Troubleshooting Series: Cervical Spine

Troubleshooting Series: Cervical Spine Injuries in Swimmers

Dr. GJohn Mullen Biomechanics, Blog, Dr. John Mullen, Dryland, Injuries, Latest&Greatest, Training Leave a Comment

Troubleshooting Series: Cervical Spine Understanding cause-and-effect lies in the heart of effective movement correction, both in and out of the water. The better grasp we have of the body’s movement fundamentals, the more capable we can decipher the visual presentation of stroke flaws. The quotations around “flaws” are intentional, as the flaw that catches our attention on deck may be the body’s default way to compensate for an underlying physical limitation. To achieve lasting results, it is critical to examine the body’s movement fundamentals. Put another way, injury and poor performance are often the results of unchecked dysfunction. While smart training remains paramount, coaches should be heartened that not all injuries are the result of overuse alone. Training exposes movement deficiencies. As such, the greater the training demands, the higher standard of physical preparedness required.

The road to stroke improvement is peppered with both potholes and landmines. We know WHAT the potholes are and we know WHAT the landmines are…less clear is how to identify their location and how to avoid them. Common stroke flaws are like potholes on the road: you can hit a few along the way and still reach your destination safely, but hitting too many will cause damage. The more robust the vehicle (or body), the less disruptive the potholes will be. However, we need not detour around ALL potholes as doing so could add unnecessary time to the trip.In the pool, there are certainly occasions in which time constraints prevent coaches from avoiding all the potholes. The demands of college scholarships and qualifying standards can limit the coach’s flexibility. Not every coach is in a position to commit to a potentially multiyear process to overhaul every technical flaw. However, such decisions are best made on a case-by-case basis, but not addressing these potholes can lead to injuries. Landmines are injuries and it’s no secret what the landmines are in swimming (shoulders, necks, backs…).Our Troubleshooting series will map these potholes and landmines. Fortunately, the same landmarks that guide us around potholes will also help avoid the landmines and can minimize the damage if we happen to swim through one. Since we know where the problems lie, it behooves us to take a proactive approach to assess each individual swimmer’s movement propensities and injury risk factors. Identifying the root of each problem allows us to pick the best tool for job.

Troubleshooting the Stroke and the Body: The Cervical Spine

Why is the neck important?The cervical spine, or the neck, is a delicate area that protects critical elements of the nervous system. Some refer to the neck as the body’s “circuit breaker.” Neck dysfunction and pain have cascading effects throughout the body and minor insults to this region can have profound implications in swimming. Likewise, the neck is sensitive to other movements in other regions of the body, particularly the thoracic spine (upper back), which sits immediately below the cervical spine. Fortunately, many neck corrections will clean up other aspects of the body’s movement, both in and out of the water. Improvements can take both a top-down and bottom-up approach. Most of what we describe in this post will progress from the top-down by addressing head and neck mechanics before looking at areas further down the body. However, bottom-up approaches with a primary focus on the feet, legs, and hips can also improve the head and neck. Which approach is best will vary by situation, but do note that both approaches are viable.

Common neck related stroke flaws (potholes)

1) Chronically extended neck/excessively high head position – There are several causes of WHY this flaw may appear in all four strokes, including full-body postural syndromes that affect the activation of the neck muscles. However, focusing locally on the neck itself can facilitate improvements elsewhere.2) Head bobbing – potentially from instability, the neck is like a golf ball on a tee, without proper muscle strength the head will weave throughout the water. This will impede velocity and increase risk for injury, double whammy.3) Lifting the head to breathe – Neck mobility limitations frequently contribute to this flaw. In freestyle, we know a swimmer with improper breathing biomechanics lifts their head, but what is the root cause? Is it because the swimmer is compensating their rotation deficit with cervical extension? This flaw can cause closure of the interformanial space and lead to various injuries.

Landmines – Are these caused by swimming or does swimming have greater consequences for issues that athletes bring from outside the pool?

It would be misleading to say that swimming “causes” neck injuries in the same way that getting tackled in football causes concussions and fractured bones. Swimming places high repetitive use demands on the neck through flip turns and breathing. Although neither of these tasks is dangerous in themselves, if the neck is not adequately prepared to meet the demands, injuries can result. Plenty of runners have poor neck posture and limited neck mobility, but because running places little stress on the neck we don’t see many neck injuries in running. We must also consider lifestyle factors that predispose swimmers to neck injury such as hours in the car and behind a desk, whether in class or at work. Swimmers who bring physical deficits to the pool are more likely to encounter a landmine.1) Facet syndrome2) Fusions3) TMJ and other jaw-related conditions4) Postural syndromes – Upper crossed and lower crossed posture, or a combination of the two.5) Any pain, whether or not related to pathology

SCREENING AND ASSESSMENT

One basic question behind assessment and correction for swimmers: “Does the swimmer have a physical limitation that prevents him/her from doing what they need to do in the water?” If no, we can go straight to the in-water correction through drills and stroke cues. If yes, we must take the steps to correct it. However, an objective baseline is helpful to have to observe any changes even when an assessment reveals no limitations. Swimmers can have similar looking strokes but get their different ways. For example, lifting the head to breathe is a common freestyle flaw. Some swimmers have perfectly functioning necks but lift their head to breathe because they feel like doing so gives them access to more oxygen. Other swimmers lift the head to breathe because the neck lacks rotation ability and they compensate by adding neck extension. The assignment of drills and dryland programming must focus on the needs of each swimmer. While we understand the concern of having to individualize in a large group, the proper assessment allows coaches to identify trends within a team and to create appropriate grouping based on collective need. Some key points to look for in the neck-Multidirectional mobility – Can the neck flex, extend, and rotate?-Stability – Can the neck muscles physically support neutral neck posture?-Overall posture – Faulty neck position can result from postural syndromes involving the whole body (upper crossed and lower crossed along with hybrids of the two)-Breathing – Training in a semi-chronic hypoxic environment and often breathing poor quality air indoors, swimmers are susceptible to developing ‘tight’ breathing muscles (scalenes, levator scapulae), particularly with the stress placed on respiratory muscles while swimming-Coordination into global movement – Does the neck function in isolation but lose function when combined with another body movements?-Medical history – Remnants of old injuries can create lasting limitations. Even if the swimmer doesn’t have pain from the injury, they may have evolved subconscious avoidance habits around the injured site. Additionally, jaw problems are more prevalent than most people realize, especially in young kids. Coaches obviously can’t practice orthodontics, but this information can be useful to understand the swimmer’s tendencies.

CORRECTION

First let’s talk about what NOT to do…

  1. Ballistic neck circles and rolls!
  2. Random static stretching of that neck that has no other justification besides “feeling good.” Tightness can be a protective mechanism and random stretching can turn a mere annoyance into a medical problem. Stretching is appropriate in some cases, but make sure you know what you are stretching and why you are stretching it. This stretching can elongate nerves in the armpit, leading to larger problems.
  3. Heavy weights on the neck machines in the gym
  4. Yoga poses that load the neck, unless under the direction of a capable yoga instructor.

Correction -Dryland

What to do:-Neck exercises-Rolling: Neck coordinates with the body roll in a movement that is non-threatening, yet challenging for many people. After all, the long axis strokes are simply an applied form of a partial body roll. Babies and young kids roll with ease, but many people lose this skill as they age.-Breathing: Watch the athlete breathe. Do they extend the neck to breathe? If you need the neck muscles to obtain oxygen and sustain basic life, can you expect these muscles to be available for use under the crucible of hard training and racing?-Cueing neutral neck and breathing in ALL exercises – Once you establish a neutral neck at rest, then challenge the athlete’s ability to maintain neutrality under heavier loads. Note, by heavier loads we aren’t necessarily referring to loads upon the neck itself but rather the overall loads of the exercise.-Posture – Ultimately, correcting the neck may be part of an overall posture improvement (stay tuned for future posts in the context of the thoracic spine, lumbar spine, and hips)

Correction – In water

-Most coaches already have a vast library of drills (remember each drill should be specific and address a swimmer's flaw) and ways to communicate with swimmers. Neck assessment should help refine the choice of what drills are most appropriate based on the underlying dynamics rather than the visual alone. Furthermore, there’s also value in being able to rule out the neck as the culprit.-Snorkel is an underutilized tool for coaching proper neck position. Many neck problems are the result of excess tension. Masters swimmers and triathletes often have no idea what swimming with the neutral neck is like. The snorkel gives them a chance to do so. However, I would exercise discretion in using the snorkel on swimmers with a history of orthodontic treatment and/or jaw pain.-Create stability with paddles. Paddles are not only used for propulsion. The increased grip that paddles offer with the catch can create better overall stability, which frees the neck to rotate with greater ease (“mobility through stability”).To Wrap it UpLimitations in the cervical spine can limit a swimmer’s ultimate potential in the water. Virtually our entire skeleton sits beneath our cervical spine. The slightest change in the neck can have cascading effects throughout the body. In coaching, we need to know what the neck is capable of doing before we ask it to support repetitive advanced movements in the water under physical and mental duress. Dryland screening and assessment gives us a more complete picture of each athlete to help guide the most appropriate coaching strategy. A healthy and properly functioning neck must have the stability to remain neutral yet also freely rotate, flex, and extend when needed. If swimmer’s neck doesn’t possess those abilities, there’s a good chance their stroke has evolved around those limitations. We should not address any aspects of the stroke that affect the neck without addressing the neck itself.

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