Swimmer's Guide to Knee Pain

Take Home Points on Swimmer's Guide to Knee Pain

  1. Knee pain is noted in approxiately 87% of breaststroke swimmers.
  2. Patellofemoral pain syndrome (PFPS) is the most likely cause of knee pain in breststroke swimmers.
  3. 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 SystemSwimming ScienceSwimming Science Research ReviewMobility System and the Swimming Troubleshooting System.

Dryland Mistake: Lunge

Take Home Points on Dryland Mistake: Lunge

  1. The lunge is an acceptable strengthening exercise, but it is often performed excessively with improper form.
  2. Proper form requires hip, knee, ankle, alignment, reducing stress at the hip and knee.
Most exercises have a proper time and place, if dosed and performed with correct biomechanics. Unfortunately, the lunge is one of the most incorrectly performed exercises, despite the common use in the swimming community. I can't tell you how many times I see swimmers performing god awful lunges (specifically walking lunges), only to see them with knee pain later in the week or a few years down the line. This unacceptable practice is perpetuated by many swim coaches claiming dry-land is meant to prevent injuries, when they in fact are likely increasing the risk of injury (Krabak 2013). Now once again, there truly are few bad exercises and the lunge is not a poor exercise, it just contains a lot of bad implementation.

How the Lunge can be Dangerous

One of the biggest benefits of dry-land is helping prevent the repetitive demands of swimming. Unfortunately, many breaststroke swimmers [learn how to swim the breaststroke] already have a lot of repetitive stress on their medial knee structures, causing lax ligaments, which can be perpetuated by poor lunge biomechanics [Ryan Lochte's Knee MCL Rehabilitation] . To ensure proper form, safe progressions and regressions, as well as knowledge in biomechanics is a necessity. Simply put, most coaches (not only swim coaches) do not have this education, as they spend their necessary time on learning swimming biomechanics, going to swim meets, season planning, etc. This makes it crucial to find someone who is qualified, at least in exercise prescription and biomechanics. This can be as simple as a parent volunteer who is also a strength coach, who can at least monitor exercises properly. Now, if you are working with a volunteer strength coach or someone without a background in swimming, specific criteria are mandated, as bodybuilding principles are not likely the most beneficial for swimming. Now, some may argue these principles can work, we all must realize although results may correlate during years of maturation, it doesn't mean it caused improvement. If you are a coach with an interest in becoming educated, take a strength and conditioning certification (ideally a CSCS certification). Note, not a simple class focused on swimmers, these courses have their time and place, but in my opinion, should be used to complement the base knowledge of strength and conditioning.

Common Lunge Flaws


When we're talking about lunging we want to focus on clean, crisp, and efficient movements. This is actually far from the norm! Here are the main lunge flaws in dry-land:


Error #1: Forward Lean

You'll see this quite often in people who are tight in their hip flexors/quads or are very quad dominant. You may need to do some SMR of the hip flexors, along with glute activation work. The SMR work can include foam rolling to the thighs and the glute activation can be as simple as glute squeezes.

Good coaching cues to break this habit include keeping the chest up throughout the movement and resetting yourself between reps if necessary. With some people it's an actual structural issue (as in the above example), where as with others it's either being lazy or not using the correct cues. Reset and think "tall" before each and every rep.

Error #2: Knee Caves In

This is a very common issue in people with weak glutes, as the gluteal muscles are mainly external rotators, which control the femur. 

When we lunge and are forced to absorb/create force on one leg, we're immediately challenging our gluteals to provide stability and strength in the frontal and transverse planes [learn more on our basics page]. When our glutes are inactive (or simply not strong enough), we can't properly decelerate hip adduction/internal rotation, and therefore our knees cave in.

Once again, some glute activation prior to the lunge can help clean this up. Try some simple glute squeezes for the novice athletes, or some side-steps/4-pt hip ext.



One set on the weak hip should be sufficient; after all, the goal here is neural activation, not gluteal exhaustion.

Coaching cues include keeping the core tight, landing on the heel, landing under control, and keeping the majority of the pressure on the back/outside of the foot.

Error #3: Foot Caves In

Typically if someone's knee caves in, his foot caves in as well. This is the term for overpronation. 

Excessive pronation is attributed to two issues:
  1. Weak floor-to-ground muscles
  2. Weak gluteal muscles
In the first scenario, if the swimmer has poor strength of the muscles around the ankle,  specifically, the gastrocnemius, soleus and/or peroneals are short/stiff and the tibialis anterior is weak. Some foam rolling for the short/stiff muscles, coupled with an activation set for the tibialis anterior, could go a long way to correcting this flaw.

The second scenario is common in those with weak glutes (just like above) causing the knee to collapse which can transfer all the way to the foot.

Coaching cues include forcing your big toe into the floor to stabilize the arch of the foot. Another cue is to contract the glute, preventing hip collapse as before.

Proper Lunge Form and Progressions

Once again, every exercise has a time and place. To understand the proper time and place, a coach could perform an out-of-water troubleshooting screen to help connect the dots between their out-of-water movement patterns and in-water deficiencies. Now, these two areas don't always connect, but if someone can't control their knee motion during a single lunge, then it is likely their knees are excessively stressed during the breast kick. The difficult thing for a coach, is realizing that even though the swimmer may not have pain during the kick, that over time this increased stress can default these structures and cause pain. 


Lunge Progression

However, simply prescribing the lunge for each swimmers is not enough for a coach, finding the most appropriate form of the lunge is key. Now, this may sound simple, but for continued improvement, it is necessary to find the form of the lunge where a swimmer can perform correctly for multiple repetitions, but be challenged and fail without mental engagement or fatigue. Once again, finding this place may take a few sessions, but with the Troubleshooting screen, the time can be cut-down. 
  1. Alternate leg stance for 30 seconds
  2. Static Lunge
  3. Alternating Reverse Lunge
  4. Alternating Forward Lunge
  5. Alternating Reverse Weighted Lunge
  6. Alternating Forward Weighted Lunge
  7. Walking Reverse Lunge
  8. Walking Forward Lunge
  9. Walking Reverse Weighted Lunge
  10. Walking Forward Weighted Lunge
  11. Bulgarian Deadlift (rear-foot elevated lunge)
  12. Weighted Bulgarian Deadlift
  13. Bodyweight Valslide Reverse Lunge
  14. Barbell Walking Lunge
  15. Barbell Zercher Walking Lunge
  16. Dumbbell Contralateral Load Deficit Reverse Lunge

Summary

The lunge can be a highly effective dry-land exercise is dosed and performed properly. As a coach, "doing no harm" is mandatory. Make sure you are not doing harm, instead helping prevent injuries and benefit your swimmers, while they swim and later on in life!

One last thing, order your copy of the Swimming Troubleshooting System or any other products before the end of the week and get 20% off! See the big sale here!

References:
  1. Krabak BJ, Hancock KJ, Drake S. Comparison of dryland training programs between age groups of swimmers. PM R. 2013 Apr;5(4):303-9. doi: 10.1016/j.pmrj.2012.11.003. Epub 2013 Jan 29. 
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.

Flip Turn Flaws


I'm a simple man with simple pleasures. I'm also a stickler on a few points:
  • People who don't turn off their phone in movies. Easiest thing in the world, vibrate or silent (preferably silent, but I've given up on this request and will accept vibrate). I mean you're not that important no one is, trust me I've worked all kinds of egomaniacs and each one is as much a loser as the next.
  • People who don't honk at others when they are slowing traffic. Come on! Everyone needs a quick honk from time to time to get moving, whether the person is shaving, texting or beating their children they may need a honk to refocus.
  • Grocery stores that don't open the self check-out, I mean what is it doing there? Four lines operated by one overseeing clerk is light years faster than one line period, open up the self check-out! Quit wasting everyone's life!
Why isn't anyone using this!
Get me on a pool deck or in a weight room and this list will exponentially grow. I'll save you the infinite list, but I'm going to pound one home...flip turns. No matter the skill level, if I step on deck at a Master's, age group or elite swimmer work out I always see improper, lazy flip turns.
If you're serious about improving your swimming, then I suggest getting to know the flip turn. Flip turns are the easiest way to improve your swimming times with minimal effort or skills.

Proper flip turns set apart elite swimmers from pretenders. I mean you can get away with sloppy turns, but you'll never be elite unless you fix them. Once you get to a certain level, you either accept this fact or your don't get any better, because no one can compete with the best when they lose a second on each turn (this goes for LCM, SCY and SCM).

I mean if you're not doing flip turns correctly, what are you doing? Flip turns are the easiest part of swimming and if you don't utilize them you're either hard headed or so unathletic you should grab a baton and try out for color guard.


Turn like an Athlete
Lucky for swimmers, not everyone does the sport. For example, everyone up to a certain age plays soccer or shoots a basketball, therefore being an elite soccer or basketball player requires the whole package (as far as athleticism). Don't take this the wrong way, but some of the top swimmers are not pure, blood thirsty, ACTN-3 double allele containing athletes. This is a great thing and allows the determined, hard workers to become great even without natural ability. However, this is a common excuse for sloppy turns.



In my opinion, one's ability to do a flip turn directly correlates with one's athleticism. It isn't the end-all, be-all, but it's a simple indicator of true athleticism. Flip turns are a complex motion, requiring multiple joint movements in every plane to function in synchronous rhythm, sounds so eloquent! The flip turn utilizes a flip, pseudo-squat and a full 180 degree of rotation. All functions every swimmer has to perform, unfortunately every athlete does not have these tools.



Tools for Improvement
Before I get into proper form, it is mandatory to have the proper tools to perform one correctly. The body is similar to a ship; unfortunately society's ship is made of gum, glue, toe nails and straw. We need to start building a stronger ship, tackling waves throughout life. The main aspects of this ship are proper length, strength and timing. To perform a proper turn, these three categories are mandatory. Before I discus the meat and potatoes of a proper turn, I'm going to talk about the issues that tend to pop up repeatedly with athletes I work with. A proper turn requires the following:

  1. Core strength
  2. Hip Mobility
  3. Ankle Mobility
  4. Hip Strength
  5. Thoracic Mobility
These are the mandatory movements for a proper turn. Here are some tips to improve and warm-up these areas prior to swimming.


Core Strength: Flip turns requires a full somersault and trunk flexion followed by rapid trunk extension. This requires core stability in combination with concentric and eccentric control. I recently discussed spinal flexion in great detail and Tad Sayce has discussed core strength in great detail. In my opinion, spinal flexion exercises with proper form and dosing are appropriate for swimmers.


A weak core is seen when swimmers go into a turn and they do not have the strength to accelerate into the wall. At first thought, it seems the athlete has poor range of motion since they do not fully tuck. But after further analysis, it is clear they have poor stability since many have full flexion range of motion outside of the pool. If an athlete does not have trunk stability, then they will not go into full range of motion as they are unstable.
Often times having an athlete engage in core exercises before swimming, will help them activate and control the motion. For this reason I have my athletes use 100% stabilization with the March II exercise for 5 repetitions prior to swimming to activate the muscles.
March II 

To improve strength of spinal flexion, my favorite exercise is the the eccentric bosu curl-up. This forces proper control and strength needed for flip turns.
Ecc Bosu Ball



Hip Mobility: The most common inhibitor of proper flip turns in Master's swimmers is poor hip flexion. However, age group swimmers are starting to show limitations in this range due to their bent over, World of Warcraft lifestyle. Hip flexion is often inhibited by numerous structures from tight hip extensors (glutes and hamstrings) to tight adductors or lacking hip internal rotation. Breaststrokers often have adequate hip internal rotation, unfortunately many swimmers cannot do breaststroke, likely due to poor internal rotation mobility.


Two drills to improve hip internal rotation are:
Lying hip IR/ER

Skiers



Another muscle we look at is the adductors. This tight muscle group can hold your legs together, preventing hip flexion and extension. This area can be enhanced with manual therapy or....
Spiderman Mobility



There are two groups of adductor, short and long adductors. To adequately stretch the long adductors, the knees need to be bent.
Kneeling Adductor Circles



The most important aspect of hip mobility is improving range of motion of the hip flexors. Once again, there are long and short hip flexors and both structures need to be mobile.
Kneeling Hip Flexor

Standing Psoas



Ankle Mobility: When a swimmer lands on the wall, their ankles rapidly approach 90 degree. After landing, the ankle rapidly pushes off and points into plantar flexion. Unfortunately, many triathletes cannot find proper mobility from being stuck in excessive dorsiflexion their whole life on a bike. Standing calf stretch with towel under their arch prevents pronation and forces proper mobility. Perform this mobility with the back leg straight and bent to focus on the gastrocnemius and soleus.
Ankle Dynamic Mobility



Glute Strength: Proper glute strength is a component of proper flip turns, unfortunately the swimming community is assless. Assless syndrome is beneficial for decreasing Eddy currents, but it can greatly impede an athlete's ability to explode off the wall! My favourite glute activation exercises:
Super Dog



Prone Alternating Arm and Leg



Thoracic Mobility: Thoracic mobility is essential for many proper functioning structures; however, it is quintessential in the flip turn since an athlete goes from rapid flexion to extension and rotation.


Having poor thoracic mobility will inhibit extension as the athlete pushes off the wall, preventing proper streamline.
Foam Roll Mobility



Wrap-up
These are some tools to improve your ship to be able to handle a proper turn, next week we will hit the biomechanics of the turn, get to work on these in the mean time.



By Dr. G. John Mullen, DPT, CSCS. He is the founder of the Center of Optimal Restoration and head strength coach at Santa Clara Swim Club.

Training Hip Rotation in Breaststroke

Last week we discussed the importance of hip rotation in breastroke, both for performance and for injury resistance. This week we’ll explore four critical aspects of dryland training to improve hip rotation: Tissue quality, joint centration, mobility, and coordination.
Self-massage: 
Many athletes looking to improve mobility go directly to stretching, which is often ineffective when used as the lone intervention. Improving tissue quality helps us stretch the right muscles when we stretch. If tissue quality is poor in a hip rotator and that muscle is unable to move properly, stretching the hip into rotation will add unintended stress to surrounding joint systems and the muscles of the hip not designed for rotation. For information on hip pain in swimmers, see Dr. Mullen’s recent video: 

Tools of the trade for self-massage include foam rollers, PVC pipes, lacrosse balls, softballs, and tennis balls. Foam rollers or PVC pipes work best for the groin, quadriceps, and ilotibial band. The various balls are effective for the glute medius, posas, tensor fascia lata, piriformis, and quadratus lumborum. Be sure to avoid pressure on the bony structures of the pelvis and hips.


Some question the need for the youngest athletes to perform tasks like foam rolling or using lacrosse balls for self-massage, since many of them are too young to have developed poor tissue quality. In my opinion, being responsible for bringing a lacrosse ball and/or softball to practice (in addition to their other swim gear) builds accountability at a young age. Further, exposing kids to this warmup and/or cooldown ritual establishes sound habits for the rest of their careers.
Joint centration
A joint out of position can disturb optimal muscle firing patterns. Hip rotators won’t be available for rotation if the body relies on these muscles to hold the joint in place. If the body has a choice between performance and preservation, it will usually choose preservation!
Self-massage before exercise can help calm down overactive muscles and make it easier to re-train the “ball” of the femur to sit more comfortably in the “socket” of the pelvis. A common hip dysfunction is for the femoral head (the “ball”) to sit too anteriorly in the joint. Below is one exercise to coax the femoral head into the posterior capsule.

Mobility
Once we prep the muscles for movement and establish joint centration, we are then ready to add mobility. Below is one exercise to train hip internal rotation. There are many exercises to do the job, but this one is easily coachable, user-friendly for a large group setting, and easily repeatable as homework while watching TV.
For external rotation, please see Dr. Mullen’s recent video on at Swimming World:

Coordination
Many athletes are familiar with mini-band lateral walks to train the lateral hip muscles. Here is one variation from Tim Vagen more specific to breaststroke with the knees narrower than the feet.
Another option is to place an additional mini-band near the ankles to cue tibial external rotation, which is also advantageous to the breaststroke kick.
Conclusion
There’s no doubt that some athletes are born to swim breaststroke. Children with the right pelvic anatomy and early exposure to the stroke have a clearer path to greatness. However, due to suboptimal control of the hip joints and use of the hip muscles, most swimmers don’t achieve their potential in the stroke. A system of improving tissue quality and joint centration before stretching and strengthening can improve return-on-investment during breaststroke training in the water.
Guest Post by Allan Phillips. Allan and his wife Katherine are heavily involved in the strength and conditioning community and more about them can be found at pikeathletics.com

Hip Rotation in Breaststroke

Continuing our theme of exploring the unique physical characteristics of elite swimmers, this week we’ll look at hip internal and external rotation in breaststroke. There’s an old adage that great breaststrokers are born and not made, lets explore these adage!

Many elite breaststrokers have visible internally rotated hips, which can appear as knock-knees. Experienced coaches can sometimes identify potential breaststrokers just by looking at their lower body anatomy. In fact, Leisel Jones’ knock-knees were so extreme her family contemplated surgery to have her legs straightened.

However, it is important to recognize there is more to breaststroke kick than internally rotated hips at rest. A knock-kneed posture with internally rotated hips can be advantageous, but posture alone is not sufficient. Training the movements of hip internal and external rotation can help keep natural breaststrokers healthy and can help others improve their breaststroke kick.

Assessments

While a pair of knock knees may be a cue of internal rotation, formal assessments will help identify the functional range of motion. There are several clinically accepted methods to check hip internal and external rotation, but lying prone is the most swim specific way. Although the photo sequence below uses a measuring device, coaches in a group setting can likely eyeball who has the underlying range of motion for an effective breaststroke kick. On land, our greatest concern is identifying who can’t perform the basic movement.

The first step requires finding the neutral position, this can be done by having the swimmer lie on their back. Swimmers with natural internal rotation might subjectively feel externally rotated in this position. The left side of the below picutre shows a passive test for internal rotation. Passive testing will identify whether underlying restrictions are present in the joint. Also test for active rotation, which involves the exact same movement but without manual assistance. Internal rotation deficits can lead to the common stroke flaw excessive hip abduction the in the first phase of the kick, which leads to kicking too wide.

The right side of the image shows a test for external rotation. Although the breaststroke kick in the water doesn’t reach the range of motion shown above, external rotation is the primary movement that brings the feet together at the end of the kick. Jagomagi and Jurimae (2005) found that hip external rotation was predictive of breaststroke kick speed along with knee external rotation and ankle supination. Interestingly, hip internal rotation in static posture was not correlated with kick speed, which suggests that kick improvements are more trainable than many suspect.

Injury considerations

Breaststroke related knee injuries are among the most common maladies in the sport. While the research indicates a correlation between breaststroke training volume and injury rates (Knobloch, 2008), improving hip movements will minimize stress on the knees. Ensuring adequate internal and external hip rotation will transfer the rotary stress of the breaststroke kick away from the knees and into the hips, which are better suited to handle rotary forces.
The breaststroke kick can also stress the groin if an external rotation deficit exists. A deficit could either be insufficient range of motion or a faulty movement pattern that relies on the muscles of adduction (the groin) over the muscles of rotation. Researchers at Stanford (Grote 2004) found that 42.7% of breaststrokers and 21.5% of IM-ers in a sample of 296 competitive swimmers missed practice time due to groin pain. (note, the lead researcher in this study was Olympic gold medalist breaststroker Dr. Kurt Grote, M.D.).

Summary

Breaststroke specialists may seem like the anatomical freak shows of the pool, but improvements in hip internal and external rotation are possible for swimmers of all ages. In the next installment we’ll cover dryland strategies to improve these aspects of hip performance.

References

  1. Jagomägi, G. Jürimäe, T. The influence of anthropometrical and flexibility parameters on the results of breaststroke swimming. Anthropol Anz. 2005 Jun;63(2):213-9
  2. Knobloch, K. Yoon, U. Kraemer, R. Vogt, PM. 200-400m breaststroke dominate among knee overuse injuries in elite swimming athletes. Sportverletz Sportschaden. 2008 Dec;22(4):213-9. Epub 2008 Dec 15.
  3. Grote, K. Lincoln, TL. Campbell, JG. Hip Adductor Injury in Competitive Swimmers. Am J Sports Med. 2004 Jan-Feb; 32(1): 104-08.
By Allan Phillips. Allan and his wife Katherine are heavily involved in the strength and conditioning community, for more information refer to Pike Athletics.

Friday Interview with Lori Briggs

Please introduce yourself to the readers (how you are involved in swimming, your credentials education, etc.) 

My name is Lori Briggs and as owner of Core Body Solutions my focus is to assist coaches, elite athletes, junior athletes, or clients who are interested in overall fitness and wellness in developing training programs that will enable them to reach their goals.


For 3.5 years I was the dry land specialist for the USA Swimming National Team.  I developed dry land training programs that were tailored to optimizing efficiency of Olympic swimmers.  I also developed programs for Fullerton Aquatic Sports Team (FAST) under the direction of Olympic Coach Jon Urbanchek.  In addition to this Post-Graduate Training Center in Fullerton, I have also worked one-on-one with athletes at the Olympic Training Center during high altitude training camps in Colorado Springs, CO.  In preparation for the 2008 Games in Beijing, I assisted the USA National Team Head Coach with strength and conditioning programs and dry land training for the athletes.  My experience also includes tailoring workouts for Figure Skaters and Ice Dancers at Junior National Competitions.     

I have over 30 years experience in the fitness industry.  My unique approach to health and fitness emphasize core strength and nutrition as the foundation for optimizing wellness.  I am a Certified Personal Trainer (CPT) through the International Sports Medicine Association (ISMA).  I have written articles for Medical Voyce focusing on women’s health issues and created DVD’s on improving core strength.  Featured articles have been written about me in Colorado Avid Golfer Magazine, Orange County, CA Register and Western State College Alumni Magazine.  I have held positions of Athletic Director at the Club at Flying Horse, a private country club, and have been honored as Colorado’s top personal trainer.  Through the years, my involvement in bodybuilding and figure physique competitions, have brought me medals, trophies and great personal satisfaction.  I believe my success has been based upon my commitment, discipline and high intensity training.  For over 20 years I owned and operated a Jazzercise franchise that gave me an opportunity to use my gifts of empathy, humor, physical fitness and passion to mentor and nurture women to feel good about their bodies and health.  Other areas of expertise center on weight and lifestyle coaching from a total health perspective, healthy eating strategies, weight training and cardiovascular endurance.  I hold a certification in the TRX Suspension Training that utilizes total-body resistance exercises to achieve sport specific goals that my client’s have.  Pilates, Functional Integrated Movement Patterns, Training for Power and Partner-Assisted Stretch are certifications that enhance my areas of technical expertise when implementing training programs for all sports.  
 
My personal interests include:

  • Road races and cycling rides consisting of century rides and elevation climbs of 10,000 feet
  • Pikes Peak Incline – 2,000 feet vertical climb in 1 mile followed by a 4 mile run
  • National Physique Competitions   
How do you implement resistance training in an athlete’s off season?

Implementing resistance training in the off season can work major muscle groups when recovery and regeneration is the most important goal.  I use stretch cords, bands and tubing to strengthen many of the tiny connector muscles, ligaments and tendons that can become overused or overlooked while training in the pool during the season.  When used correctly, I use them for patterning, movement prep and correction.  If you are just using them as another form of resistance you’re missing the most important component of band training.  The reactive techniques are by far the most impressive because they yield quick results.  I believe using tubing and band work immediately following flexibility work during the off season is the best time.  That is also the best time for patterning and stability.  A swimmer must use the motion they gain or they will lose it and the must pattern it and stabilize it before they load it.  Strong and durable jump bands can be incorporated into workouts and allow for high tempo-dynamic movements with efficient thoracic rotations to be learned.  I like to also introduce power jump bands in the off season to teach proper knee alignment, balance, and explosiveness in jumping (mimics jumping off the blocks).  Resistance training can be combined with core stabilization and balance exercises for performing chops, lifts, presses, pushing, pulling, rotations and anti-rotations.  My favorite exercise is using a resistance band to fire the “powerhouse” core muscles while increasing flexibility and postural alignment in a supine position.  It is an exercise that adds elements of strength, intensity and balance during the off season.    

How long do you spend on correcting mobility, muscle imbalances, etc?

Understanding movement principles of the body and how they work can help coaches and their athletes exercise in a deeper and more meaningful way.  It is not so much a question of “how long” we spend correcting mobility or muscle imbalances as gaining an understanding of physiology and biomechanics so you can decide what is right and what is wrong for your athletes.  Below you will find nine key principles (briefly defined) that I use in my dry land training programs that address all foundations of movement:

  1. Breathing – Breath is integrated into every movement we do in order to keep our awareness on what exercise we are doing.  It is an essential link between our mind and the body.
  2. Concentration – Without concentration the exercises lose their form and their purpose.  When teaching swimmers it is important to have them do only as many repetitions as they can without losing their concentration.
  3. Control – To be in control is to understand and maintain the proper form, alignment and effort during an entire exercise.  My clients never perform an exercise without engaging the mind to control the movement and the effort that the body is making.
  4. Centering – All movement radiates outward from the center.  Developing a strong, stable and flexible center is one of the defining features of exercise.
  5. Precision – Understanding proper forms and placement and being able to perform exercises with efficiency comes with practice.  Precision is the end product of concentration, control, centering and practice.
  6. Balanced Muscle Development – Understanding, developing and maintaining correct alignment and form is essential.  With practice, these principles become second nature and lead to improved posture and enhanced performance for swimmers.
  7. Rhythm/Flow – All movements are done with a sense of rhythm and flow.  Flow creates smooth, graceful and functional movements.
  8. Whole Body Movement – Integrating the mind and body to create clarity, purpose and performance.
  9. Relaxation – We learn to use just the amount of effort needed to complete the exercise correctly, no more, no less.
How do you use speed training within your resistance training programs?

When training to increase speed in the water, obviously workouts differ significantly from endurance workouts.  The intensity of the training, not the distance you swim, is the critical part of the workout.  I leave the workouts designed for the “wet side” to the coaches and their expertise.  What I attempt to blend in with the dry land resistance training program are exercises focusing on the fast twitch muscles.  Often times I use very light dumbbells to accomplish this goal.  Dry land programs will mimic “interval training” where athletes attempt to perform each exercise for the duration of 2 minutes.  Of course form and alignment during the 2 minutes is always priority.  Athletes will be kept to a short 30-second recovery break before moving to the next dry land station.   

What aspect of resistance training or exercise in general do you feel coaches use incorrectly?

In the world of competitive swimming, coaches know the most important propulsive element in swimming is the Early Vertical Forearm (EVF) or the catch.  However utilizing resistance training properly so the athlete acquires and improves this critical skill can be the challenging factor.  If a swimmer can’t demonstrate the EVF out of the water, most won’t be able to accomplish the skill in the water.  Coaches should develop a dry land program that strengthens the posterior rotator cuff muscles.  Coaches should give themselves plenty of opportunities to see that their swimmers can perform the skill correctly.  Videotaping dry land exercises and isometric training drills on the pool deck can be effective training tools for an athlete.  Having athletes mimic the swimming stroke of world-class swimmers using a great EVF position can be very beneficial.  Resistance training exercises must be incorporated in every swimmers training regime.  From a variety of dry land positions on deck, the coach can tell their swimmer what they’re looking for, and then can manipulate a swimmer’s arm until they can hold the effective position without help.  Stabilizing and strengthening exercises specific to the rotator cuff, deltoids and the muscles of the upper and middle back can then be incorporated into a comprehensive resistance training program.  But most importantly, coaches should emphasize that all exercises are done with the principles of control, precision, breathing, focus, concentration, and finally stabilizing the joint and mobilizing the limb with fluid and efficient movement.  Using proper exercise form and learning to stabilize the shoulder girdle or scapula before beginning each shoulder exercise will help the athlete be more efficient in the water and with less chance of injury.  My goal in a resistance training program is to incorporate all three areas including:  stretch, stabilize and strengthen.  

What projects are you working on now or we should anticipate in the future?

I have just recently launched a professional website that coaches and athletes can utilize for additional training needs and programs.  You can log onto www.corebodysolutionsllc.com to view the site.  Core Body Solutions has a unique approach to developing dry land training programs for professional athletes.  

  • Step 1:  Core Body Solutions begins with an Evaluation Process that answers the question, “How Balanced Are You”?  Multidimensional training programs are designed to use fitness assessments to tailor strength, endurance, and flexibility exercises for individual needs.  Simple but challenging tests will determine whether you have deficiencies in body alignment, flexibility or lack of rotational movements.

  • Step 2:  We will design programs that guide you and show you how to train for smooth, fluid movements, prevent muscle imbalances, mobility, restrictions, stability problems and keep injuries at bay.  Putting together optimal movement skills and conditioning programs will enhance your athletic performance.

  • Step 3:  Evaluating and assessing your athletic goals and accomplishments will be addressed and necessary modifications will be made to your training programs