita).

Written by G. John Mullen received his Doctorate in Physical at University of Southern California (USC) and is a certified strength and conditioning specialist (CSCS). At USC, he was a clinical research assistant performing research on adolescent  diabetes, lung adaptations to swimming, and swimming biomechanics. G. John has been featured in Swimming World Magazine, Swimmer Magazine, and the International Society of Swim Coaches Journal. He is currently the owner of COR, providing Physical Therapy, Personal Training, and Swim Lessons to swimmers and athletes of all skills and ages. He is also the creator of the Swimmer's Shoulder System, Swimming Science, Swimming Science Research Review, and the Swimming Troubleshooting System.

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Friday Interview: Sumiaki Maeo Ph.D. Discusses Co-Contractions

1. Please introduce yourself to the readers (how you started in the profession, education, credentials, experience, etc.).

Thank you for your interest in my research. My name is Sumiaki Maeo, and I am a Research Fellow of the Japan Society for the Promotion of Science. I received my BSc (2009), MSc (2011), and PhD (2014) in physical education, with a strong background in exercise physiology, from National Institute of Fitness and Sports in Kanoya, Japan.

My research is mainly focused on adaptation to resistance training. My doctoral dissertation is about the effects of maximal voluntary co-contraction training on neuromuscular function (explained below).

2. You recently published an article on co-contraction training, could you please

explain what this means?

Co-contraction refers to simultaneous voluntary contraction of antagonistic pairs (e.g. elbow flexors and extensors), and it produces resistive forces that act against each other. I recently reported that voluntary co-contraction of elbow flexors and extensors can be an effective form of resistance training modality for improving the muscle strength and size, without any use of external apparatuses.

3. Why are you interested in co-contraction training?

Personally speaking, I have been doing resistance training for more than a decade, and have seen several bodybuilding competitions. I realized at some point that posing, which is considered to be the same physical action as voluntary co-contraction and what bodybuilders do on stage and when practicing (I believe that many of us have also done it in front of a mirror), is actually an exhausting or a high intensity exercise in and of itself. I thought that if this type of exercise could increase the strength capability of the involved muscles, many people could benefit from this cost- and apparatus-free resistance training modality. 

4. What type of study design did you perform?

I conducted training intervention studies where a training group completed a 4-week or 12-week training program (3 days/week), which consisted of 4 seconds maximal voluntary co-contractions of elbow flexors and extensors at 90 degrees of the elbow joint, followed by 4 seconds muscle relaxation (10 repetitions/set, 5 sets/day). Another group served as a control group.

5. What were the results of your study?

After the 4-week intervention, the training group showed significant increases in static and dynamic strength, as well as agonist electromyographic (EMG) activity during maximal voluntary contraction (MVC), for both elbow flexors and extensors. Also, significant increases in muscle thickness for both muscles were found after the 12-week training intervention. The control group did not show any significant changes in all measured variables.

6. Do your results apply to athletes or highly trained individuals?

The participants in my co-contraction training studies were all untrained individuals, and thus effects on athletes or highly trained individuals are unknown. However, in my co-contraction training studies, muscular activity levels during the maximal voluntary co-contraction training, which was assessed with EMG and expressed as a relative value to its maximum (% EMGmax or % MVC) and can be considered as exercise intensity, did not change in both elbow flexors (~40%) and extensors (~60%) after co-contraction training, and never reached high-intensity (greater than 70 %) level. Trained athletes require higher exercise intensity to achieve additional improvement in muscle strength than non-athletes. In addition, to improve maximal power production in many sports performances, training programs should be primarily based on ballistic, plyometric, and weightlifting exercises involving sports-specific and/or multi-joint movements, which seems difficult to achieve by performing maximal voluntary co-contraction. For these reasons, athletes may not optimally benefit from this training modality and they should consider maximal voluntary co-contraction as a supplementary exercise to maintain their muscle strength capability.

7. How can your results be used in rehabilitation?

Since this training modality does not require any external apparatuses, co-contraction certainly can be a first step to exercise one’s muscle in rehabilitation. However, caution is needed and one should avoid starting co-contraction training with maximal effort at first because it may induce some pain if muscles are injured or not recovered yet. Gradually increasing intensity (effort) would be a good idea to avoid such pain and/or further damage.

8. Do you think co-contraction training is appropriate for youth athletes?

As mentioned above, its effects on athletes including youth are unknown, and thus I cannot say that co-contraction training is appropriate (or not) for youth athletes. However, because performing co-contraction requires one to concentrate on activating his/her muscles, co-contraction training can be considered one type of motor-control training, and youth athletes may benefit from this training modality, especially in the early phase of their sports career. That said, youth and adult athletes should consider maximal voluntary co-contraction as a supplementary exercise.

9. How did your results differ from resistance training studies?

Basically, the results of the co-contraction training studies concerning its effects on muscle strength and neural adaptation (increased agonist EMG during MVC) were similar to those reported in other studies which used traditional resistance training (using weight and/or machine). However, although significant increase in muscle thickness was also found after the 12-week co-contraction training, the gain was only +4% for both elbow flexors and extensors, which is relatively low compared to other training studies. This is probably due to the lower level of muscular activity (40-60%) during co-contraction training. In fact, a training study using high intensity (80% MVC) showed +27% increase in muscle thickness after 16-week elbow extension training. Considering these, while voluntary co-contraction can be an effective training modality (at least for untrained individuals), its effect on muscle size may be less compared to high intensity resistance training.

10. Who is doing the most interesting research currently in your field? What are they doing?

Regarding the research on co-contraction training, only a few studies have been published. So, more generally speaking, in the field of resistance training, I often find articles reported by Dr. Per Aagaard at University of Southern Denmark (mainly on neuromuscular adaptations to resistance training) and Dr. Stuart Phillips at McMaster University (mainly on metabolic responses to acute and chronic exercise) to be well-structured and very interesting.

11. What makes your research different from others?

My research is the first study that showed voluntary co-contraction training can increase both static and dynamic strength, as well as the size of the exercised muscles. Also, my research suggested that voluntary co-contraction may not be an optimal training modality for athletes or trained individuals for the aforementioned reasons (e.g. limited muscular activation level during training).

12. Which teachers have most influenced your research?

My PhD program supervisor, Hiroaki Kanehisa at National Institute of Fitness and Sports in Kanoya, inspired me the most and his ideas and encouragement greatly aided my research. He is an expert in the field of exercise physiology and has published many research articles. I am really thankful of his willingness to give his time so generously.

14. What research or projects are you currently working on or should we look from you in the future?

I am currently working on a new research project, neuromuscular adaptions to eccentric exercise. I will be a visiting research fellow at Edith Cowan University in Western Australia from April 2014 onwards, where I will research acute and chronic responses to eccentric exercise. I hope my future research will help those who are interested and involved in the field of sports and exercise, and I hope that I can be invited to this interview in the near future once again… on the theme of eccentric training. Thank you.

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Low Bone Mineral Density in Swimmers is Caused by Magnesium Deficiency?

Take Home Points on Low Bone Mineral Density in Swimmers is Caused by Magnesium Deficiency?

Low magnesium levels predicted low bone mineral density and lean soft tissue in elite Portuguese swimmers Adding 100 mg of magnesium a day improved these levels

Nutrient and supplements are a huge market for athletes. Swimmers (the small market we are) even have our own supplement line targeting swimmers. Now, proper nutrition and a well-balanced diet are essential for success, but how do you know what to take and how much? 

Individualized nutritional and supplement programs are ideal, as everyone consumes and metabolizes food differently. If looking for the top advice, have some blood work, then consult a physician or nutritionist on your deficiencies. Now, which blood markers influence performance is not well understood (vitamin D deficiencies are often low, but may not influence performance), but adequate nutrient levels likely influence long-term health.

In swimmers, bone mass and muscle mass are important considerations due to the lack of joint loading. Magnesium (Mg) appears influential on bone mineral density (BMD). It is estimated that 1300 g of calcium, 14 g of Mg and 60 g of phosphorus in bones of a 70 kg human (154 – pound human) (Synder 1975). Therefore, understanding the influence of Mg on bone and lean body mass an essential consideration for athletes.

Matias  (2012) had seventeen elite swimmers (M=8, F=9; ~16.6 years; Sprinters=6, Middle distance=9, Distance=3) from Lisbon with at least:

1)    Minimum period of activity of approximately six years

2)    > 10 hours training per week

3)    Negative test outcomes for performance enhancing drugs

4)    Not taking any medications or dietary supplements

All the swimmers underwent body composition testing (BOD POD), dual energy x-ray absorptiometry (DEXA), recorded energy and nutrients for a seven day period.

Males had significantly lower bone mineral density than normative values. Mg, P, and vitamin D intake were significantly lower than the recommended daily allowances. Mg values were a predictor of lower bone mineral density. There was also a direct correlation between bone mineral density and lean soft tissue (muscle mass).

Magnesium and Bone Mineral Density

Mg correlates with BMD and lean soft tissue (LST). In fact, this study suggests that Mg intake explains an additional 24% of BMD than LST by itself.

If these calculations are accurate, adding 100 mg of Mg a day would increase BMD by 0.259 g/cm2, providing normative values.

Practical Implication for Swimmers

Young swimmers should consume foods high in minerals. If low in magnesium, consider adding dark leafy green vegetables and nuts into the diet. However, extrapolating this data blinding is a flaw, as individual nutrition and guidelines are mandatory for cost efficient, effective nutritional and supplement recommendations.

 References

1. Snyder WS, Cook MJ, Nasset ES, Karhausen LR, Howells PG, Tipton IH. Report of the Task Group on Reference Man: a report. Oxford:Pergamon Press, 1975.
2. Matias CN, Santos DA, Monteiro CP, Vasco AM, Baptista F, Sardinha LB, Laires MJ, Silva AM. Magnesium intake mediates the association between bone mineral density and lean soft tissue in elite swimmers. Magnes Res. 2012 Jul-Sep;25(3):120-5. doi: 10.1684/mrh.2012.0317.

Written by G. John Mullen who received his Doctorate in Physical at University of Southern California (USC) and is a certified strength and conditioning specialist (CSCS). At USC, he was a clinical research assistant performing research on adolescent diabetes, lung adaptations to swimming, and swimming biomechanics. G. John has been featured in Swimming World Magazine, Swimmer Magazine, and the International Society of Swim Coaches Journal. He is currently the owner of COR, providing Physical Therapy, Personal Training, and Swim Lessons to swimmers and athletes of all skills and ages. He is also the creator of the Swimmer's Shoulder System, Swimming Science, Swimming Science Research Review, Mobility System and the Swimming Troubleshooting System.

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Swimmer's Guide to Knee Pain

Take Home Points on Swimmer's Guide to Knee Pain

Knee pain is noted in approxiately 87% of breaststroke swimmers. Patellofemoral pain syndrome (PFPS) is the most likely cause of knee pain in breststroke swimmers. Improving muscle length, strength, and timing is ideal for improving PFPS knee pain.

Knee pain is the third most common injured areas for swimmers. Rovere (1985) noted 87% of swimmers examined had a history of at least one episode of knee pain. PFPS isn’t the only condition which can occur at the knee for breaststroke swimmers, but is the most common from my experience. 

Patellofemoral pain syndrome (PFPS) affects the kneecap and surrounding area. PFPS has a broad scope: it is a “condition of conditions,” with many possible variations and causes. In many cases, a more specific diagnosis is possible, but it’s considered PFPS if a more specific diagnosis cannot be found.

This condition is patellofemoral pain syndrome and the textbook definition is:

“Patellofemoral pain syndrome (PFPS) is a syndrome characterized by pain or discomfort seemingly originating from the contact of the posterior surface of the patella (back of the kneecap) with the femur (thigh bone). It is a frequently encountered diagnosis in sports medicine clinics.”

If you are unsure if you fit PFPS, here are some questions to ask:

• Is your pain somewhere around the kneecap? 
• Is pain worse when going up stairs or hills?
• Does deep knee flexion bother the knee?
• Does your knee hurt during the outsweep of the breaststroke kick?
• Does your pain occur when sitting with the knee bent and hurt worse when you get up?

These aren't the only questions for ruling in PFPS, but help narrow down the likelihood.

Why do Swimmers get PFPS 

Clearly breaststroke is an awkward position at the knee. This motion puts stress at the knee, specifically the medial compartment. Stulberg (1980) noted breaststroke swimmers had evidence of patellofemoral osteoarthritis. Keskinen (1980) concluded:

“a combination of high angular velocities at the hip and knee and external rotation of the tibia relative to the femur repeated in excessive amounts might be the primary cause for the medial synovitis documented in these patients. The breaststroker's knee thus seems to be an overuse syndrome”.

These older studies are some of the only research on the subject. New research in this field is required, but that takes time and funding.

Fixing PFPS in Swimmers

Helping PFPS in swimmers is a multifactorial approach. This approach requires focus on strength, length, and timing (for elite athletes, this means motor control and biomechanics). 

Common muscles with altered position

Impaired tissue quality or tissue length is common in the muscles below. These muscles can also inhibit strength of the gluteal muscles (see below). From my experience, improving the tissue quality of the muscles below is paramount for recovery. Improving these is possible with self-myofascial releases (SMR) or working with a skilled manual therapist. 

MUSCLE	ORIGIN	INSERTION	ACTION	INNERVATION
Tensor Fasciae Latae	Anterior Superior Iliac Spine	Lateral Condyle Tibia via Iliobial Tract	Tenses fascia Lata Abduction Hip Flexion Hip Internal Rotation Hip	Superior Gluteal Nerve
Piriformis	Anterior Surface Sacrum	Greater Trochanter Apex	External Rotation Hip Abduction Hip Extension Hip	L5-S2 Direct Branches from Sacral Plexus
Rectus Feormoris	Anterior Inferior Iliac Spine and Acetabular Roof	Tibial Tubersity via patellar Ligament	Flex Hip Extend Knee	Femoral nerve
Iliotibial Band	Anterior Iliac crest Anterior border of ilium Outer Surface of iliac spine	Gerdy's tubercle on the lateral aspect of tibia tubercle	Flex hip Abduction Hip Internal Rotation Hip Stabilize Knee	Superior Gluteal Nerve

Commonly Weak Muscles

The gluteal muscles are commonly weak or inhibited in those with PFPS. In swimming, if the glutes can not control the internal rotation at the knee, then the thighs will separate and increase stress at the medial knee. 

Gluteus Maximus (upper)	Sacrum Gluteal surface ilium Thoracolumbar fascia	Lateral condyle tibia via Iliotibial tract	Ext hip ER hip Abd hip	Inferior gluteal nerve
Gluteus Maximus (lower)	Sacrum Gluteal surface ilium Thoracolumbar fascia Sacrotuberous ligament	Gluteal tuberosity	Ext hip ER hip Add hip	Inferior gluteal nerve
Gluteus Medius	Superior gluteal surface ilium	Lateral Greater trochanter	Abd hip Ant: Flex and IR hip Post: Ext and ER hip	Superior gluteal nerve
Gluteus Minimus	Inferior gluteal surface ilium (below origin of glut med)	Anterior Greater trochanter	Abd hip Ant: Flex and IR hip Post: Ext and ER hip	Superior gluteal nerve

Impaired Biomechanics

Swimmers often use too much hip abduction, increasing the distance of the leg from the body and the amount of torque at the knee joint. The further the foot is from the body, the more stress and increased injury risk. Coaches should instruct a narrow thigh position, with a maximal internal rotation allowing high force production with the feet, while minimizing the stress at the knee. 

Although kinematic film analyses did not demonstrate statistical differences between cases and controls, dramatic differences in the injury rate were noted when hip abduction angles at kick initiation were less than 37 degrees or greater than 42 degrees (Vizsolyi 1987). 

Often swimmers with PFPS and knee pain lack hip internal rotation or simply don’t know how to use it. To test, have your swimmer lie on their stomach and sweep their feet out. This simple troubleshooting demonstrates the range of motion for the kick. If they have enough range of motion, perhaps they are simply not capable of performing this movement with resistance or able to coordinate the body. 

Another test is to have have them perform this motion with added resistance. This is a great initial stress test for re-checking the symptoms after any treatment, but also identifies weak swimmers, unable to perform this motion in the water. 

Prevention

Looking for a bulletproof knee program, then an individualized dry-land which frequently monitors your hip strength, range of motion, soreness/pains, and biomechanics is mandatory. Also, gradually increasing breaststroke volume at the beginning of the season is also prevent overloading the tissue.

Summary

Improve your muscle length, strength, and timing for improvement of your PFPS in swimming. If you are looking for a prevention program, frequent montioring and screening for individual risk factors is most effective. If these tools aren't available, consider using the rehabilitation principles, but realize they may not be necessary.

References

1. Vizsolyi P, Taunton J, Robertson G, Filsinger L, Shannon HS, Whittingham D, Gleave M. Breaststroker's knee. An analysis of epidemiological and biomechanical factors. Am J Sports Med. 1987 Jan-Feb;15(1):63-71.
2. Rovere GD, Nichols AW. Frequency, associated factors, and treatment of breaststroker's knee in competitive swimmers. Am J Sports Med. 1985 Mar-Apr;13(2):99-104.
3. Keskinen K, Eriksson E, Komi P. Breaststroke swimmer's knee. A biomechanical and arthroscopic study. Am J Sports Med. 1980 Jul-Aug;8(4):228-31.
4. Stulberg SD, Shulman K, Stuart S, Culp P. Breaststroker's knee: pathology, etiology, and treatment. Am J Sports Med. 1980 May-Jun;8(3):164-71.

Written by G. John Mullen who received his Doctorate in Physical at University of Southern California (USC) and is a certified strength and conditioning specialist (CSCS). At USC, he was a clinical research assistant performing research on adolescent diabetes, lung adaptations to swimming, and swimming biomechanics. G. John has been featured in Swimming World Magazine, Swimmer Magazine, and the International Society of Swim Coaches Journal. He is currently the owner of COR, providing Physical Therapy, Personal Training, and Swim Lessons to swimmers and athletes of all skills and ages. He is also the creator of the Swimmer's Shoulder System, Swimming Science, Swimming Science Research Review, Mobility System and the Swimming Troubleshooting System.

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