Science of Performance: Return to Swimming After Injury, Part 1.5

By G. John Mullen of SwimmingScience.net and CenterofOptimalRestoration.com, Swimming World correspondent

SANTA CLARA, California, December 8. FOR those who missed part I, read it now! Also, if you closely followed part I, you're expecting a piece on health care professionals and coaches approach and view on shoulder injuries. This piece will be later in the multi-part series, but understanding the injury process comes first.

Every active individual will be injured in their life. The more activity you perform, the more likely you will endure a musculoskeletal injury. This may scare or shock some of you, but look on the bright side, a musculoskeletal injury is better than a heart attack, stroke, or diabetes! Also, when I say musculoskeletal injury, I'm not talking about a hangnail, a stubbed toe at the post 2008 Olympic Trials after party, or the thought of doing 10×200's butterfly – I'm talking about an injury requiring more than 20 seconds of whining.

If you are a swimmer, it is likely this injury will occur to your shoulders. It is estimated 80 percent of swimmers will experience shoulder pain during their career. This incidence increases as you age, Masters swimmer beware! If you stave off shoulder injury, it is likely you will injure another body part. No matter the site of injury, there is a physiological process the body goes through depending on the type of injury. This article will discuss the types of injury and their associated physiology process. We are going to go deep on this article, so it's important to focus!

Types of Injury
There are two main types of injuries, macrotraumas and microtraumas.

Macrotraumas are the big, bad uglies; you'll know when they occur. Think of Willis McGahee's knee bending like a flamingo or a swimmer breaking their hand on a relay after going 22.0 SCY…yes I've seen this before. That is a macrotrauma, more specifically: fractures, dislocations, sprains (injuries to ligaments), strains (injuries on muscles and tendons), tears (ligaments), lacerations (deep cuts) and large contusions (bruises).

Microtraumas are typically chronic, overuse injuries. These injuries can start as soreness and progress to certain macrotruamas (sprains, strains). These are sometimes thought as less serious injuries, but can transform into ugly, stubborn injuries. These injuries include tendinitis and stress fractures.

Many athletes ignore microtraumas, trying to push through the pain. Whether this view is self-aided or provided by an overzealous coach, it will perpetuate the injury. However, rest won't necessarily heal the microtrauma either. Nothing worse than getting the courage to allow your coach to take a few days off of workouts to recover and upon returning realizing that, 1) you feel like a wet noodle and 2), your microtrauma hasn't improved. This has pushed swimmers to quitting physically and mentally for years.

Physiological Steps
After any injury (again no hangnails), the body goes through specific steps to repair itself. This linear process takes time and the body goes through each step, never pulling on the lane line to finish earlier.

Step 1 – Inflammation
Everyone is familiar with inflammation. I mean, who doesn't pop a few Non-steroidal Anti-Inflammatory Drugs (NSAIDS like Advil, Aleve) from time to time? This process occurs within minutes of every injury, but can linger for weeks or months with bad injuries or treatment. Inflammation is stemmed by infiltration of cells entitled neutrophils 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 and the release of enzymes of neutrophils and macrophages are responsible for eliminating the injurious agents and thus constitute 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 which can remain for weeks to months, perpetuating injuries.

The classic signs and symptoms of inflammation are swelling, redness, throbbing, radiating heat and constant pain, especially when you wake up (not for 5 seconds, I'm talking pain for 30-60 minutes upon waking). Understand, just because you had the initial injury 4 months ago, doesn't mean inflammation has resolved or hasn't returned. Pay closer attention to the signs and symptoms than the duration.

Step 2 – Repair
Once inflammation resolves (remember, this is not a constant variable), the body attempts to repair itself. Humans and animals amazing machine, living in an open system with minimal tune ups required. Think of your dog, if it hurts it leg it will lay around allowing the body to repair itself. The body uses collagen, the body's gum, to repair injured structures. Unfortunately, it doesn't always repair itself properly. The body lays collagen in an erratic, inefficient fashion.

Remember, the body is repairing in this phase, not repaired. Just because the injury feels better, doesn't necessarily mean it is fixed!

Step 3 – Remodeling
The last step is remodeling, lasting anywhere from 2-4 months. This lengthy process attempts to return the body to a "pre-injury" state, which takes time to do properly. The body is now able to lay collagen in an orderly fashion, optimal for recovery and success. In this phase the body will begin to return to full strength and function. However, the body is still more susceptible for a re-injury during this time. It is essential to play close attention to any aches and pains.

Summary
If you are active, injuries are unavoidable. Once injured, it is essential to know which steps and precautions to take to maximize recovery and minimize time away from the pool, wet noodle syndrome (WNS). The next installment in this series will tackle the view of injury from the side of health care professionals and coaches. Stay healthy in the meantime…

Dr. G. John Mullen is a Doctor of Physical Therapy and a Certified Strength and Conditioning Specialist. At USC, he was a clinical research assistant at USC performing research on adolescent diabetes, lung adaptations to swimming, and swimming biomechanics. G. John has been featured in Swimming World Magazine, Swimmer Magazine, and the International Society of Swim Coaches Journal. He is currently the strength and conditioning coach at Santa Clara Swim Club, owner of the Center of Optimal Restoration and creator of Swimming Science.

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