Other Medical Issues

A Place to Start swim cap and goggles on chair

Below is a brief overview of medical issues that our athletes may encounter during their swimming career. Swimmers' Shoulders, Breathing Issues and Concussions get further coverage on this site, but there are other medical issues swimmers may ask about. Parents and swimmers can use this general information to prepare them for problems they may face in the future. It is not medical advice or diagnosis. It is for educational purposes only and is not intended to be a substitute for medical or professional care.

As you review the information, please keep in mind two things:

Pain Should a swimmer face a medical issue that involves pain, parents, coaches, and medical professionals will need to know how much pain the swimmer is in. Is this the expected soreness from training or pain? How severe is it? What brings it on? This has always been a difficult issue. Researchers have devised a pain scale for shoulders (see Resources) that can also be used for other conditions. In general, a medical professional will ask questions such as how intense is the pain, whether it has lasted over a week, gets better after a few days of rest, or interrupts sleep or other normal activities. Preparing answers in advance will make the appointment more productive.

TUE Policy

Drug Testing Swimmers with temporary conditions should confirm that any medications they take are allowed. Consult the Global DRO before taking any prescription or over-the-counter medications. Swimmers with chronic conditions that require medication must know about USADA and NCAA Anti-Doping policies. The rules for Therapeutic Use Exemptions are strict and require some lead time.

A positive test for banned substances carries serious consequences that can follow a swimmer beyond their athletic career. See Anti-Doping for more information.

Challenges to Performance

Elite swimmers see obstacles as a part of the journey. There are NCAA Champions and Olympic Medalists who have battled chronic conditions such as asthma and epilepsy or come back from acute injury or illness. Every one of them started by learning more about their condition. The best source of information is a trained medical professional, ideally one who is familiar with the unique demands of swimming. This overview is designed to start your journey toward understanding the challenges.

  • Asthma

    Asthma can be thought of as an increased sensitivity of the linings of the airways. Airways are stimulated by triggers such as cold or dry air, exercise, allergens, pollutants, airway irritants, and upper respiratory infections. Poor diet, increased body mass index, and dehydration may multiply the trigger effect. The irritated airways respond by producing excess mucus, become inflamed, and begin to constrict, or spasm. It is a common condition, even among elite swimmers. Doctors encourage many asthma sufferers to swim because swimming causes less severe bronchoconstriction then other sports, and exercise improves cardiovascular and lung performance. Exactly why swimming is beneficial has not been proven. Some think that the warmer, more humid air may be a factor. Immersion in water is known to improve improve circulation, as is exercising in a prone position. For some, the practice of rhythmic breathing may improve neural feedback. The benefits of swimming may be offset in some by exposure to chlorine and its byproducts. Others may suffer from "diving reflex" which can lead to bronchorestriction. However, for most asthma sufferers, current treatment regimes, prescribed and practiced correctly, provide good control.Many Olympic medalists and NCAA Champions compete successfully despite their asthma.

    Diagnosis Asthma is potentially life-threatening and should be suspected in children whose breathing becomes restricted by triggers such as those mentioned above. Wheezing on exhalation is the classic symptom, especially when there is a medical history of eczema, hay fever, or seasonal allergy. Silent, chronic asthma is often dismissed as post-exercise coughing or wheezing. Untreated, it can lead to irreversible damage. Ideally, a diagnosis is made by a respiratory specialist who has performed and analyzed pulmonary function tests and worked with you to create an Asthma Action Plan. This plan lays out what kind of medicines your child takes and when they take them. It will also describe how to handle worsening asthma, or attacks, and when to call the doctor or go to the emergency room. Please share your swimmer's asthma action plan with his or her coaches.

    Overdiagnosis Parents should know that asthma is widely overdiagnosed for children. Overdiagnosis and unnecessary treatment can mask other health issues and may trivialize the diagnosis of asthma, potentially leading to a child with severe asthma failing to get the treatment he or she needs. Because of the high incidence of overdiagnosis, USADA (United States Ant-Doping Agency) will not issue a TUE (Therapeutic Use Exemption) for swimmers who use non-approved anti-asthma drugs without a proof of a positive respiratory function test and evidence of the reversibility of bronchospasm in response to specific inhaled drugs.

    Several conditions can be confused with, or co-exist with asthma. One is Vocal Chord Dysfunction (VCD). Symptoms and triggers are often similar to asthma, and the conditions can co-exist. VCD is difficult to diagnose because tests must be performed while the athlete is symptomatic. Asthma medications will not treat VCD, but speech therapy is often effective. Another masking or co-existing condition is Gastroesophageal Reflux Disorder (GERD). The primary symptom of GERD in adults is heartburn, but in children the symptoms often more closely mimic asthma. The two conditions often co-exist and can exacerbate each other. Treating asthma without addressing GERD is generally not successful.

    Overuse of rescue inhalers Overuse of rescue inhalers can lead to serious consequences. It can mask uncontrolled asthma, and may actually worsen the condition. Overuse can also cause side effects such as tachycardia (rapid heartbeat,) nervousness, and insomnia. Some users can become psychologically dependent on the rescue inhaler, which may encourage overuse. Only your child's qualified medical professional can instruct your child on the use of their rescue inhaler. However, USA Swimming's Network Task Force on Asthma (2004) stated that: "Generally speaking, if a swimmer is using an inhaler more than two to four times per workout, this should be a red flag that the swimmer’s asthma is not under control and/or the athlete is not using the medication as directed." More recently, breathing specialists suggested that if a swimmer relies on an inhaler at every practice they may have poor asthma control, needs additional education about their asthma, or may be dealing with more than one condition - such as VCD or GERD.

    Some non-asthmatics use relief inhalers, believing they will improve their athletic performance or for the slight feeling of euphoria some experience. Rescue inhalers will not improve performance in non-asthmatics, and using them may lead to performance-impairing or even dangerous side-effects. Education is critical to ensure inhalers are used correctly and only by the patient for which they were prescribed. If your swimmer uses a rescue inhaler please be certain is labeled with their name.

  • Athletic Anemia

    Anemia means there is not enough iron available to make hemoglobin, which red blood cells use to carry the oxygen cells need. Low iron stores happen when you are not getting enough iron in your diet, something is interfering with iron absorption, or you are losing too much iron through sweat or blood loss. Vigorous physical exertion destroys red blood cells, but in healthy athletes with adequate stores of iron, the body ramps up red blood cell production to keep pace. In some cases, a condition known as “sports anemia” happens when red blood cells are being destroyed and hemoglobin concentration drops. This is usually associated with a sudden, dramatic increase in intense training coupled with a diet that is low in iron.

    Symptoms Anemia causes pale skin, inexplicable levels of fatigue, and shortness of breath. Sometimes it causes tachycardia - rapid heartbeat. Swimmers with undiagnosed anemia complain that their strokes "feel off", have trouble concentrating in the pool or at school, and sometimes lose interest in their sport or other activities due to fatigue. Anemia can be diagnosed by a simple blood test.

    Females Menstrual blood loss must be offset by additional iron consumption. Vigorous physical exertion and childhood growth also increase the need for iron. Dieting can contribute to low iron since it takes approximately 3000 calories a day of the typical American diet to get enough iron for the average daily requirement. As many as 10 percent of young female athletes are anemic.

    Vegetarians Iron in meat is more easily absorbed. Fruits, vegetables and cereals are not as readily available, so vegetarian athletes must factor their nutrition plans to include sufficient iron or should consider taking iron supplements.

    Growing Athletes Adolescents who are growing rapidly are also expanding their blood volume quickly. They need enough iron to keep up with demand.

    Iron Supplements Iron supplements are useful for swimmers who need additional iron. However, excess iron consumption will not improve performance and can be dangerous. Iron supplements can cause side effects, such as nausea, vomiting, diarrhea, dark stools, or constipation. Iron overdose from supplements have killed young children and endangered adults, particularly those with a common condition that causes them to absorb up to three times as much iron as other people. Symptoms of iron poisoning include severe vomiting, diarrhea, abdominal pain, dehydration, and bloody stool in children.

  • Orthopedic Issues

    Musculoskeletal injuries in young swimmers usually heal quickly with an early, accurate diagnosis. Recovery depends on the severity and proper treatment of the injury, corrections to any stroke flaws that exacerbate the problem, and the swimmer's willingness to adhere to their rehabilitation program at the pool and at home.

    Swimmer's Shoulder A serious competitive swimmer may make as many as 2 million arm strokes a year during training. Inevitably, that many repetitive motions can challenge a joint as mobile and fragile as the shoulder joint. Swimmer's shoulder is an important topic for all swimmers to understand. It is covered in further depth on our Healthy Shoulders page.

    Swimmer's Knee Knee pain is another common complaint, particularly for breaststrokers, water polo players and synchronized swimmers. Anterior (front) knee pain is often caused by the repetitive flexion/extension of the knee. Athletes complain of pain when they sit for long periods (why this is also known as "moviegoers knee") or walk up and down stairs. The athlete may also describe a grating sensation. This is not usually an indication of the severity of the injury. The injury is usually associated with an unstable patella (kneecap) and underdeveloped quadriceps. It is more common in female swimmers. Bracing and taping the patella, icing and massage will provide temporary relief at best. A medical professional can teach the swimmer specific exercises to correct the pull of the quadriceps.

    Breaststroker's Knee In the breaststroke, the shape of the kick - with knees rolled toward each other, can stretch ligaments, damage the medial meniscus, or irritate the bursa. The swimmer complains of pain in the inside of the knee. Resting the area can usually resolve the pain. Ice and massage are also helpful. Coaches should check stroke mechanics and ease a swimmer back into kicking after the pain subsides.

    Butterflier's Back In butterfly, the dolphin kick relies on repeated lumbo-sacral (lower back) hyperextension, particularly during the breathing phase. That can cause stress on the lower back, resulting in chronic pain. A complete medical diagnosis is required. X-rays can reveal localized bone stress, but often radiological techniques such as MRI or CT scans are ordered to rule out bony injury and reveal the integrity of the soft tissue, including the intervertebral discs. Bone injury Stress fractures should be closely monitored by an orthopedic specialist. Muscle or ligament strain must be taken seriously. A rehabilitation plan should involve the swimmer, coach, physical therapist and physician. It will include analysis and treatment of stroke flaws, poor posture, trunk mobility, hamstring tightness, and core strength and stability.

  • Ears, Eyes and URT

    Swimmers are frequently exposed to water that has chlorine byproducts, sweat, urine, and other contaminants that blow into or get tracked into the pool. Early recognition and treatment of the results of that exposure can lead to good outcomes.

    Swimmer's Ear (otitis externa) The warm, moist environment provided by the ear canals is an ideal place for bacteria to grow. In Swimmer's Ear of the outer canal, waste from the bacteria cause irritation and itching. Reaching for a cotton swab can make things worse - irritating the ear canal lining so that is swells and pushing ear wax into the canal opening. Subsequently, the smaller opening traps even more moisture and bacteria thrive. Doctors may prescribe drops for pain and to treat infection. Often, they recommend using drying drops (Swim-Ear is a good brand) or a hair dryer set on low after swimming to ward of future problems.

    Ear Infection (otitis media) A diagnosis of an "ear infection" usually refers to an infection of the middle ear chamber. Swimmers complain of severe ear pain, dizziness, or trouble hearing. Sometimes you can distinguish between swimmer's ear (otitis externa) and an ear infection (otitis media) by having the swimmer pull gently on the affected ear. If it hurts worse when they tug on it it is often swimmer's ear. If tugging on it helps to relieve the pressure it is more commonly a middle ear chamber infection. This is often accompanied by an upper respiratory tract infection that has blocked the eustachian tubes that allow drainage from the middle ear to the back of the throat. Antibiotics and decongestants will help resolve the swelling and prevent a ruptured eardrum. However, some of these medications are on the banned substances list. Check your meds on the Global Drug Reference. A doctor's prescription is not a defense against a failed drug test.

    Conjuctivitis Conjuctivitis is the inflammation of the sclera (whites of the eyes) or inside of the eyelids. Swimmers complain of "gritty" eyes and discharge. This condition may be allergy-related, a bacterial infection or a viral infection. It must be properly diagnosed by a medical professional before an athlete returns to team workouts to rule out highly contagious viral infections such as herpes simplex.

    Sinusitis The Upper Respiratory Tract (URT) includes the nose, mouth, sinuses, and throat. Healthy sinuses warm and humidfy the air we breathe and trap airborne particles. When they become inflamed they do not drain properly. They can become infected and filled with mucous. Swimmers will complain of congestion, pressure behind the eyes and headaches. For swimmers with chronic sinusitis, they will have thick nasal discharge and a persistent night cough. An ENT specialist is the best bet to address an acute condition. Medications that can help treat the condition but are not on the banned substance list are available. In extreme cases, surgery may be called for.

  • Infectious Mononucleosis

    Mononucleosis is caused by the Epstein-Barr virus, which adolescents in close contact can easily spread. Early symptoms include flu-like symptoms with a pronounced sore throat, fever, muscle or joint aches and extreme fatigue. In swimmers, coaches may notice a "loss of form" and sometimes attribute it to psychological factors. This is particularly true because athlete's immune systems are less responsive during periods of heavy training, making the athlete more susceptible to the virus at a time when the strain of the training load is physically and psychologically greatest. Once the acute symptoms of mono are gone, the swimmer may return to practice. However, the fatigue from the infection may last for months, and coaches and athletes should be aware that intense training during this period will only prolong the symptoms. Low intensity training will maintain water feel and help build stamina. In seventy percent of cases the spleen becomes enlarged, increasing the danger of a rupture. No diving or water polo play should be allowed while this condition exists.