Our
study confirms the data from the literature which reported an
incidence ranged from 40 to 80% of shoulder complaints in swimmers
(4) in whom overuse is believed to be one of the responsible factors
for shoulder pain (4). Indeed, depending on the particular stroke, up
to 90% of the propulsion is generated from the arm pull.
Almost
all the swimmers swam freestyle, butterfly or backstroke. Because of
the biomechanics of these three strokes, with wide shoulder
movements, the incidence of the shoulder injuries is increased. In
contrast, those who swim the breaststroke, which involves much less
shoulder abduction, are rarely afflicted with shoulder pain (13).
The
most common cause of pain and impaired shoulder function was
subacromial impingement - 26 cases – because of the repeated positions
of wide abduction and maximal internal rotation of the shoulder in
swimming (2,7,8,15).
Abduction
with internal rotation is an important measure of a swimmer's ability
to achieve and maintain a high elbow throughout a stroke cycle.
The
stroke technique is also of great importance in impingement
development. Swimmers at high risk of experiencing shoulder
impingement had three characteristics in freestyle stroke techniques:
a) a large amount of internal rotation of the arm during the pull
phase, b) a late initiation of external rotation of the arm during
the recovery phase and c) a small amount of tilt angle (16).
Several
authors suggested that the movement of external to internal rotation
during a swim stroke causes abutment of the greater tuberosity
against the coracoacromial arch leading to impingement (3,8).
The
avascular areas in both supraspinatus and biceps tendons are the most
vulnerable to mechanical impingement. Repeated microtrauma in this
area results in an inflammatory response with narrowing of the
subacromial space and a vicious cycle that becomes clinically
apparent.
Many
swimmers with impingement syndrome had postural dysfunctions
(increased thoracic kyphosis and/or forward and internaly rotated
shoulders) favouring a secondary impingement because of the resulting
dysfunction of scapular kinematics (1,6,10,11,12).
The
majority of the injuries, especially those of the shoulder, were
registered in water-polo, both because of the maximal amplitude
repetitive movements and of the throwing movements (90°
abduction and maximal external rotation), the last also predisposing
to shoulder injuries (12).
The
shoulder on the dominant side was affected more often. Most cases
were registered in the first half of the competitive season, probably
because of the trainings with increased volume, focused on swimming
improvement in spite of technico-tactical strategies.
The
great number of miositis and tendinopathies of the muscles implicated
in static and dynamic stability of the shoulder complex (anterior,
middle and posterior deltoid, rotator cuff, middle and inferior
trapezius, biceps brachii) comparative with other localisations, is
easy explicated by their intense implication in the repetitive
movements in swimming.
Another
polarization of the pathology during the analised period was the knee
with 4 cases of pes anserinus tendinitis and 3 cases of medial
collateral ligament entezitis. Knee pain in swimmers occured
primarily in those who prefered breaststroke because much of the
speed achieved using this style is contributed by the lower limbs.
The specific position places excessive valgus and external rotation
stress on the medial supporting structures of the knee as thighs are
adducted and the legs are rapidly extended during the propulsion
phase of the kick.
Among
the cases of low back pain, we point out the two phase III lombar
discal hernias and the spondylolisthesis, all three in water-polo
centerforward players.
In
the case of disc hernia phase III stage II, the conservative
treatment with rest, kinethotherapy, nonsteroid antiinflammatory
drugs and electrotherapy solved the acute stage but the 29 years old
player considered the moment to cease sports activity had come.
In
the second situation, the discal hernia (phase III stage III)
determined peroneal nerve paresis and it needed urgent surgery. In my
opinion, the injury is explained by the fact that althow the athlete
played several years as left wing he was obliged for
technico-tactical reasons to play as centerforward, position for
which he was not somatometricaly fited because he was a
normal-weighted, longilin person with insufficient musculature for
that place in the field. At three month after surgery he was
completely rehabilitated and returned sports activity.
The
case of spondylolysis with spondylolisthesis L5 was registered in an
17 years athlete, several mounth after he had been invited at the
senior team trainings. Highly motivated both by his desire for
playing and by the perspective of entering the senior team, he
increased strength training without correlating it with his age and
existing muscular strength. After such a weight training, he
experienced high intensity low back pain, requiring imagistic
investigations (radiography and MRI) which established the diagnosis.
After a period of rehabilitation and gradually returning to sports
activity, he participated in the National Championship games and in
those of the national junior team, with good results and without
other low back pain episodes.
Recent
research on pelvic stability has shown that movement at the shoulder
is preceded by activity of the stability muscles in the pelvic
region. That's way, in rehabilitation of the three athletes, I
emphasized the regaining of motor control of transversus abdominis,
multifidus and psoas (fasciculi posterioris).
The
great number of sprains and even disjunctions of the hand joints is
easily explicated if we consider the force of the ball's kick,
especially if the hand is in a relaxed position. The case of fracture
of the proximal phalanx was registered in a water-polo goalkeeper
who, in his attempt to keep the goal, kicked the crossbar. The
fracture of the nasal pyramid in a water-polo player was followed
after returning sports activity by repeated nasal bleedings, which
stopped everytime without the help of ENT specialists.
The
small number of contusions can be explicated only by not coming for a
medical exam when the pain was moderate. A special remark for the
ocular contusion with subconjunctival haemorrhage in a water-polo
player who needed rest and sustained ophtalmological treatment, with
total recovery.
Conclusions
Between swimmers,
water-polo players are at high risk of
posttraumatic injuries both because of the maximal amplitude repetitive
movements in stroke cycle and of the throwing movements.
The most common was
shoulder involvement, especially
subacromial impingement syndrome, in the first half of the competitive
season.
The water-polo
players in centerforward position are
susceptible to injuries with important consequences, especially if they
have not the necessary strength training.
The necessity of
good surveillance and of individualisation
of training programs in junior swimmers invited to train together with
seniors.
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