Background on Knee Pain in Swimming
Knee pain for during breaststroke is one of the most common occupational hazards in the sport, both for breaststroke specialists and non-specialists, with 3 out of every 4 swimmers reporting breaststroke knee pain. The volume demands tax all swimmers, as even the non-breaststroke specialists will take thousands of breaststroke kick cycles per year. The breaststroke kick is hardly a natural movement and can trigger breaststroke knee pain in all swimmers. Though non-specialists may be at risk due to suboptimal joint morphology for the stroke, specialists may have an even higher risk due to much higher breaststroke volume. Additionally, the fact the same knee hypermobility that makes some ideally suited for stroke performance can also contribute to problems if stability is not present to match extreme ranges of motion. Every swimmer is different, so making broad generalizations ineffective. But we can offer the most pragmatic strategies to prevent breaststroke knee pain. Although eliminating all breaststroke knee pain is unrealistic, we can take steps toward reducing its occurrence.
10 Mandatory Tips Minimizing Breaststroke Knee Pain
1. LESS HIP ABDUCTION, MORE HIP INTERNAL ROTATION, MORE HIP EXTENSION
The “unhappy triad” of breaststroke knees is excess hip abduction (legs spread too far apart), limited hip internal rotation, and limited hip extension. Although we did not mention the knees here, optimal function in these three patterns will protect the knees more than isolated knee work. The knee has very limited multiplanar movement ability. The hip, in contrast, has an expansive degree of freedom to move in all three planes. If any parts of the unhappy triad are present, excess responsibility is transferred to the knee, which may ultimately result in injury. Take note that there are several ways you can address these joint movements, whether through exercise, manual treatment, or strengthening. You are never limited to strategy so long as the end outcome is favorable.
DRYLAND TIP: INCREASE HIP FLEXION FOR BREASTSTROKE
1a. MORE ANKLE DORSIFLEXION AND EVERSION
There is not much evidence on the role of the ankle in breaststroke, but we can infer that optimal ankle function can help alleviate stress on the knee based on their relationship in the kinetic chain. In land-based sports, the foot/ankle complex is often a source of knee problems. Improving ankle dorsiflexion and eversion adds another layer of insurance to protect the knees.
A warm-up can increase local blood flow and decrease the viscosity of the joint. Though the same can be said for every joint, the knee seems to benefit more from warm-ups than other joints, although the evidence is limited linking a warm-up to breaststroke knee pain. (Rovere 1985) One unanswered question is whether a land or water (or some combination) is most beneficial if there’s even a difference.
3. TRAINING VOLUME
Though it is easy to say cut back volume to prevent injury, in reality, the answer is far more nuanced. If you are a breaststroker, then doing a lot of breaststroke training is unavoidable. For non-breaststrokers ask how much is really essential, if the goal is simply to keep the team together on IM sets. Injury free training is far more important than having a distance freestyler struggle through IM/breast training.
Also, consider these other possibilities: Maybe the swimmer is spending too much time in intense training zones forcing otherwise solid technique to break down. Or maybe the swimmer is doing too much slow swimming, as many swimmers technique deteriorates in easy swimming. Maybe the swimmer is in a wrong lane and is forced to swim above their ability each day to keep up. Maybe the overall work wasn’t rotated properly or there was insufficient buildup, or the peak mileage was held too long. Does your team have a systematic plan for increasing breaststroke volume for reducing overloading the knee joint? Bottom line, though training volume is often a factor, don’t assume that doing less training is the best answer.
4. SAFE DRYLAND
The fact remains that many swimmers get injured on dryland doing unsuitable training. The pain merely expresses itself in the water. What many swimmers see as a swimming problem is really a dryland problem. Simply watch the poorly executed lower body movements in the gym and mindless jogging assigned by coaches for dryland, and it makes sense why knee pain would get exposed in the breaststroke. One way to enhance quality control in dryland for the lower body is to emphasize single limb training, such as single leg deadlifts and single leg squats.
5. QUICK FIX
Sometimes there is nothing wrong with a quick fix. It should be just that: a quick fix, not a substitute for a long-term solution. Kinesiotape is a safe, noninvasive remedy that may help low-grade symptoms sufficiently to avoid missed practice time. Don’t expect this to cure any symptoms. It certainly won’t address the cause of any pain either. But it CAN help keep a swimmer in the water, which may ultimately prevent any secondary injuries that often strike when a swimmer sits out for one injury but then gets a different injury upon return due to lost proprioception during the convalescent period.
If the knee pain during breaststroke steams from patellofemoral pain syndrome, consider trying a more aggressive taping procedure with McConnell tape. Unfortunately, this tape is so tight it doesn’t stay well on the knee during swimming but could be an adjunct between workouts.
6. THE MIND GAME
Speaking of breaststroke knee pain, remember that pain has a psychological component. Looking at radiological imaging it is actually quite difficult to distinguish the painful knees from asymptomatic ones. Patient/athlete education is critical, as swimmers can exaggerate a relatively minor condition into a full-blown injury if they have been convinced something is “broken.” Language is critical, along with graded exposure to increasing loads, whether in normal training or in rehabilitation. Avoid using language with gloomy undertones such as “broken” or “damaged” (unless there truly is a break or tear). When working with children, stressing the importance of an injury, but not making them a hypochondriac is a fine line. Try not to exaggerate the severity, but persists on fixing the issue.
This is somewhat related to the first point about hip abduction/rotation/extension. But there is far more to technique than joint angles. Every swimmer’s body is unique and will have some variation on the theme of good technique. The key is to understand what the swimmer’s technique looks like when healthy to have a baseline for if the stroke begins to break down.
How does torso to leg length or femur length influence technique? Does it matter? Some items to consider when suggesting biomechanics for swimmers. Also, how deep is the hip socket, these anatomical differences may alter the ‘perfect’ technique for a swimmer.
8. SELF CARE
We don’t know the mechanisms of self-myofascial release, but we do know that swimmers often feel better. We’re not making any structural changes to tissue, but we are affecting the nervous system in a way that can permit the joints to function in the healthiest manner. Daily massages are unrealistic for all but a handful of professional swimmers. For everyone else, a few minutes of self-care in keys areas of the lower extremities can help preserve soft tissue quality and also serve as a “check-in” for whether any abnormal discomfort is developing.
Drills are somewhat controversial as to their effectiveness, but they are a way to sustain in-water training momentum if breaststroke knee pain prevents normal training loads. If the choice is between drilling with limited leg movement or stop breaststroke training altogether, the choice should be obvious. Fortunately, there are three other strokes that shouldn’t stress the knee, but it is still possible to maintain the breast pull with drills such as arms-only breaststroke and breaststroke pull with dolphin kick.
The knee is an especially vulnerable joint in hypermobile individuals because it enjoys a vast range of motion in the sagittal plane (front/back, or flexion/extension) but anatomically is limited in other planes. Hypermobility can stress the joint at or beyond its limits, despite your best efforts with technique and training volume. Learn to recognize if you are dealing with a hypermobile swimmer. Though many swimmers will benefit from increased mobility in the hips and back, some may actually need LESS mobility.
Summary of 10 Mandatory Tips Minimizing Breaststroke Knee Pain
Clearly, having breaststroke knee pain is detrimental to performance. Therefore, creating a systematic approach to keeping knees healthy in your breaststrokers is key! Manage volume, work on technique, and use prevention and health care professionals as tools for your team and you’ll be the coach that has the “secrets” of keeping knees healthy.
Written by Allan Phillips. Allan is a Certified Strength and Conditioning Specialist based in San Antonio, Texas and is the owner of Pike Athletics. He holds a Level 2 certification from the ASCA and is a Level 1 USA Triathlon coach. As a dryland specialist, he is a Level II kettlebell and bodyweight instructor through StrongFirst. Along with writing for Swimming Science, Allan is a regular columnist for SWIMMER Magazine.