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

Coded for Swimming Science by Cameron Yick

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Us Old Swimmers...

This was an article submitted to Swimming Science. Although it lacks scientific literature or
references, it's anecdotes provide an necessary look into the possible long-term effects of the sport. Although the writer is just one person, so is Michael Phelps. Although opposing ends, Phelps and the writer are just one, uncommon result, with the author having a more likely result than Phelps.

 Coaches, parents, and swimmers remember exercise is a life-long journey. For some, you'll have great success during adolescents and teenage years, but always question...will this add up when I'm older? Coaches, realize you can help swimmers in the short- and long-term, just ensure safe programs and healthy environments for long term success. 

I have added some editor notes, which are indicated with brackets, enjoy!

Take it Laura

Warning to all coaches and swimmers,

Bodies break down. It may take only a few years, but when the former swimming athlete is progressing into middle age his/her body will scream out for pain relief. When doctors tell you, “swim, itʼs a non impact, great exercise" or  "It's good for you”, watch out.

Some of you know know that swimming is probably the last thing you should do, as the mere thought sends pain throughout the body. If you feel as though a nice easy thousand yards would be the right ticket for your swirling mind, then you realize the agony of pushing off of the walls and twisting your neck turns you into a blithering pain ridden fool and stops you.

Hear me out.

This is my story of the body versus mind and whatʼs become of a relatively honed body.

I was never a top ranked swimmer. I was among the thousands of girls who had very few athletic opportunities in the 1950ʼs-60ʼs. My father, who ran swimming pools throughout New Jersey, private country clubs, public pools and taught swimming at Seton Hall University introduced me to swimming at birth. He taught me and many others, and he introduced the “swimming meet” to the clubs. One day after I suffered a bad asthma attack my doctor told said. “Get her on a swim team. The humid water and breathing rhythm will help with the asthma. And it did. I remember the first day, at age 7, like it was yesterday [there is some conflicting research on asthma and swimming, despite the common physician recommendation].

Boylan Street Pool in Newark, 50 meters x 25 ydʼs. It was BIG! Lots of girls swam up and down the pool. The coach, “K”, greeted me and said, “You stay in the outside lane, and if you need to hold on there is the wall”....

“Are you kidding me!”

Thus began the years of up and back....

In those days, we didnʼt have weight training per say. We had K. Under Kʼs leadership we did pull ups from the pool to the deck. She filled buckets with cement and attached them to a rope and spindle, which we curled up and slowly let down, and we dragged each other on our pulling lengths. She used cut off broom handles for sticks to keep our hands out in front swimming freestyle. She had us meet at a local university in the “off” season to run the track, throw discuses and shot puts, and hop over hurdles. K was an Olympian runner! She yelled, she screamed and we did lots and lots of miles. K taught form in stokes. We did starts and turns for what seemed forever. We never thought we were wearing out our joints. No one did. Until...

Now, I have participated in many sports since then. I played basketball for the CYO, tennis when allowed at the clubs, and many pick up games of whatever was playing in the streets and parks of Maplewood, so my cross training was all on my own. I have sprained my ankles many times, broke a nose from an angry bat wielding brother, and flown off many a bike. But when, in the midst of a awesome beach volleyball game, I swung my arm to spike a shot, it stuck there....


I tried to just go with it for months, I finally saw a doctor, who is a well known specialist in Boston who says, “Where you a swimmer?” [personally, this is a bold prediction by any physician, but whether it is from swimming or another overhead sport, there is a common shoulder presentation.]

Ah yes.

Hmmm swimmersʼ shoulder, he diagnosed! He knew from the tests that I had over used my shoulders from swimming, not from all the other sports. We scheduled the operation to clean out the shoulder of calcium deposits, bone chips and shave down the acomion to give rotation some room. He removed the bursa sack sewed me up I was good to go, until the next shoulder gave out.

He did the other side. Same procedure. The explanation for all this was “When you were swimming, those years, you didnʼt do the correct exercises to pull your shoulders back. You needed to do back strengthening exercises. Overall, youʼll be fine. You can swim, but use fins to eliminate the pressure on your shoulders while swimming laps." He then asked, "How are your knees?” Really! “Pretty good”.

Perhaps I spoke too soon, ten years later I had my left knee meniscus trimmed. This was the second time a doctor said to me, “Were you a swimmer?”
“Bet it was breast stroke.”

He then told me I could swim if I didnʼt push hard off the walls [as a Physical Therapist, I'd be more worries about twisting the knee or large knee flexion].

All was going well until I turned sixty, and all hell broke loose in my body. I donʼt know if hormones are to blame, but doing workouts to stay in some kind of shape to avoid the dreaded weight gain, caused injuries that I couldnʼt shake. First a torn hamstring, then a strained Achilles tendon, and now a massive amount of arthritis in my right knee [all uncommon injuries in swimming. When asked Laura reports golfing, weight lifting, and officiating during this time period.]. Now the right knee!

So I see my knee guy and he sends me to his top surgeon and he says to me, “you were a swimmer right, bet a breaststroker!”

Ahh come on guys.

So, they canʼt give me anymore shots into it, cortisone or synvisc, or use any other delay tactic. Walking is wicked painful bone on bone and the wonder how I even can walk and when I'll soon need a total knee replacement.

I am throwing this out there because we need research to pass on to the new generations of swimmers. We need data from all us olʼ folks who swam and swam for preventing short and long term effects of swimming. I am a big believer in doing multiple sports. Overuse is hurting out bodies. Some of the techniques and equipment being used by coaches with their swimmers is hurting them. I officiate meets and watch young children walking around with ice packs wrapped on their bodies.

This is not good.

Knowledge and science is available. We need to pass it on. Parents and coaches need to develop their athletes without causing injuries.

Written by Laura Menza Wanco. Born and raised in New Jersey. She swam with the Watchung Lake
Swim Club an AAU team under the coaching of Catherine D Meyer, long time AAU Coach and Official with the US Olympic Committee. Laura coached summer club teams, was a lifeguard, and swim instructor in summer clubs. She started along with a group of former swimmers the Women's Swim Team at Seton Hall University in 1968 after a year of swimming with the men's team.

She started the Women's Basketball Team at Seton Hall University in 1971, from the Intramural teams. Coached Tennis at Summit High School, Mens and Women. Coached High School Swimming Team at Columbia High School.

She moved to Cape Cod, MA. where she started a team in the local health club and became an official. She has 
 officiated local, sectional, and state tournaments, swimming and diving and officiated at the NCAA Womens D1 championships.

Does Low Back Pain Resolve Itself?

Take Home Points for Does Low Back Pain Resolve Itself?
  1. Yes, low back pain typically resolves itself, yet underlying issues persist likely increasing the risk of re-injury.
Low back pain (LBP) is extremely common in the general and athletic population and swimmers
even have a higher risk of low back degeneration. Despite this frequency, no resolutions exist for eradicating pain. Luckily, most cases of LBP are acute and remiss over a month. This brevity in symptoms leads many not to seek treatment. However, resolution of pain, without treatment, may but a person at risk for a recurrent injury, as the recurrent rate of low back pain is extremely high.

This situation puts everyone in a bind, as everyone thinks they can wait out pain and get better. However, is waiting out the pain and having it resolve on it's own the best option? Sure, low back pain gets better in most people without any treatment, but is this passive treatment worth the risk of having a higher risk of recurrence?

Does Low Back Pain Resolve Itself?

Butler (2012) recruited fifty-four subjects without LBP and 33 people with a previous low back injury (LBI). In this study, electromyography of the core musculature and motion analysis was taken during the following task: 

“Subjects stood at a table (adjusted to standing elbow height) and performed three trials of lifting and replacing a 2.9 kg load using both hands in two reach conditions while minimizing trunk and pelvis motion. Subjects were required to move the load 4–5 cm off the table in a controlled manner and lower within a standardized 3-s count. An event marker identified lift, transition and lowering phases. Only the lift phase was examined given similar patterns were found for the two other phases. If trunk or pelvis motion was visible during the trial or upon review if the any of the three angular displacement traces exceeded 3, the trial was repeated (Butler 2012).”

The results showed a slight difference between the control and LBI, as the LBI group was slightly older and had a higher body mass index (BMI). Moreover, different movement patterns during the above tasks were noted between both groups. The LBI group also had higher muscle activation for the all the muscles except the external oblique, which showed decreased activation. 

Why is it Different?

All joints have passive structures (ie bones) and active structures (ie muscles). The higher muscular activation in the LBI group may be from a decrease in passive stability, requiring an increase in activity stability. Though high activation is assumed a good thing for stability, it may lead to increased fatigue and increased injury risk. This increases stiffness (stability) could also be a compensatory pattern for an underlying injury. A decrease in the external oblique activation may inhibit force distribution and overall core stability, as one muscle not working properly is theoretically disrupts stability according renowned spinal biomechanist Stuart McGill. 

These “scores indicates that the LBI group included individuals with inhibited as well as enhanced activation in local muscles, suggesting that there are potential subgroups. This may have implications for therapeutic interventions in that those with enhanced local activity may not benefit from therapies that focus on selectively activating deep muscles. Thus our results provide evidence of local muscle alterations although it is the first time that these impairments are reported during a functional but highly controlled task in those recovered from an episode of LBI (Butler 2012)”.

In summary, Butler concluded: “specifically, an overall increase in activity of abdominals and back extensors, increased agonist–antagonist co-activation strategy, reduced posterior oblique fiber activation and impaired local muscle responses to increased demand was found in the LBI

Practical Implications

Swimmers often have low back pain which symptoms quickly resolve. However, this study suggests underlying motor programming and impaired muscle activation exist after the resolution of symptoms. This makes it essential to seek rehabilitation or at least work on improving these imbalances, preventing a relapse. 

For some examples of core training, check out the COR Low Back Solution.

For more examples, consider purchasing Dryland for Swimmers.

  1. Butler HL, Hubley-Kozey CL, Kozey JW. Changes in electromyographic activity of trunk muscles within the sub-acute phase for individuals deemed recovered from a low back injury. J Electromyogr Kinesiol. 2012 Nov 28. doi:pii: S1050-6411(12)00195-2. 10.1016/j.jelekin.2012.10.012. [Epub ahead of print]
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.

Thoracic Outlet Syndrome: What it is, How to Spot it, a Case Report, and Prevention!

Take Home Points on Thoracic Outlet Syndrome: What it is, How to Spot it, a Case Report, and Prevention!:
  1. Thoracic outlet syndrome is a narrowing between your collarbone and first rib, putting pressure on your neurovascular structures.
  2. There are many neurovascular impairments at the shoulder.
  3. Monitor shoulder pain, symptoms, and alter sensation closely, and adjust prevention programs and biomechanics for greatest improvement.
Though shoulder impingement is the most common form of shoulder injury in swimmers, other cases of shoulder pain exist. These other syndromes impact other tissues, typically the nerual, arterial or vascular. Although these shoulder conditions are not well known, they still occur in overhead athletes. Asymptomatic pitchers even have impaired blood flow on their throwing side, a potential risk factor for Thoracic Outlet Syndrome (TOS). Some of these issues are treated conservatively, while others require surgery.

Types of Thoracic Outlet Syndrome

Knowing what occurs and the symptoms of tissues other than the muscular system is beneficial for a coach and rehabilitation staff. Here are some examples:
  1. Nerogenic Thoracic Outlet Syndrome: Compromising the brachial plexus. Symptoms are pain, numbness, tingling, and weakness. 
  2. Vascular Thoracic Outlet Syndrome: Compromising the venous or arterial system. The typical presentation includes pain, numbness, tingling, weakness, and/or the presence of vascular compromise. Venous TOS is more common than arterial TOS and is characterized by swelling and cyanosis, pain, and a heavy feeling. 
  3. Paget-Schroetter Syndrome: A thrombosis of the subclavian vein.

Clinical Tests for Thoracic Outlet Syndrome in Swimmers

There are manual and diagnostic test for identifying vascular compromise. Sadeghi-Azandaryani (2009) notes:

"Sensitivity of clinical tests was acceptable overall (mean 72%). The EAST test showed the highest sensitivity with 98%, followed by the Adson (sensitivity: 92%) and Eden tests (sensitivity: 92%). In contrast, the sensitivity of the Hoffmann test (47%) was low. Nevertheless, a positive EAST, Eden, Adson, Green-stone or Adson test was not associated with a poorer outcome (p≥0.05).

Systolic blood pressure was measured before and after exercise. Mean systolic blood pressure of the afflicted side in the group of patients with good or fair outcome (85.9% of all patients) showed an average systolic blood pressure of 123.1 ± 12.5 mmHg before exercise and 108.9 ± 12.8 mmHg after exercise (average decrease: 16.2 ± 9.6 mmHg). A decrease in blood pressure of more than 25 mmHg could not be found in this group. In the group of patients with a poor outcome, the systolic blood pressure before exercise was 140.6 ± 24.6 mmHg and 106.7 ± 21.8 mmHg after exercise (average decrease: 35.0 ± 14.1 mmHg). Statistical analyses showed that a distinct decrease in blood pressure after exercises was associated with a poorer outcome (p = 0.0027)."

Here are some of the most common tests:
  1. Roo's test: The patient stands and abducts shoulders to 90 degrees, externally rotates the shoulders, and flexes the elbows to 90 degrees. The patient then opens and closes the hand slowly for three minutes. The test is positive if the patient is unable to complete the test or experiences heaviness, numbness, tingling or pain.
  2. Adson's test: The examiner locates the radial pulse while arm is held in extension, external rotation and slight abduction. The patient is instructed to take a deep breath and turn head toward the test arm while extending the neck. If there is compression, the radial pulse will be diminished or absent. The goal of this test is to tense the anterior and middle scalenes.
  3. Costoclavicular test: The examiner palpates the radial pulse and then draws the patient's shoulder down and back. If the pulse disappears, the test is positive. The goal of this test is to provide compression of the costoclavicular space.
  4. Halstead maneuver: The examiner palpates the radial pulse and applies downward traction on the test extremity while the patient's neck is hyperextended and rotated to the opposite side. Absence of the pulse indicates a positive test.6
  5.  Wright test (hyperabduction test): The examiner palpates the radial pulse and hyperabducts the arm so the hand is brought overhead with the elbow and arm in the coronal plane. The patient takes a deep breath and may rotate or extend the neck for additional effect.
  6. Allen maneuver: The examiner palpates the radial pulse while positioning the shoulder in external rotation and horizontal abduction. The patient then rotates the head away from the test side.
Diagnostic tests also include a Doppler arteriography testing of the vascular system. If the compromise is neurogenic, nerve stimulation is sometimes used for diagnosis.

Example Swimmer with Paget-Schroetter Syndrome

The patient was a 21-year-old male swimmer who noticed swelling and pain in his non-dominant arm. The patient was advised to ice and rest his shoulder. Then, ten days after the initial heaviness, the symptoms returned and the patient was advised to seek emergency care where a Doppler venous ultrasound could be performed. The results were negative. The patient demonstrated a cease of the radial pulse, swelling, and limb cyanosis with the Wright’s hyperabduction test. He also presented with ⅘ strength on the affected side, but 5/5 strength on the non-affected side. Despite a negative Doppler venous ultrasound, the vascular surgeon suggested a venogram, since a Doppler venous ultrasound is best used as a screening tool, not for diagnostics, since it has difficulty specifically measuring the subclavian vein due to the bony structures. The venogram showed a major block of the subclavian vein, venous stenosis, and concomitant thrombosis.

The patient was then administration heparin and a tissue plasminogen activator (tPA) over a three day period in order to achieve thrombolysis.This improved the thrombus by 70%, indicating 30% of the vein had undergone permanent thrombosis. The patient was then prescribed coumadin and Lovenox as a blood thinner. Electromyography (EMG) was also performed to rule-out a neurogenic case of TOS, which demonstrated no muscle membrane instability.

The swimmer returned to the pool with great success (winning the conference in the 100 and 200 breast), then received a resection of the first rib. After the surgery, the patient complained of pain medial to the shoulder blade and demonstrated shoulder-blade winning. Manual muscle tests were performed again and noted 5/5 strength in all muscles. Fine-wire EMG was conducted again and showed normal signs of all muscles except the serratus anterior which demonstrated signs of denervation (likely due to surgical complications to the long thoracic nerve).

Despite the findings of the serratus anterior, the patient started a physical therapy program and home program which resulted in improved EMG readings for the serratus anterior, three months postoperatively.

Thoracic Outlet Syndrome Swimming Prevention Techniques

Steady Streamline:

If the arms move excessively during streamline, the upper arm and neural structures are stressed. Maintain a stable arm position during all streamline, especially dolphin kicking.

Flatter Butterfly:

Some swimmers (like Michael Phelps) press their chest down as they enter their arms in butterfly, delaying their pull. This creates a position with the arm above the chest, stretching and stretching the brachial plexus (all the nerves and vascular areas).  Try starting the pull earlier, not allowing a position of arms higher than the chest. 

Deep catch:

Many swimmers have a "catch-up" style stroke. Unfortunately, this increases stress at the shoulder joint and vascular system. If working on less stress, have the swimmer have a deeper catch as the enter the water.

Neutral Hand Entry:

Entering without hand entry is paramount for all shoulder prevention, as excessive internal rotation increases shoulder stress.

Shallow Backstroke Catch:

Entering with a deep catch in backstroke stresses and strains the neurovascular structures in the front of the shoulder...no good! Instead, have a wider, more shallow catch, similar to Missy Franklin's technique. 

Thoracic Outlet Syndrome Dryland Techniques

Foam Roll Thoracic Spine:

SMR Scalenes:

SMR Pectoralis:

Nerve Mobility:

First Rib Mobilization: 

Anterior Neck Strengthening:

Scapular Strengthening:

Summary on Thoracic Outlet Syndrome for Swimmers

Some cases of TOS require drastic treatment, like surgery (first rib resection). Instead of dealing with potential surgery, keep a close eye on TOS symptoms and begin early with treatment and technique modifications at the first instance of symptoms. 

These are only some technique modifications and treatments, as each person is individual and different stroke biomechanics and rehabilitation/prevention programs are necessary for each person. Moreover, just because some swimmers perform with techniques which increase shoulder stress, doesn't necessarily result in TOS or injury. Therefore, if you are suffering from TOS, see a rehabilitation specialist for guidance and individualization.

If looking for more injury prevention techniques, consider purchasing the COR Swimmer's Shoulder System.

  1. Nitz AJ, Nitz JA. Vascular thoracic outlet in a competitive swimmer: a case report. Int J Sports Phys Ther. 2013 Feb;8(1):74-9. 
  2. M Sadeghi-Azandaryani, D Bürklein, A Ozimek, C Geiger, N Mendl, B Steckmeier, J Heyn Thoracic outlet syndrome: do we have clinical tests as predictors for the outcome after surgery?Eur J Med Res. 2009; 14(10): 443–446. Published online 2009 September 28. doi: 10.1186/2047-783X-14-10-443
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.

Kinesiotape for Swimmers: Length, Strength and Timing. Part II

Take Home Points on Kinesiotape and Swimmers:
  1. The evidence does not suggest that kinesiotape aids athletic performance
  2. Kinesiotape may affect knee mechanics and improve pain in those with patellorfemoral pain syndrome
  3. Kinesiotape has been shown to increase acromiohumeral distance, potentially limiting risk for shoulder impingement symptoms. 
This is not a new topic to this blog (See Part I). But like any topic, one snapshot of the evidence is never the final word. So is there anything new to report in the literature on kinesiotape, especially as it may relate to swimming?

Overall, the general consensus is that the performance effects of kinesiotape are negligible to non-existent. Fortunately though, there appear to be no detrimental effects on performance (minus the potential opportunity cost of forgoing other potentially more effective mechanisms). 

In a recent systematic review, Drouin (2013) noted, “There is scant evidence to support kinesiotaping techniques as a successful means of affecting athletic-based performance outcomes such as improved strength, proprioception and range of motion, in healthy persons.” This appears to be definitive statement on the effects of kinesiotaping, but does it end the discussion?

One problem is that in most studies, kinesiotape is applied randomly as opposed to particular subjects for whom kinesiotaping is theorized to work. While the latter approach may sacrifice objectivity for potential bias, the latter may be more reflective of how the intervention is applied in real life. Be careful of labeling any intervention as “good” or “bad” as a blanket statement. Instead, the follow up should be “good or bad for whom?” It is a mistake to justify kinesiotape for performance based of any supporting literature for injury/pain, just as it is mistaken to outright dismiss kinesiotape as a clinical adjunct based on a lack of evidence to support performance improvements. 

Swimmers often focus on taping for the shoulder, but don’t forget the possibilities in the lower extremities, particularly for dryland and breaststroke. Song (2014) recently found that kinesiotaping caused significant shifts in patellar positioning in females with patellofemoral pain syndrome compared to the application of sham tape or a no tape condition during a single leg squat. However, both the sham tape and kinesiotape were successful in pain reduction. 

One especially pertinent study for swimming (Luque-Suarez 2013) published after our previous blog post, examined whether kinesiotape affects acromiohumerdal distance in healthy subjects (a potential measure of shoulder impingement risk). Authors of this randomized controlled trial noted that although the kinesiotape group had significantly greater increases in acromiohumeral distance compared to the sham taping group, direction of taping did not matter.


Overall, little has changed in the evidence on kinesiotape, especially regarding the lack of support for its theorized improvement on performance. However, recent studies have opened relatively new lines of inquiry regarding potential improvements in knee and shoulder biomechanics, both of which may be helpful for swimming health and technique.


  1. Luque-Suarez A1, Navarro-Ledesma S, Petocz P, Hancock MJ, Hush J. Short term effects of kinesiotaping on acromiohumeral distance in asymptomatic subjects: a randomised controlled trial. Man Ther. 2013 Dec;18(6):573-7. doi: 10.1016/j.math.2013.06.002. Epub 2013 Jul 4.
  2. Song CY1, Huang HY1, Chen SC2, Lin JJ3, Chang AH4. Effects of femoral rotational taping on pain, lower extremity kinematics, and muscle activation in female patients with patellofemoral pain. J Sci Med Sport. 2014 Jul 24. pii: S1440-2440(14)00135-2. doi: 10.1016/j.jsams.2014.07.009. [Epub ahead of print]
  3. Drouin JL1, McAlpine CT, Primak KA, Kissel J. The effects of kinesiotape on athletic-based performance outcomes in healthy, active individuals: a literature synthesis. J Can Chiropr Assoc. 2013 Dec;57(4):356-65.
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.

Do Growth Spurts Increase Injury Risk?

Take Home Points on Do Growth Spurts Increase Injury Risk?
  1. It seems the injury rate increases during growth spurts, but research is very limited. 
Growing pains are common in children, yet the cause and treatment of growing pains are not well known. Some hypothesize growing pains occur from muscles pulling on bones creating discomfort. Others believe increase in bone size simply increases discomfort from an increase in mechanical pressure. 

Growing pains are one type of "injury" during growth spurts. Specific adolescent injuries also exists, which I commonly see for Physical Therapy

Adolescent Injuries

  1. Osgood-Schlatter's Disease: is a painful swelling of the bump on the upper part of the shinbone, just below the knee. This bump is called the anterior tibial tubercle. It is believed to occur in active children who's patella tendon pulls on the tibial tubercle. 
  2. Sever's Disease: inflammation of the growth plate in the heel of growing children, typically adolescents. The condition presents as pain in the heel and is caused by repetitive stress to the heel and is thus particularly common in active children. It usually resolves once the bone has completed growth or activity is lessened.
  3. These are just a few common musculoskeletal injuries effecting children. Many other injuries can occur during growth spurts and parents for decades believe children have a higher injury risk during a growth spurt. Combine this injury risk with chronic poor posture from computers/electronics and early sports specialization and you've got a high injury risk for child...scary!

Growth Spurts and Injuries

Now, before we jump to conclusions about the injury incidence and growth spurts, we should consult
the limited literature:

Yukutake (2014) had 654 baseball players aged 6-12 years, all male, complete an original questionnaire that included items assessing demographic data, developmental factors (increase in height and increase in weight over the preceding 12 months), and baseball related factors. Multiple regression analysis was used to identify the risk factors for elbow pain during the 12 months prior to the study.

The data collected for 392 players without omissions or blank answers were submitted to statistical analysis. The results found that 19.1% of Little League baseball players had experienced elbow pain in the 12 months leading up to the study. The analysis revealed that height and increase in height were risk factors that increased the risk of elbow pain after adjustment for demographic data, developmental data, and baseball related factors.

Wild (2012) looked at ACL injury rates in adolescent boys and girls, noting girls have a higher ACL injury rate from:
  1. The effects of changes in estrogen levels on the metabolic and mechanical properties of the ACL
  2. Changes in musculoskeletal structure and function that occur during puberty, including changes in knee laxity, and lower limb flexibility and strength. 
  3. How these hormonal and musculoskeletal changes impact upon the landing technique displayed by pubescent girls.With limited research, limited conclusions are possible. 
However, the risk of injury increases during periods of growth. Unfortunately, recommendations now are purely theoretical. Some would suggest decreasing activity during maturation, but these are the peak years of motor learning. Instead, decreasing training volume and varying activities may be the best solution. This website has brought up the idea of a "swim stroke count", similar to a pitch for baseball. However, swim stroke counts may not be effective nor practical as many other factors influence musculosketetal stress on maturing bodies. Looks like we need more research on maturing athletic children!

  1. Yukutake T, Nagai K, Yamada M, Aoyama T. Risk factors for elbow pain in Little League baseball players: a cross-sectional study focusing on anthropometric characteristics. J Sports Med Phys Fitness. 2014 Apr 9.
  2. Wild CY, Steele JR, Munro BJ. Why do girls sustain more anterior cruciate ligament injuries than boys?: a review of the changes in estrogen and musculoskeletal structure and function during puberty. Sports Med. 2012 Sep 1;42(9):733-49. doi: 10.2165/11632800-000000000-00000. Review.
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.

Are Push-Ups Safe for Swimmers?

Take Home Points on Are Push-Ups Safe for Swimmers?
  1. Push-ups are a safe and effective exercise for swimmers with proper biomechanics and programming.
Questioning the safety of push-ups seems like it would make for a rather straightforward article, and 
if it was as straightforward as it seems, I would say that they are undoubtedly safe, and an extremely effective exercise for swimmers, at that; however, we need to create some more questions in order to form an educated answer. Is the coach qualified to supervise a push-up? Do they know what to look for in the exercise? Do they understand what variations may be best for different populations? Is the athlete doing enough mid and upper back work to balance the effect push-ups may have on the muscles of the shoulder girdle? 

Is the Coach Qualified to Supervise a Push-Up and Do They Know What to Look For?

When I say ‘qualified’ I don’t mean certified in Strength and Conditioning, or having a background in exercise science, all I mean by this, is that the coach or athlete has a basic understanding of what is really happening during a push-up, and what contraindications to look for in their respective populations.

Some of the most common flaws in an athlete’s push-up pattern are: poor arm position (either too close or too far from the body), extended or flexed head position (looking up, or down too far), and the most common—sunken hips with an arched back.

When judging arm position the rule of thumb is to put 45 degrees of space between the torso and the upper arm. This 45 degree position prevents the athlete from flaring the arms out too far and therefore placing too much stress on the shoulder girdle, it also prevents the arms from being in too close, causing too much flexion at the elbow, and therefore acute elbow pain or tendinitis.

A flexed head position is caused simply by the athlete either looking to make sure the arms are in the correct spot or just general poor body awareness (very common in swimmers). The best neck position is going to be neutral, where the head is looking straight down; not down at the feet, but simply down at the ground directly below their face.

An extended neck position is the result of some poor mechanics lower in the body. When the head is hyperextended, it is generally following the rest of the spine. When the spine is hyperextended, it is generally a result of passive restraints dominating throughout the core and hips. To mitigate this, the athlete must be cued to squeeze the glutes, as well as the abs. This whole complex of muscles firing is one reason why I trust athletes who tell me they can do 5 push-ups more than those who tell me they can do 50—at this number, it is very likely that the athlete is relying on passive restraints (ligaments, tendons, and bones) rather than actively engaging the appropriate muscles, and likely shortening range of motion, as well. 

If push-ups are done correctly, it is very possible for the abs and glutes to give out before the triceps or chest. This weakness usually subsides as the athlete becomes more experienced.

Does the Coach Understand What Variations May Be Best for Different Populations?

This question is crucial. Athletes have many different backgrounds, levels of experience, shoulder pathologies, leverages, and strength—all of which can drastically change exercise prescription. Most swimmers should stick with the simplest variations of push-ups, focusing on a tight core, as well as going through as large of a range of motion as possible (without pain). Even with a basic push-up many swimmers are not strong enough to demonstrate an entire set with decent form, and in many cases can’t even perform one single repetition. Many coaches here would have the athlete do push-ups from the knees, this variation however, tends to really hamper core activation, among other things, which drastically changes the movement. I prefer to have the athlete be assisted with bands. You can do this by setting up a large band around low pegs in a squat rack, then having the athlete lay over the band so that they are assisted as they get closer to the ground, and less as they get closer to the lockout, this is known as accommodated resistance. The further up the legs/torso that the band is placed, the athlete receives more assistance, the further down, less assistance is given. If a band is not available, a secondary option is to have the athlete perform a push-up to a bench or wall. Again, the more upright the athlete is, the most assistance they are receiving, so try to work the athlete to get close to the ground, and in the banded set up, have the athlete work at lowering the band placement each session. 

Some of my favorite progressions for the exercise are: hand-release, clapping, foot-elevated, single foot, gymnastic ring push-ups. These are all rather advanced and should only be attempted after a mastery of the standard push-up is present. On the other hand, some of the best regressions are the aforementioned band-supported, and incline push-ups (to a wall or bench).

It is very possible that having the hand on the ground during the push-up can irritate the athlete’s wrist. In this case, I suggest using dumbbells, placing them slightly outside of shoulder-width, and having them turned so that the hands can be slightly supinated—this will further reduce pain/ joint problems. Dumbbells with hexagonal bells are ideal here because they won’t roll away from the athlete during the movement. 

Is the Athlete Doing Sufficient Upper and Mid-Back Work to Balance the Effects of the Push-Ups?

Push-ups are partially so awesome because they can be done anywhere that there is the space to perform them, but what is not so awesome is that push-ups can make up far too much of a swimmers dryland program because there may be very restricted access to further equipment. Too many pressing exercises can pull the shoulder girdle forward over time causing pain, as well as poor performance. To counter problems associated with this, we must make sure that enough work is in place for the mid and upper back to keep the shoulder girdle in a neutral resting position. Many strength coaches go as far as saying that the ratio of pulling to pushing exercises should be 3:1, I however, think 1.5:1 is more reasonable, as long as the athlete already has a decent resting posture. 

This back work should hit the lats, traps (upper, mid, and lower), rhomboids, and rear delts. Great exercises for this are dumbbell rows, pull-ups, chest-supported rows, rear delt raises, among others. There are thousands of variations to the exercises already listed, focusing on these, and variations thereof, will give you enough dryland programs to last for years. 

Many argue that the demands on the back are high enough in swimming that there should be a reduction in back work during dryland to compensate. The work done by the back in swimming is usually too low in intensity/load to make significant hypertrophic differences, plus the fact that outside of the pool time, many athletes are in a state of flexion, be it at a desk at work or school, at home watching tv, or driving, which all needs to be accounted for (the 22 hours outside of practice are frequently overlooked during program design). 

The push-up is a fantastic exercise for swimmers and should be a mainstay of a swimmers’ training programs. Proper coaching of the exercise is more likely to determine its safety and effectiveness more so than any other factor. Keeping exercises balance is another huge key to long-term athletic development and safety, so be sure to implement a full dryland regimen to improve body awareness, speed, and conditioning.

Written by John Matulevich a powerlifting world record holder in multiple lifts and weight classes, as well as a Head D-2 Strength Coach, and previously a nationally ranked college athlete. His concentrations are in sports performance, powerlifting, and weight training for swimming. To learn more about how John trains his athletes, check his Twitter page: @John_Matulevich. He can also be reached at MuscleEmporium@gmail.com with inquiries.

Friday Interview: Dr. Lizzie Hibberd Discusses Swimmer's Shoulder Prevention

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

Hello all! My name is Lizzie Hibberd and I am currently serving as an Assistant Professor and the Director of the Athletic Training Research Laboratory in the Department of Health Science at The University of Alabama. I received my B.A. and M.A. degrees in Athletic Training from the University of North Carolina at Chapel Hill (2008 and 2010) and received a Ph.D. in Human Movement Science from the University of North Carolina at Chapel Hill in 2014.

My interest in athletic training began when I was in high school. After injuring my shoulder and relying on the help of athletic trainers for evaluation and rehabilitation, I began working as a student athletic trainer. From my experience as an injured athlete and working as a student athletic trainer, I chose to attend UNC-Chapel Hill and started in the Athletic Training Program. After undergrad, I stayed at UNC and worked as a graduate assistant athletic trainer for UNC’s Swimming and Diving and JV Basketball teams. As soon as I began working with the UNC Swim Team, I realized there was a huge gap in the literature about prevention, assessment, and treatment of swimming related shoulder injuries. In order to improve the quality of care for athletes and advance the profession through evidence-based medicine, I continued my education in the Human Movement Science Program. While in the program, my research focused on injury biomechanics and injury prevention in overhead athletes- primarily swimming and baseball.

2. You have been the predominant researcher in the US on swimming shoulder injuries. What have been your pieces and interest in the sport?
My interest in the sport developed when I was working as an athletic trainer with the UNC Swimming Team. This was really my first exposure to the sport, where I understood the demands that were placed on the athlete. The first few months were definitely a huge learning curve for me to really understand the training and the culture of the sport. During this time, I developed such an appreciation for a sport that very few people know anything about. As I was treating athletes and trying to develop injury prevention programs, I discovered that there was a huge gap in the literature related to swimming injuries. From this experience, I decided that I wanted to focus on clinically applicable research to improve the quality of care for swimmers and other overhead athletes and began my research career on injury biomechanics and injury prevention. During this time, I have worked with youth, collegiate, and masters swimmers both in clinical and research capacities.

3. For your paper regarding the general rehabilitation program and scapular stability (dyskinesia), what did you look at?
For this paper (Effect of a 6-Week Strengthening Program on Shoulder and Scapular-Stabilizer Strength and Scapular Kinematics in Division I Collegiate Swimmers), we looked at the effect of a shoulder injury prevention program on physical characteristics in collegiate swimmers during the training season. The injury prevention program that we used was adapted from exercises that have been shown to be effective for injury prevention or strengthening scapular stabilizing musculature in baseball players. The characteristics that we looked at as part of this project were glenohumeral range of motion, scapular kinematics, posture, shoulder and scapular stabilizer strength, and pain score.

4. What were the main results?
In this project, we found that overall all swimmers moved in to greater forward shoulder posture and altered scapular kinematics that promote impingement regardless of group assignment. The strengthening program that was used in this paper was not robust enough to counteract the demands of the training load during the training season.

5. How could the rehabilitation programs prescribed be improved?
From the results of this study, the biggest places for improvement is on the timing of implementation. While most swimmers take a short rest period before their training season, this may be the most beneficial time to complete an injury prevention program. During the training season, the fatigue they experience from high training loads increases their risk for the development of injury. Completing a strengthening program prior to this heavy training would put the athlete in better position to mitigate the demands of the training. During the training season, a maintenance program should be completed with a greater emphasis on stretching.

Also, the findings of this study highlighted the importance of research specific to swimmers. Many times all overhead athletes are grouped into the same category and programs that are effective for baseball players are automatically applied to swimming. The demands and adaptations are unique to each overhead sport, and research is needed specific to each sport to best help the athlete.

6. You had another study monitoring shoulder pain via questionnaire in club swimmers. What were the main results of this study?
In this study (Practice Habits and Attitudes and Behaviors Concerning Shoulder Pain in High School Competitive Club Swimmers), we looked at 13-18 year old competitive swimmers that are training on the top training level at their clubs in order to understand the culture of swimming. We found that these adolescent club swimmers have a high frequency of practices, comparable to collegiate and professional swimmers. They believe that shoulder pain is normal and should be tolerated to complete practice and are regularly taking pain medication in order to manage their pain so that they can complete practice yardage.

On the plus side, we found an association between the swimmers' attitudes and behaviors, which indicates that interventions that educate the swimmers, coaches and parents may be effective in changing their attitudes and ultimately their behaviors, and potentially changing these cultural norms.

7. As a PT, these results really upset me. What were your thoughts on the incidence of pain and current practice?
From working clinically with swimmers, I was not surprised that training with shoulder pain is the cultural norm in competitive swimmers. Currently, the training demands in these youth athletes are tremendous and so far, there is only anecdotal evidence that these training methods are effective. This high volume of training leads to alterations in physical characteristics that predispose swimmers to shoulder pain and injury. In the future, I hope coaches and researchers partner to identify training methods that maximize performance while minimizing injury risk. This will take a lot of collaborative work, but I will be imperative in preventing these injury and making evidence-based practice and injury prevention guidelines.

8. If a swimmer is having pain in their shoulder in practice, in your opinion, what should the coach do?
I think the biggest thing that the coach can do is make it known that injury prevention and awareness is a priority. It seems like many of the swimmers that I have previously worked with (across levels) are afraid to tell their coach or don’t even think that it is something they should report because shoulder pain has been normalized in the sport. It would be beneficial for coaches to have education sessions with their athletes, or even better bring in a sports medicine professional, to talk about shoulder pain and injury prevention.

If an athlete does report true shoulder pain, where they are having pain and altering their stroke mechanics in order to complete the necessary yardage, the coach should remove the athlete from practice for that session, have then kick (not with a kickboard because that is impingement position!), or have them do some type of cardio out of the water. Removing from practice is only one part of the solution, though. The coach should talk with the athlete to determine what bothers them and evaluate how dryland training, weights, or specific swimming drills may be contributing to their pain. Making these alterations would benefit that specific athlete, but also others who are not reporting their pain. It would also be imperative for this athlete to begin a rehab program- which is where a sports medicine professional (physician, athletic trainer, or physical therapist) would be crucial.

9. Recently, you were part of a study monitoring stroke biomechanics in college swimmers. What did this study look at and find?
In this study (Prevalence of Freestyle Biomechanical Errors in Elite Competitive Swimmers), we evaluated the prevalence of biomechanical stroke errors in collegiate swimmers using underwater cameras. We focused primarily on freestyle, because of the heavy training load in the freestyle stroke regardless of stroke specialty. Both coaches and an athletic trainer graded each swimmer based on the defined errors. The biomechanical errors that we defined were a dropped elbow during the pull-through phase, a dropped elbow during the recover phase, an eyes-forward head-carrying angle, incorrect hand position during hand entry, incorrect hand entry angle, incorrect pull-through patter, and inadequate body roll. We found a high prevalence of errors in these elite swimmers, with dropped elbow during the pull-through and the recovery phases with the highest prevalence. We also found relationship between dropped elbow during recovery and improper hand entry position and angle and eyes-forward heady carrying angle with incorrect pull-through pattern. This indicates that presence of one of these errors is related to having an additional error.
10. Did these results surprise you?
Not really. From previous work that we have done, most youth athletes believe that there is not enough time spent on technique work in practice. I think there is so much emphasis on the number of yards that the quality of the yards is sometimes put aside. Further, the errors that we identified were from a variety of coaching and biomechanical literature, but to our knowledge a comprehensive list of stroke errors related to injury had not previously been created. Finally, some of the coaches the evaluated the videos commented that while they understood why this was biomechanical error, performance-wise it was how they taught the stroke. This is another area of opportunity for biomechanists and coaches to work together to identify ways to maximize performance while minimizing injury risk.

11. What steps can be made for improving biomechanics in college swimmers?
In my opinion, the biggest way to improve biomechanics is to put an emphasis on it in age-group swimming. It is hard to change the motor patterns of a collegiate swimmer, who may have been swimming with a certain stroke for 13+ years. However, if you do have an athlete that you want to focus on changing their stroke, I believe video is one of the most important tools for the athlete. Many athletes, and especially swimmers because they rarely get to see their stroke, respond well underwater video where they see the problem in their stroke, as well as have their progress tracked as they make the change. While there are many expensive software and cameras out there for this, things like GoPros and even iPhones with an underwater case may be adequate as a beginning step in film evaluation.

12. Same question, but with age-group swimmers?
This is the place where there is the greatest opportunity for installing proper swimming mechanics and making changes! An emphasis on proper stroke regularly during practice, individual work if necessary, video analysis, and modeling of proper strokes is imperative at this age. Ensuring proper mechanics before moving on to high yardage is critical.

13. What research or projects are you currently working on or should we look from you in the future?
I recently completed a project tracking youth swimmers over the course of their training season to identify what physical characteristics change during the training season and how this relates to alterations in pain levels and another project tracking postural changes in collegiate swimmer during the season. The findings from this study will help in developing evidence based injury prevention programs.

My future research agenda includes: validation of an evidence-based injury prevention program, development of a swimming pain and function survey, prospective analysis of risk factors for injury in competitive swimmers, and research on training load and recovery. All of these areas/projects will hopefully help in maximizing performance while minimizing injury risk in competitive swimming!

Thank you for the opportunity to discuss my research with you! Please feel free to contact me with questions, research ideas, or comments.

Elizabeth Hibberd, PhD, ATC
The University of Alabama
483 Russell Hall
Box 870311
Tuscaloosa, AL 35487-0311

Post-Operative Prognosis for Swimmers

Take Home Points on Post-Operative Prognosis for Swimmers

    1. Many factors determine shoulder surgery outcomes
    2. Prognosis for return to prior levels of performance is bleak for overhead throwing athletes
    3. Limited research exists on post-op outcomes on swimmers
    Shoulder injuries are unfortunate realities of competitive swimming.  Most commonly, injuries can be treated with some combination of rest, treatment, and exercise.  Evidence favors conservative care before trying surgery and also encourages rehabilitation post-op for optimal function.  Unfortunately though, many injuries progress to needing invasive care (ie surgery). 

    Many factors go into surgery: surgical skill, injury mechanism, severity, patient status (Age, health, etc), patient motivation, among others variables.   But what are realistic expectations for surgical outcomes among swimmers?  At the extremes, some believe you can never return to prior performance, while others believe surgery cures all.  The truth likely exists somewhere in the middle. 

    Asking the right questions is imperative: what are the chances of returning to prior level of performance (or even higher)?  Surgeons may sometimes evaluate success based on a) the quality of their craftsmanship (it didn’t break!!!!) and b) whether the patient can resume normal activities of daily living.  The problem for swimmers is that the swimming shoulder has far greater demands than 99 pct of the general population. 

    To my knowledge, there has been no formal study on post-op outcomes on return to level of performance in swimming.  Designing these studies can be difficult too, with the temptation of surgeons to cherry pick cases with a likelihood of a favorable outcome.  Though swimming has unique demands, research from other sports can offer some clues. 

    One recent study (Fedoriw 2014) examined professional baseball players who suffered superior labrum anterior posterior (SLAP) tears.  Of the pitchers, 22% who attempted conservative (non-surgical care) returned to a prior level of performance or higher, with level marked by the level of league in which they competed (A, AA, AAA, Majors).  Only 7% who underwent surgery returned to prior performance levels though 48% returned to play at all.  However, among non-pitchers, 54% returned to prior performance levels.

    A similar study by Van Kluenen (2012) focusing only on pitchers revealed another low rate of return to prior performance.   All players studied underwent surgery (no conservative care in this study) but only 6 of the 17 players in the sample returned to their same or higher level of play following their procedure.  Notably, all the patients in this study presented with Glenohumeral Internal Rotation Deficit (GIRD). 

    Another review (Sayde 2012) expanded the inquiry beyond baseball players and found
    better results among non-overhead athletes.  Overall, 83% had "good-to-excellent" patient satisfaction and 73% returned to their previous level of play whereas only 63% of overhead athletes returned to their previous level of play.”  Though the results seem more favorable when expanded beyond pitchers, it’s still unclear where swimming falls on the continuum between non-overhead athletes to pitchers.


    Shoulder surgery is a very personal choice.  While favorable outcomes are very possible in high level athletes, the prognosis gets bleaker with greater overhead demands on the shoulder.  If we equate swimming shoulder demands to baseball pitchers, at best we can say that return to prior performance levels is unlikely.  That said, there can be many confounding variables at work.  Better surgical skill and deeper athlete motivation can make or break and outcome.  Ultimately, know that swimmers who return to higher levels of performance after shoulder surgery have done so against long odds. 


    1. Fedoriw WW1, Ramkumar PMcCulloch PCLintner DM.  Return to play after treatment of superior labral tears in professional baseball players.Am J Sports Med. 2014 May;42(5):1155-60. doi: 10.1177/0363546514528096. Epub 2014 Mar 27.
    2. Van Kleunen JP1, Tucker SAField LDSavoie FH 3rd.  Return to high-level throwing after combination infraspinatus repair, SLAP repair, and release of glenohumeral internal rotation deficit.  Am J Sports Med. 2012 Nov;40(11):2536-41. doi: 10.1177/0363546512459481. Epub 2012 Oct 10.
    3. Sayde WM1, Cohen SBCiccotti MGDodson CC.  Return to play after Type II superior labral anterior-posterior lesion repairs in athletes: a systematic review.  Clin Orthop Relat Res. 2012 Jun;470(6):1595-600. doi: 10.1007/s11999-012-2295-6.
    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.

    Are Ice and NSAIDs Beneficial for Recovery?

    Take Home Points on Are Ice and NSAIDs Beneficial for Recovery?
    • Ice helps decrease pain, but does increase muscle damage.
    • NSAIDs restore function, but improve bone, but not soft tissue healing.
    The use of non-steroid anti-inflammatory drugs (NSAIDs) and ice are common staples in
    sports medicine. Yet, the use of these modalities has recently received resistance from some online experts (Kelly Starrett, Dr. Gabe Mirkin). Despite this criticism, these modalities are still frequently used, sometimes ad libium. Now, before I make a notion on these modalities, it is important to understand the injury process, below is an exert from the COR Swimmer's Shoulder System.

    Everyone is familiar with inflammation. The inflammatory process occurs within seconds of every injury, but can linger for weeks or months with bad injuries or poor management.

    Inflammation is stemmed by the infiltration of cells, entitled neutrophils, during the first 6-24 hours; they are replaced by other cells (monocytes) in 24-48 hours. These cells will try to attack the inflammation and remove injurious agents. Phagocytosis is involved in the process of engulfing foreign particles and releasing the enzymes of neutrophils and macrophages which are responsible for eliminating the injurious agents. These are two major benefits derived by the accumulation of leukocytes at the inflammatory site.

    Chronic inflammation is a different warrior. The key player is another type of cell, the macrophage. Macrophages are large cells that can remain for weeks to months, perpetuating injuries.

    The classic signs and symptoms of inflammation are swelling, redness, throbbing, radiating heat, and constant pain. These pains especially occur when you wake up in the morning and last between thirty and sixty minutes. Also, just because you had the initial injury four months ago doesn’t mean inflammation has resolved or hasn’t returned, so pay closer attention to the signs and symptoms as opposed to the duration.

    Once again, the inflammtory process initiates every injury. This process is beneficial in restoring the body, but does decrease strength. This decrease in strength is why many seek improvement [well and the pain]. This has resulted in the use of the two most common modalities NSAIDs and ice. Unfortunately, these two modalities may prevent the normal physiological reaction of an injury. This impairment is thought to alter long-term improvement. However, many people take NSAIDs and ice for short-term gains. If someone needs improvement, for a quick return to the pool, then NSAIDs and ice are beneficial. However, the use of these modalities likely decreases long-term recovery, perhaps increasing the risk of re-injury. Unfortunately, most of this research is based on rodents, not humans and as I've mentioned before, rodents have different inflammatory processes! This makes the research nontransferable to humans ... oh well! Nonetheless, lets look at the research we have!

    NSAIDs on Healing

    The authors reviewed the effectiveness of NSAIDS and selective (COX-2 inhibitors) NSAIDS on soft tissue and bone healing. A total of 44 articles reviewed (9 on soft tissue and 35 on bone healing). Thirty-nine of these articles were on animals and 5 on humans.

    No humans studies have been done on humans assessing the interaction between NSAIDS and soft tissue healing. Of the studies reviewed, there is a controversy between the administration of selective and non-selective NSAIDS after surgery, as many studies suggest detrimental effects on bone and soft tissue healing. However, the literature on this subject in humans is minimal.

    It appears inflammation mediated by prostaglandins is necessary to improve bone healing. However, in soft tissue injury, growth factors are more important and prostaglandins less involved. This suggest NAIDS are likely beneficial in soft tissue, but potentially not bone healing.

    Improving inflammation is necessary to decrease symptoms, however the use of NAIDS during bone repair may impair recovery, therefore only use NSAIDs in soft tissue injuries. However, more human clinical trials are necessary before a definitive answer is possible.

    NSAIDs on Gut Bacteria

    One potential hazardous result of NSAID consumption is the potential loss of integrity of bacteria, making the gut permeable to harmful substance.

    Nine male trained cyclists underwent small intestine lining permeability in four different conditions (Van Wijck 2012):

    1) during and after cycling after intake of ibuprofen

    2) during and after cycling without ibuprofen

    3) rest with prior intake of ibuprofen

    4) rest with prior ibuprofen intake

    The small intestinal lining was evaluated by providing the subjects a sugary drink, then assessing the amount of human intestinal fatty acid binding protein (I-FABP).

    The ibuprofen conditions took 400 mg of ibuprofen the night before and 1-hour prior to cycling on a fasted stomach. The cyclist performed roughly 90 minutes of cycling at moderate/hard cycling.

    In both exercise conditions, the I-FABP levels gradually increased with cycling. However, cycling with ibuprofen ingestion resulted in even high levels of I-FABP.

    These results show cycling alone increases both gastroduodenal and small intestinal permeability. This difference increased with ibuprofen intake. This is thought to be from splanchic hypoperfusion, reducing the blood to the gut and including injury to the enterocytes. One of the major pathways suspected for GI damage is:

    “to be involved is the inhibition of COX isotypes 1 and 2, resulting in local inflammation and vascular dysregulation, ultimately reducing perfusion and promoting mucosal integrity loss within the splanchnic area (Van Wijck 2012)”.

    Unless ergogenic benefits from NSAIDs exists, swimmers should not use these medications prior to exercise. Moreover, inflammation may yield greater results in endurance sports. One flaw with the study is the fact the athletes were fasted while taking NSAIDs. However, one note is the athletes were fasted during this test, this may have increased the intestinal lining to susceptibility.

    For rehabilitation, NSAIDs may still be beneficial, but at this time it is not certain if the benefits outweigh the risks.

    Ice and Muscle Damage Healing

    Eleven male college baseball players underwent two trials: sham application and topical cooling. Each trial was used five sessions of 15-min cold pack application to the exercised muscles 0 hours, 3 hours, 24 hours, 48 hours, and 72 hours after eccentric exercise training.

    The eccentric training protocol consisted of 6 sets of 5 eccentric contractions with 2 min rest between sets at 85% of their maximal strength. Muscle hemodynamics (hemoglobin most notably), inflammatory cytokines (multiple interleukins), muscle damage markers (Creatine kinase), visual analog scale (VAS), and muscle isometric strength.

    After topical cooling, rapid and sustained elevations in total hemoglobin and tissue oxygen saturation were noted. Also, creatine kinase was noted in both trials, but was elevated after topical cooling. Inflammatory markers were not changed following cooling. VAS was not different between groups, however topical cooling significantly increased rating of fatigue post-exercise. No significant differences were noted in strength between groups.

    Increased muscle damage, most notably the creatine kinase increase, was apparent in the topical cooling group. This is thought to occur from the rapid deviation in blood supply to the muscle.

    Using ice after practice improves muscular soreness, but appears to increase muscle damage due to rapid changes in ischemia. Therefore, unless injured topical cooling should be avoided.

    Ice and Blood Flow

    Nineteen subjects participated in this single-blinded, where the clinician was blinded. There was no history of lower extremity injuries for the past 6 injuries. Each participant visited the laboratory four separate times where baselines were measured at the first two visits, then the next two visits a trial of ice (750-g of crushed ice placed on the medial gastrocnemius) and a control trial.

    “There was a significant correlation (r = 0.49) between subcutaneous tissue thickness and change in intramuscular temperature immediately after treatment (P = 0.05) for the cryotherapy condition. Significant correlations were also found for change in temperature during the rewarming period and change in blood volume at rewarming (r = 0.53, P = 0.033) and change in blood flow at rewarming (r = 0.56, P = 0.025) for cryotherapy (Selkow 2012)”.

    Microvascular perfusion of the gastrocnemius did not decrease from baseline with cyrotherapy was applied, despite the decrease in subcutaneous temperature. The result was different than past studies, as many think cryotherapy decreases blood flow. This may be from no alterations noted in the microvascular.

    In the healthy population, cryotherapy appears not to alter blood-flow. Therefore, benefits and risks associated with cryotherapy application for inflammation may be negligible. However, next research must look at inflammation specifically. Until then, the effects of ice for injuries seem purely for slowing nerve conduction to gate pain.

    NSAIDs or Corticosteroids for Recovery

    Zheng (2014) performed a systematic review of all the high-quality studies comparing NSAIDs and corticosteroid injections, a total of ten full articles. Overall, 267 patients were analyzed and of the six studies two focuses on rotator cuff tendonitis patients, two on shoulder impingement syndrome, one studied frozen shoulder of diabetes and the other investigated shoulder pain.

    Of these studies, NSAIDs and corticosteroids did not have a significant difference in pain improvement. Corticosteroids were significantly better for remission of symptoms. Five of the studies reported range of active shoulder abduction and note NSAIDs did not significantly improve the active shoulder abduction compared to corticosteroids. The studies assessed were 4 – 6 weeks in length.

    Compared to NSAIDs, corticosteroid injections provide faster relief. However, comparisons of other therapies and conjunctions of therapy are needed, as well as longer study periods and follow-ups.

    My Recommendations

    If you are injured, stop exercising. If the pain is non-stop, see a rehabilitation specialist like a physical therapist. At this time, apply ice, as it does reduce pain and doesn't seem to alter blood flow. However, apply the ice for a short period, as it may increase muscular damage. I suggest applying the ice for up to 10 minutes and remove it for 20 minutes. Only ice immediately after the injury, ~6 hours after the injury. If you are competing at a meet and must perform, NSAIDs can help decrease pain and restore function. However, if you are not in a rush for return, try not to ice and consider compression instead. Compression helps naturally clear the fluid from the joint, facilitating recovery. When you are able to move comfortably without pain, do so. Movement also helps move fluid out of the joint and restore function. However, do not move into pain, as this can alter movement patterns and impair function. 

    Try and prevent using NSAIDs, unless unrelenting pain exists and the injury appears muscular. If recovering from an injury, a corticosteroid injection is likely better than just NSAIDs, but remember other rehabilitation is needed. 

    We have much more research needed on the subject, but it isn't clear that ice and NSAIDs are a “no brainer”. Until more research is performed, I'll continue the suggestions I've made for years, if you're in no rush, let the inflammation naturally make it's way throughout the body, giving yourself rest and compression for improvement. Once you're able to move naturally do so! However, if you are in a rush, like at a big competition and need to get in the pool, NSAIDs and ice can help!


    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.