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Data Source: Zamparo P, Bonifazi M (2013). Bioenergetics of cycling sports activities in water.

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Why Swimming Increases Low Back Degeneration

Take Home Points on Swimming and Low Back Degeneration

  1. Swimmers have greater disc degeneration than low load swimmers.
  2. Swimmers have one of the highest degeneration rates among athletes.
  3. While competing, swimmers do not have a higher injury rate for LBP compared to low load swimmers, but when pain is present the severity is higher.
The newest edition of the Swimming Science Research Review was released on Sunday.

Make sure you pick your copy up today to enhance your swimming and evidence-based coaching. 

$10/month

Background on Swimming and Low Back Degeneration

The shoulder is the primary site of injury in swimmers, but the low back is the second most commonly injured site. In fact, ~8% of those competing at a 2001 International competition experienced low back pain. Despite the anecdotal claims, few studies have compared low back pain and degeneration in swimmers to a control population. Also, comparing specific stroke specialists has also not been performed, limiting the stress from each swimming stroke.

Many feel butterfly and breaststroke are the most problematic strokes to the low back due to the amount of flexion cycles, but this website has already debunked the flexion cycle debate. In fact, rotation actually increases spinal stress, due to the shear stress at the joints.

Research on Low Back Degeneration in Swimmers

Kaneoka (2007) had fifty-six elite swimmers (M=35, F=21, ~19.6 years) and a control group (38 recreational swimmers; M=24, F=14; ~21.1 years) underwent a magnetic resonance image (MRI). Disc degeneration was compared between groups. Participants also completed a questionnaire about their main strokes as well as their low back pain history.



Thirty-eight (68%) elite swimmers and 11 (29%) controls had degenerated discs at various levels. Disc level L5-S1 was more frequently degenerated in the elite swimming group. However, there was no significant relationship of low back pain symptoms associated with this increase in disc degeneration. Swimmers had a lower rate of low back pain, but back pain was more debilitating.


 
Hangai (2008) analyzed 308 well-trained university athletes (baseball, basketball, kendo, runners, soccer players, and swimmer) and 71 nonathlete university students. Disc degeneration was evaluated with a T2-weighted magnetic resonance image (MRI). A questionnaire concerning low back pain was also performed.


Disc degeneration was significantly higher in baseball players and swimmers compared to the nonathletes. There was an association between low back pain and degeneration and the degree of severity of low back pain with disc degeneration. 

Conclusions on Low Back Degeneration in Swimmers

The L5-S1 segment undergoes greater degeneration in elite swimmers. However, the lack of associating symptoms brings to light the lack of correlation between defects in imaging and symptoms.


Repetitive sports such as baseball and swimming appear to increase incidence of disc degeneration. These sports also have greater rotation than the others studied, one possible mechanism of degeneration.


Disc degeneration is a higher risk in swimmers compared to nonathletes, yet injury rate was not significantly higher in swimmers. It seems low back pain and degeneration do not correlate, at least in the acute term. Longer studies must assess the degree of degeneration and injury rate later in life. Nonetheless, it seems swimmers have greater degeneration, but not injury rate. Moreover, swimmers and coaches should not be alarmed if an athlete undergoes an MRI and sees degeneration, as degeneration is greater in asymptomatic swimmers.
 
This month, the Swimming Science Research Review focused on low back pain. If you are looking for a quick and easy way to stay up-to-date with swimming research, subscribe today for only $10/month! 

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See the below December Table of Contents:
    1. Injury May Predict High Risk Individuals | PREVENTION
    2. Low Back Stabilization Prediction Rule not Validated | REHABILITATION
    3. Manipulation Responders have Higher Disc Diffusion | REHABILITATION
    4. Core Strength is Supposedly Important in Rehabilitation | REHABILITATION
    5. Multi-planar Strengthening Appears Important in Rehabilitation | REHABILITATION
    6. Core Stability Still Requires More Research for Performance Enhancement | DRY-LAND
    7. Instability Training Improves Joint Proprioception | PREVENTION
    8. Core Stability Improves Reflex Amplitude in LBP Patients | REHABILITATION
    9. Core Training Improves Throwing Accuracy | DRY-LAND
    10. Endurance Performance Improves with Addition of Core Stability Training | DRY-LAND
    11. Instability Training Improves Proprioception | DRY-LAND
    12. Dual Task Core Training Increases Core Stability | REHABILITATION
    13. Dynamic Core Strength Correlated with Ground-Based Performance | DRY-LAND
    14. Core Stability Improves Throwing Velocity | DRY-LAND
    15. Chinese Ointments may Enhance Rehabilitation with Massage | REHABILITATION
    16. Medicine Ball Throw Correlates with Core Stability | DRY-LAND
    17. Disc Degeneration Greater in Swimmers | REHABILITATION.. 29
    18. Disc Degeneration Greater, but Pain Lower in Elite Swimmers | REHABILITATION
    19. Free Weight Exercises Increase Core Muscle Activation | DRY-land
    20. Myofascial Release Systematic Review | REHABILITATION
    21. Prevention of Recurring Low Back Pain | REHABILITATION
    22. Trunk Motor Responses Increase in those with LBP| REHABILITATION
    23. Application of Stability Training to Sports Conditioning | DRY-LAND
    24. Glossary
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    Reference

    1. Kaneoka K, Shimizu K, Hangai M, Okuwaki T, Mamizuka N, Sakane M, Ochiai N. Lumbar intervertebral disk degeneration in elite competitive swimmers: a case control study. Am J Sports Med. 2007 Aug;35(8):1341-5. Epub 2007 Apr 3.
    2. Hangai M, Kaneoka K, Hinotsu S, Shimizu K, Okubo Y, Miyakawa S, Mukai N, Sakane M, Ochiai N. Lumbar intervertebral disk degeneration in athletes. Am J Sports Med. 2009 Jan;37(1):149-55. doi: 10.1177/0363546508323252. Epub 2008 Sep 17. 
    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.

    Dryland Dissection: Poor Hamstring Range of Motion

    Take Home Points on Dryland Dissection: Poor Hamstring Range of Motion

    1. Poor hamstrings mobility is common in swimmers.
    2. Stretching the hamstrings isn't the only method for improving forward flexion.
    Dry-land dissection is the report of a single case study. Remember, the results of this case study are simply observational and may only work for this specific person. Keep this in mind when prescribing this to your swimmers.

    Tight hamstrings are common described by many athletes, not just swimmers. Unfortunately, a proper method for alleviating tight hamstrings is not always as easy as performing a hamstring stretch. When determining the root cause of poor forward flexion range of motion, remember to look at the entire person and consider all the potential mechanisms preventing range of motion. This is essential as individualization is key, since many studies note individual differences (Moore 1980; Curry 2009; Dalrymple 2010). 

    The Swimmer with Poor Forward Flexion

    Like a lot of swimmers [particularly boys] S. S. was unable to be to touch his toes. He commonly reported tightness in the back of his legs, but did not have a history of low back or lower extremity pain. Now, you should be asking "why does he need to touch his toes?", a valid question. In all honesty, he doesn't need to be able to touch his toes to be an elite swimmer, as this motion does not occur in swimming. However, if a swimmer does have tight hamstrings or excessive pulling in the back of their legs, then they may be at more risk or injury or even have poor biomechanics. For example, if a swimmer has tight hamstrings, when they contract this muscle, they will likely extend the hip and flex the knee (both actions of this muscle). This position will disrupt and impair streamlining and possibly horizontal velocity.

    S.S. was a 17-year-old distance swimmer with goals of competing in the 2012 Olympic Trials before entering college. He was quite talented, but subjectively noted having poor turns and his "legs dying during races longer than 200-m". These subjective comments must be taken into consideration, but are far from scientific. 

    Tests and Assessments

    Visual Assessment
    S.S. had a common swimmer's posture, with rounded shoulders, a kyphotic thoracic spine and flat lumbar spine. This position shortens the hamstrings and puts the entire spinal cord on a slight stretch. 

    Movement Assessment
    During our Troubleshooting Screen, it was clear the swimmer had poor posterior saggital core strength. This was tested, as the swimmer could not maintain a flat back during any hip extension exercise. 


    We also wanted to see how much lordosis S.S. was able to achieve. To test this, we performed a simple "cat/camel" exercise. S.S. had poor "cat" mobility. This lack of mobility is a sign for poor thoracic extension and lumbar arching, both things we saw during the visual assessment. 


    Swimming Assessment
    To check S.S.'s subjective view, I watched him swim a 400-m. Sure enough, when he fatigued his hips tightened and he had no "up-kick" on his stroke [see how to swim the freestyle]. If someone can not perform the upkick, their stroke can become unbalanced and lack coordination. A lack of coordination can cascade a slew of events, often accelerating fatigue. 

    Dryland

    Mobility
    For S.S., a combination of mobility and strengthening was indicated. When someone feels "tightness" in their hamstrings, it is likely the peripheral nerves indicating this sensation, suggesting full nerve mobility is indicated. To help this condition, a series of thoracic spine foam rolling exercises were provided on a daily basis.

    Foam Roll Thoracic Spine


    On top of this, some self myofascial releases (SMR) were prescribed along the sciatic nerve, all the way into the balls of the feet. 

    SMR Foot

      Lastly, a short hamstring stretching routine was provided for him to perform each evening before bed. The goal of this treatment was not to elongate the muscle, but to relax the muscle's H-reflex and the sympathetic nervous system (Farinatti 2011). 

      Strength
      Mobility was not the only method needed for this swimmer. A series of strengthening exercises were prescribed and progressed to help strengthen the posterior sagittal plane.
      1. Unilateral glute squeezes
      2. 4-pt hip extension
      3. Prone alt arm and leg raise
      4. SB Walkout
      5. SB Walkout alternating legs
      Prone alt arm and leg raise

        This progression took different time periods for each motion, but allowed him to continually be challenged, but see progress.

        The Outcome

        At the end of the season, S.S. had superior posterior sagittal plane strength (assessed by mastery of the prone alt arm and leg and 4-pt hip extension) and improved thoracic mobility. 

        This stiff swimmer was actually able to touch his toes after ~4 weeks of individualized dry-land training [important for the athlete's psychology], but more importantly he achieved 3 Olympic Trial time standards that summer. Remember, performance is the main indicator of improvement for athletes, not mobility, force, torque, etc.

        Summary and Recommendations

        Now, it is easy to dismiss this dry-land and and suggest it had no bearing on his performance. Unfortunately, we will never know the true implications of each form of training for this or any swimmer (nutrition, dry-land, in-water, psychology). Nonetheless, the swimmer statistically improved, indicating the whole program enhanced performance. When assessing a swimmer at the beginning of a season, their in-water and out-of-water characterisitcs must be considered. Then an individualized in-water and out-of-water program are mandatory for maximal success. Unfortunately, it doesn't stop there. As research continues to be released, more subjects in sports become clearer, unfortunately they are never clear. This forces the coach to mold practical and scientific information together, for the benefit of the athlete. Balancing and doing this makes each swimmer enjoy the sport and improve, the two most important criteria for a swimmers. If you are looking staying current with the literature, consider the Swimming Science Research Review.


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        References:



        1. Moore MA, Hutton RS. Electromyographic investigation of muscle stretching techniques. Med Sci Sports Exerc. 1980;12(5):322-329.
        2. Curry BS, Chengkalath D, Crouch GJ, Romance M, Manns PJ. Acute effects of dynamic stretching, static stretching, and light aerobic activity on muscular performance in women. J Strength Cond Res. Sep 2009;23(6):1811-1819.
        3. Dalrymple KJ, Davis SE, Dwyer GB, Moir GL. Effect of static and dynamic stretching on vertical jump performance in collegiate women volleyball players. J Strength Cond Res. Jan 2010;24(1):149-155.
        4. Farinatti PT, Brand√£o C, Soares PP, Duarte AF. Acute effects of stretching exercise on the heart rate variability in subjects with low flexibility levels. J Strength Cond Res. 2011 Jun;25(6):1579-85.

        By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

        Friday Interview: Thomas Nesser Discusses Core Strength and Performance

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

        My name is Thomas Nesser and I did not start my education to be a professor. My original plans were to be a strength coach. I complete my undergraduate degree at a small college in Minnesota - St. Olaf College after serving 4.5 years in the U.S. Air Force. From there I went to the University of Nebraska at Omaha to work on a Masters degree. Returning to Minnesota to look for work, I ended up in the PhD program at the University of Minnesota. My interest in strength and conditioning remains, but now I work with students rather than athletes. I am CSCS and I serve on the written examination committee for the Collegiate Strength and Conditioning Coaches association.

        2. You recently published an article on core strength and power in the extremities. Could you briefly explain what is clear in the literature about core strength and performance?
        The need for a strong core is clear but how strong is not clear. A certain level of strength is necessary for the core to do its job - stabilize the spine and allow the transfer of forces. What is not certain is if an increase in core strength leads to an increase in the core's function, thus an increase in sport performance. A true assessment of the core is also lacking. Sport is dynamic and explosive. Identification of a dynamic, explosive assessment of the core has not been done.

        3. What are some misconceptions and things that still need to be studied?
        The core is more than the abs. It is three-dimensional: front, back, right and left sides, and a top and bottom. It is static for spine stability, but also dynamic for force transfer and limb movement.

        4. What did you study look at?
        This study was an attempt to assess the core dynamically. Most core assessment was either static or required minimal limb movement - not sport specific. We were looking for a way to assess the core that was both dynamic and explosive. We used medicine ball throws with and without the use of the core. We also tried to identify the use of the push-press as an assessment of the core (transfer of forces through the body).

        5. How did you choose these tests?
        As a group we would discuss how we expect the core to function and then determine a test to measure it. Once we get an idea we test it out on each other to identify problems and feasibility. It usually takes some time to figure out a test we think will work.

        6. What were the main results?
        From the medicine ball throws, it was determines the anterior and posterior core musculature was most responsible for static stability while the lateral portions were most responsible for dynamic stability. A correlation between the push-press and back squat 1RM was also identified suggesting the transfer of forces through the body is related to the ability to support a load on the shoulders and squat to a parallel position while maintaining balance.

        7. What is your view on flexion type core exercises?
        Flexion exercise for the core only get one aspect of the core. Personally I am not a fan of flexion exercise for the core (crunches). I feel the best way to train the core is through sport specific training.

        8. What about integrative core training?
        I do not have a problem with it other than making it too complicated. The muscles of the core know what needs to be done for a particular activity so training the movement of much more important than training the muscle. Each sport has its own movement specificity so there is no one means of training the core to meet all sport needs. As I previously mention, core training needs to be sport specific. Identify the role of the core for the sport and select exercises based on those motions.

        9. If you were prescribing a core training program for a swimmer, what would it entail?
        The core for swimming is necessary for stabilization for the extremities. Training the core would be specific to the stroke. I would suggest med ball rotational throws and Russian twists for the front crawl and back extensions for the butterfly focusing on muscle endurance rather than strength.

        10. What research or projects are you currently working on or should we look from you in the future?
        I have collected data on project looking at core muscle EMG study while performing traditional resistance training exercises (squats and presses). I am looking to establish a link between core training and weight training without creating some core specific exercise. The manuscript in still in draft form with plans to submit for publication early 2014. I plan to run another study spring 2014 to determine the use of squats to assess the core.

        Spinal Biomechanics and swimming part II: Lumbar Spine

        Last week I discussed an interesting note on the cervical spine (Spinal biomechanics and swimming Part I: Cervical Spine). This week we will address the thoracic and lumbar spine. Now the lumbar spine has been discussed greatly in the past (check out  Trouble Shooting Series: Lumbar Spine; Low Back Instability in Swimmers). If you're looking for more information on the lumbar spine, please read these first, since they address a lot of information. However, one interesting note about the lumbar and thoracic spine is their coupled motions.Coupled motions are simply, motions in different planes of motion which complement each other. For swimming, not all of these coupled motions matter for swimming, but if you can integrate your swimming and spinal mechanics, you'll be running up a smaller and easier hill!

        Unlike the cervical spine, it is believed the thoracic and lumbar spine rotate and side bend in opposite directions when the spine is in neutral or extension. For example if your spine is in neutral, then your rotate to your right side, your spine will naturally side bend left. This coupled motion is likely why many swimmers hula-hoop down the pool. 

        Luckily, there is a simple biomechanical solution, flex the lumbar spine (slightly, remember staying relaxed is key) to alter the coupled motions. When the lower spine is flexed, side bending and rotation occur to the same side. For example, if you are in slight flexion and rotate right, you will side bend right. Now, even the slightest side bending during long axis strokes likely impedes forward velocity, but it is likely easier to feed control side bending on the same side as the rotation, than motions occurring on opposing sides.

        Summary
        Use biomechanics for your benefit! Keep your lumbar spine in slight flexion to facilitate same sided coupled motions!


        G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University. He is the founder of the Center of Optimal Restoration, head strength coach at Santa Clara Swim Club, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.