Injury- Joints, Lungs and Ears

Injury- Joints, Lungs and Ears

Before we start, there is a disclaimer to this chapter. Although I am a doctor, I am not YOUR doctor. This chapter is intended to enlighten you about how the Swimming Machine breaks down and how to build it back up and prevent future breaks. It is NOT an instruction manual about how to diagnose or treat any pain or medical condition you might have. If you have a problem, go see a real doctor in real life and do what they say! Ok, now we can talk freely.

Injuries in swimming are fairly common. 10% of age groupers, 13% of senior swimmers and 26% of national team have some sort of injury and they are all overuse injuries. That means the simple motion of swimming, repeated over 100s of miles causes damage and injury to the joints and body. Some studies that looked at Division I NCAA teams found that 40-90% of swimmers were dealing with some sort of ailment. That makes sense when you understand a typical college swimmer will take over 1,000,000 strokes per year… with EACH ARM!

On top of that, humans were not made for swimming (that’s why you are a Swimming Machine, right?). For every other sport on land, the main propulsive force of the body comes from the legs, whereas in swimming we use our upper body to make movement. That’s not normal, and our upper body joints are not designed to handle that stress, which is why shoulder pain is by far the most common problem for swimmers. Knee problems, especially in breastrokers, is the second most common overuse injury because we don’t use knees normally in swimming either. The last problem that predisposes swimmers to overuse injuries is that sometimes what makes joints susceptible to injury is also what makes them better at their job.

We will go through all this step by step so you can understand why these injuries happen as well as the basics behind preventing and rehabbing. We will also touch on some swimmer specific medical problems like Swimmer’s Ear and coughing…yup, you’re not the only one who has a coughing fit in the middle of that fly set.

Big injuries like broken bones, sprained or torn ligaments and pulled muscles are obvious, rare and treated with absolute rest, physical therapy and maybe surgery. We won’t talk about those. We will focus on overuse injuries. To understand overuse injuries, you have to understand how a joint works at the fundamental level.


Joint Anatomy and Tendinitis

A joint is simply two bones that are connected to each other and can slide around each other. Here are two bones:

Bones are like tree branches. They are really rough and if they rubbed against each other for very long, the two bones would wear each other out. That’s why there is a layer of hard smooth cartilage on the gliding surface of each bone.

Tangent: Over decades, the cartilage will also wear out and thin. This is called osteoarthritis and it’s why your grandma got some new titanium hardware now.

So far, these are just two bones that are drawn next to each other. There is nothing connecting them or holding them together. Ligaments are bone to bone connections that keep bones from disconnecting from each other. They are what gives the skeleton it’s arranged form. They are the reason you can pick someone up by their head and the rest of their body would come up with them. Ligaments also keep the two bones in proper alignment when the joint is in motion, kind of like how train tracks keep the train wheels on the rails and prevent derailing.

Ligaments are made of bundles of fibers called collagen. Think of collagen as thick suspension bridge cables. Stiff, but flexible and are good at connecting things and allowing them to move at the same time. Ligaments have a maximum length they can handle. Stretch a ligament beyond that maximum length and the ligament will tear and the bones will no longer be held together tightly. That’s why sports injuries involving ligament injuries results in dislocated joints and looks really gross. No picture this time.

Tangent: Some joints have an additional soft cartilage that surrounds and “cups” the hard cartilage between the bones. This can get torn and cause a lot of pain and problems. This is called the labrum in the shoulder and hip, and the meniscus in the knees.

All of the parts so far are static structures. They are just there. They can’t move. The goal of a joint is to have the ability to move two bones and bring them closer together. For that we need muscles. Tendons are pretty much just like ligaments but connect muscle to bone instead of bone to bone. There is a tendon on each side of the muscle. One tendon connects to the first bone, while the other tendon crosses the joint and connects to the second bone (sometimes, muscles will cross two or more joints, like in your fingers).

When the muscle contracts and gets shorter it pulls the two bones closer together by pulling on the tendons. The bones then slide across their cartilage to close or open the joint. The ligaments still play a role by holding the bones in proper alignment so they move in the correct way. They also set hard limits for the maximum range of motion a joint can have, otherwise a joint would just be floppy and useless.

All joints in the body from the shoulder to the tiny spine joints in your back operate in the exact same fundamental way. No matter how simple or complicated or weirdly shaped the bone is, the same principles apply. Therefore, when overuse injuries occur in the shoulder, knee or back, the same mechanism of damage is occurring and the same ideas apply towards healing and preventing those injuries.

Some joints are made of bones that are very interlocking, like the hip. For instance, the ball of the femur (leg bone) is deep in the socket of the hip (part of the pelvis). The ligaments are tight and the joint is very stable, meaning that it is difficult to dislocate and move in a way that is abnormal for that joint. This also means the joint doesn’t provide a lot of options for movement. If you think about it, the hip joint is very limited in its ability to move compared with a less stable, less “contained” joint like the shoulder.

The shoulder is basically the arm bone hanging next to a flat surface. It gives the shoulder a huge range of motion and the arm can basically move in any direction it wants. This comes at a cost. The more movable a joint is, the less stable it is meaning that the bones have a higher chance of sliding in a direction they aren’t supposed to (getting off the train tracks). This means more chance for injury, which is why the shoulder accounts for 90% of the Swimming Machine’s problems.

To counteract this problem, the joint has stabilizers like ligaments and tendons. As you may have noticed, tendons and ligaments have overlapping jobs when holding bones close together and making them move in the proper way. This is a big deal because any weakness in one structure will cause the other one to take on the load, work harder, get stressed more and eventually get damaged. For instance, if you are swimming a lot, the muscles get tired and don’t contract as hard which loosens the tendons connecting the bones. Now that the tendons have stopped doing their job, the ligaments have to pick up the slack and carry the load of holding the bones together. At some point, those ligaments wear out too and weaken. This causes the tendons to have to compensate and work too much and get damaged… and on and on and on.

Tangent: Ligaments, soft cupping cartilage and the joint capsule are passive stabilizers while muscle and tendons are active stabilizers.

Damage to ligaments and tendons in this way happens over a long period of time and involves microtears of the collagen fibers we talked about earlier. In small doses and with enough recovery, these stabilizing structures repair and heal themselves and even adapt to get thicker and stronger. But just like overtraining, if too much damage outweighs the healing, the micro tears add up and so does the inflammation which is where we get the term tendinitis.

This inflammation causes swelling and pain in the tendons. Normally, tendons don’t have nerves or blood vessels in them so they don’t hurt. But with inflammation, blood needs to be supplied to the tendon in order to repair it and so new blood vessels develop and grow into the tendon. This is not normal. Blood vessels come with nerves and that’s where the pain comes from too.

The swelling can cause its own problems and further damage if the tendon is running through a tight space in between two bone, like in the shoulder. Speaking of the shoulder…


Swimmer’s Shoulder: Impingement Syndrome

The shoulder joint is…complicated. It has the largest range of motion of any joint and is able to move in just about every direction which also predisposes it to overuse damage. For every conceivable motion, there must be a muscle that creates that motion, and in some cases, there are multiple muscles that share a single job. That’s why shoulder problems in swimmers don’t usually come from just one cause. Any one of those tendons or ligaments can get damaged and cause pain. However, they all follow the same pattern of overuse, damage and inflammation leading to tendinitis. The most common muscle and tendon involved is the supraspinatus during impingement syndrome. But before we dive in, let’s simplify and draw out the shoulder joint.

Starting from the base and building up we see that the shoulder is made of two bones (go figure). The humerus (arm bone) connects to the glenoid (which means “mirror socket” in the original Greek). As you can see, it is pretty much a bone sitting next to a flat surface, which lets the arm bone swivel around a lot. The glenoid is just a small piece of the scapula (the shoulder blade) and this triangular bone lays on the rib cage in your back.

If you reach up and touch the farthest bone on your shoulder you will be touching the acromion (Greek for “highest”). This part of the shoulder blade connects to the collar bone. The important thing to notice is that there is a space underneath the acromion. This is called the subacromial space.

Instead of drawing in every muscle that connects to the arm bone (of which there are MANY), we will just focus on our trouble maker the supraspinatus. The shoulder blade has a bony ridge through the middle of it called the “spine” of the scapula. The supraspinatus muscle sits above this spine, hence the name supra (above) spinatus (spine).

The supraspinatus muscle connects to the arm bone with a tendon that runs underneath the acromion, through the subacromion space, wraps around the arm bone head and connects to the far side of the arm bone. The job of this muscle is raising the arm bone out to the side for the first 15°. Like this:

As you may have noticed, there is not a lot of room for that supraspinatus tendon underneath the acromion. When the arm bone is raised all the way to the top, this space gets even smaller and squishes the supraspinatus tendon inside.

Squishing your supraspinatus tendon every once in a while is not a big deal, but the average D1 swimmer can take up to 2500 strokes in a single workout and squish their tendon every time. When pain and symptoms develop, we call it Impingement Syndrome (or Swimmer’s Shoulder if that’s what the cause is). Any sport or job that requires repeated overhead use of the arms can cause impingement syndrome.

There is more to the story. Raising your arm and squishing the supraspinatus tendon a little bit isn’t usually enough to cause a lot of problems. The problem is that swimming requires the shoulder to very flexible to help it streamline and catch properly. This added range of motion comes from laxity of the ligaments that hold the arm bone and scapula closely together. Over years, the constant microtrauma to these ligaments causes them to get longer and loose and lets the arm bone shift into the sub-acromial space and crush the supraspinatus tendon.

Tangent: This shifting of the bone is called subluxation and it’s like a minor dislocation.

Now, we are not just squishing the supraspinatus tendon, we are tearing it apart! This damage needs to be fixed, which recruits inflammation. Inflammation is made up of white blood cells, new blood vessels and edema which is fluid that swells up the tendons and muscles. The white blood cells and blood vessels cause pain and the swelling edema causes the tendon to get even more squished in it’s tiny living space which just feeds the vicious cycle.

The worst parts of the stroke that make this cycle happen are the arm entry and catch position. As the arm enters the water, the transmitted force pushes the arm bone up into the subacromial space. The catch also rotates the arm bone into that space.

But wait… are we sure the laxity of the ligaments is the starting point for all this trouble? Maybe it was the damage to the tendon from hard swimming that caused inflammation and swelling which then caused the impingement? Well, that’s a real theory and the debate goes on. It’s kind of a chicken and egg problem. In either case, shoulder pain is present in about 70% of year-round swimmers and most are impingement syndrome which usually causes pain on the outside of the shoulder. Risk factors that raise your chance of getting impingement include increasing weekly yardage (over 15 hours or 30-40k per week) and level of competition.

Tangent: Other shoulder problems not talked about: Os acromion, thoracic outlet syndrome, labral tear, rotator cuff tear, bone spurs, subscapular impingement, biceps tendinitis, bursitis.

So, how can we figure out if a swimmer has impingement syndrome and not one of the other 1000 shoulder issues that it could be (other than seeing a doctor obviously)? Well, you impinge the supraspinatus tendon on purpose and see if it hurts! It’s called the Empty Can test and it is the best physical test you can do. As in the picture below, raise your arms to shoulder level, spread them out to the side a little, point your thumbs down (like you are “emptying a can”) and then have someone push your arms down while you try to keep your arms up. If your pain flares, then it is a positive test and could mean impingement. 

            Full Can                                                         Empty Can    

But be careful! If you do the same exact test but with your thumbs pointed up (called the Full Can test) and you have pain, then neither test means anything at all. There are about a dozen shoulder tests that a person can do and it takes years to master them. They mainly exist to help doctors figure out what’s going on. Another big help is called an MRI which stands for… never mind, it doesn’t matter.

An MRI takes pictures of your shoulder and can do a great job of showing all the structures of the shoulder. Even the edema will show up and signal the doctor that there is inflammation there. Most of the time, an MRI is used to look for ligament and muscle tears and rule out worse things than impingement.

Tangent: Sometimes, MRI dye is injected into the joint before the MRI is done to help light up the structures inside the joint. This is called an arthrogram (arthro = joint, gram= picture… like INSTA-gram!).

As you can unclearly see, MRI’s are tough to make out and take years of practice to be able to read them. Pointing out everything in that picture above would leave your mind in a state of mush that results from extreme boredom. That’s why we are going to move on. 

There is a section later dedicated to rehab and prehab, but since the shoulder is so important in swimming and is by far the most injured, let’s look a couple important points.

First off, if you have shoulder pain: STOP STRETCHING! Most likely it is impingement which is caused (most likely) by a shoulder that is too loose and stretched out. We need to reverse the looseness and tighten up the connections between the arm bone and shoulder blade so that the subacromial space and supraspinatus tendon don’t get crushed anymore. The first step is to stop stretching. Stretching might help in the moment, but it is causing the problem down the line.

Number two, don’t use equipment or perform strokes that make the pain worse like paddles and dryland exercises that make the pain worse. Continue not doing those things until the pain is under control with the below listed plan. “Pushing through the pain” has it’s uses and its place, but not when your training and racing is suffering and getting worse from pain. It is a fine line between good and bad pain, but the rule of thumb is that if the pain is causing you to lose performance, it’s a bad pain that needs to be fixed.

Next, see a doctor who will likely going to send you to physical therapy. GO TO IT! Not only go, treat physical therapy as a class. An hour of therapy 1-2 times a week is not going to fix your shoulder. You need daily rehab. You are going to therapy to learn the specific exercises you need to be doing on your own every day. Take your time, do them right and even if your pain goes away, you will probably need to keep doing the therapy a few times a week to keep your shoulder healthy. 

If that doesn’t work, you go back to your doctor who will likely start thinking about getting that MRI to see what else might be going on. When it comes back saying you have tendonitis, your doc might try a steroid injection. Nope… these are not the steroids that make your muscles big. These steroids are a more powerful version of the hormone cortisol (review in Hormone chapter), which suppress inflammation. In the long term, these shots rarely work. Their job is to help diagnose the correct cause of your pain and to give you enough pain relief (about 3 months if you are lucky) to rehab your shoulder with your physical therapy exercises so the tendons don’t get damaged anymore. Steroid shots are not a cure, they are just a stepping stone in your rehab.

If all else fails, the last and final option is surgery. It involves shaving off the underside of the acromion and clavicle to make more room in the subacromial space to give the tendon more room and prevent it from getting squished as much. It is a relatively simple surgery, but it will still sit you out of the water for up to three months and all surgeries come with their risks and should be avoided as much as possible.

Of course, the best way to treat impingement syndrome is to prevent it from happening in the first place! All good programs should have a dedicated and strict regiment implemented during dryland to help prevent shoulder problems in swimmers. On top of that, good swimming technique should be stressed. That involves getting enough rotation from the hips in freestyle to prevent the arm from being recovered out to the side like a butterfly recovery. This helps the shoulder use other muscles to recover the arm instead of the supraspinatus muscle. On top of that, don’t cross over the midline during the recovery. That will squeeze that subacromial space and cause problems.

Although having a good catch will impinge the supraspinatus tendon, it is not a technique we can lightly throw away. Having said that, being in pain will have a worse effect on your swimming than giving up a high elbow catch. Do all the above rehab suggestions, but also consider pulling with a straighter arm and driving the catch downwards rather than keeping the elbow high. This will keep pressure off the tendons. It’s not an ideal situation, but for a sprinter it may be a good option.

Lastly, coaches should understand the subtle signs of shoulder injuries so that early recognition and early treatment can begin.  Dropped elbows during the catch, wide hand entry and early exit during recovery are all subconscious changes to the stroke that the body is doing to help keep the subacromial space open and prevent supraspinatus impingement. These are not good swimming techniques, but the swimmer won’t be able to fix them unless their shoulder is fixed too. Even without any pain or complaints, these signs (especially if they are new to an experienced swimmer) should signal that there is an impending problem and that swimmer should start their prehab routine which we will talk more of later.

That was a lot of information about one joint but the concepts we outlined here carry over into other joints and swimming overuse injuries. Let’s talk about the number two joint problem in swimmers: the knee.


Breastroker’s Knee

Unlike the shoulder, the knee is super simple. Like all joints, there are two bones: the leg bone (femur) and the foot bone (tibia). All the knee has to do is bend forwards and backwards without rotating or moving side to side. So, all we need to keep the bones locked together are four big ligaments:

  1. ACL, Anterior (front) cruciate ligament. Prevents the tibia from going forward.
  2. PCL, Posterior (back) cruciate ligament. Prevents the tibia from sliding backwards.
  3. LCL, Lateral (outside) collateral ligament. Prevents the knee from buckling outward.
  4. MCL, Medial (inside) collateral ligament. Prevents the knee from buckling inwards.

Our main problem child when it comes to knee pain in swimmers is the MCL. On land, the other ligaments and patellar tendon (the quad muscle connection) take on most of the energy that goes through the knee because on land, we only move our knees forwards and backwards when we walk or run. The MCL is just a small ligament to keep things lined up and doesn’t usually transmit a lot of force… except if you are a breastroker.

Tangent: Other knee problems include: Medial compartment synovitis, Pes anserinus tendinitis/bursitis from MCL injury, meniscus tears, petallo-femoral syndrome, patellar tendonitis, ACL tears.

With a breastroke kick, we put our knees in positions they are not designed to tolerate very well. The breastroke kick generates force and transmits it through the MCL. This stressed the MCL, causes microtrauma, which leads to inflammation, pain, swelling… just like the supraspinatus tendon.

As you would expect, the more breastroke you do, the higher the chance of overuse injury of the MCL. 86% of breastrokers have a knee complaint at one time or another and this statistic increases with increasing years of training, volume, eliteness of the athlete, age and being a freshman in college (due to the sudden increase in workload for most people). People who regularly race the breastroke have a 5x higher change of knee pain. Interestingly, it was found that having too narrow or too wide a kick, angles less than 37̊ or greater than 42̊, had a higher chance of creating problems. Gotta hit that sweet spot.

So, how do we fix or prevent this? Like the shoulder, get rid of stuff that hurts: breastroke fins, wall/vertical kicking and dryland exercises. Unlike the shoulder, stretching seems to help and reduces the risk of overuse knee injuries fivefold. Since kicking width seems to play a role, try changing the width of your kick. Plan ahead with your training and build the breastroke kicking sets over a period of time instead of just trying to go 8,000 yards of breastroke on the first day. If you run into problems, take a few steps back, stretch more, and then re-introduce training at a slower rate.

Even in the worst cases of MCL tears (where the ligament literally comes apart), surgery is rarely needed and most MCL injuries can be taken care of with physical therapy and careful training.

(Flyer’s) Spine

The spine may seem like a complicated skeletal structure but… ok yeah it is complicated but the same principles apply as before: two bones, ligaments and tendons holding them together, microtrauma leading to inflammation and pain. For flyers and breastrokers that use their low back a lot during their strokes, the spinal joints can get worn out and cause pain. Even non-short axis swimmers can have low back problems from the hyperextension of the back for streamlining and the forceful dolphin kicking.

Think of the spine as a bendable column of bone. While the spine is bendable, it has limits to its range of motion. These limits are controlled by very large muscles in the back (the tenderloins of the Swimming Machine) as well as the abdominals in the front. The muscles themselves can get tight, inflamed and sore which causes their own pain, but that will be more on the side of the low back and not directly in the middle. When these muscles get weak and fatigue during workout, the spine bends a little out of shape which can cause the ligaments to overcompensate and get hurt.

Like the shoulder and knee, the more elite the swimmer and the more training they do, the more at risk they are. Up to 50% of short axis swimmers have low back pain and competitive swimmers were over 2x more likely than recreational swimmers to have pain. To fight this low back pain, having good endurance trained and flexible abs and tenderloins helps keep the muscles from fatiguing and also helps them coordinated better to keep the spine bones in a safe range of motion.


Pre-hab and Rehab

Obviously, the best injury is the one that never happens, but that takes time and planning to prevent and it is something we are not good at doing. It will always be tough to work towards fixing a problem that hasn’t happened yet, but good swimmers, coaches and teams should actively pre-hab their joints to keep their Swimming Machine running at 100%. Schedule time during dryland and training to actively heal and protect the joints we talked about and make it part of the weekly routine.

The goal of Pre-hab is to keep the tendons and ligaments strong, reverse any underlying damage that might already be happening without symptoms and to improve coordination of the joint muscles to improve their ability to stabilize the joint. This involves endurance training of core and shoulder muscles to keep the arms and pelvis from flailing around as well as a regular stretching routine (maybe not the shoulder though). Talk to a local physical therapist or go online and find some good exercises to do. This doesn’t have to be complicated or difficult; consistency is the key with Pre-hab. Here are some exercises to try that are routinely used:

Let’s say we are past the point of Pre-hab and already have an overuse injury. Now what? Just take a break? Give up? Quit!? NEVER!

The goal of rehab is to first heal the tendons and ligaments involved and then build them up so they are not at risk of getting hurt again. If you remember our cycle of how overuse injuries happen, they start with microtrauma to the ligaments and tendons. So, step one is to stop the trauma by getting rid of equipment, strokes and dryland exercises that cause the pain. Pain = damage.

The next step is to tone down the inflammation with RICE: Rest, Ice, Compression and Elevation… ok the elevation part might not be as useful for us, but RICE is commonly used for sudden injuries. You can even take an NSAID like ibuprofen on a regular basis for about a week or two. Talk to a doc before you start crushing meds, but 400mg twice a day won’t cause serious side effects, but it will help with reducing the inflammation.

Remember from the Tendonitis section we talked about how new blood vessels form in tendons that are damaged to help heal the damage and also cause the pain? It’s time to reverse the damage and get rid of those blood vessels. One of the best ways to do this is through eccentric exercises. Eccentric exercises are slow and controlled “down” motions that stretch the muscle while it is contracting. For instance, if you have back pain, bending down to the ground with some weight in a slow and controlled fashion for 3x15 reps will cause a different kind of microtrauma (not well understood) that ends up reversing the blood vessels that have formed.

On top of that, eccentric exercises will signal the tendon to grow in thickness and strength because the eccentric motions cause microtears in the tendon that are in line with the rest of the tendon fibers. Whereas damage caused by concentric damage (like when the arm is entering the water and squishing the supraspinatus tendon) causes damage that is not necessarily in line with how the tendon operates and that damage will further weaken the tendon instead of strengthen it. At least… that’s the theory, no one knows for sure.

Eccentric exercises can be applied to any tendon or joint. Just make sure to do it slowly, controlled, progressively increase the weight from week to week, focus on controlled movements for 10-15 reps at a time and avoid the concentric motion by using the other arm or leg to lift you back to the starting position.

Finally, when you are ready to start training again, start slow. Long, easy warmups. Even if you are in the middle of workout and switching from a freestyle set to a breastroke set, re-warmup the breastroke kick and your knees. Just because you have been swimming doesn’t mean every joint is warmed up well enough. Secondly, don’t jump in where you started. Build up to where you were slowly and in a scheduled manner. Even though there is no pain, jumping ahead will restart the cycle of microtrauma and inflammation and put you back in the rehab seat.


Coughing is one of the toughest symptoms to manage because the cause is often unclear and the coughing reflex is complicated and can be activated by a lot of signals. Coughing is a defense mechanism to keep bad things out of the lungs. In fact, a lot of old people die from lung infections because their coughing reflex becomes so weak at the end of life. So, coughing is keeping you alive even though it’s really annoying and getting in the way of your workout.

In the general population, there are about a billion reasons to have a cough which range from minor to life-threatening. In athletes, and swimmers especially, there are three big causes of cough: asthma, exercise induced bronchoconstriction and laryngeal dysfunction. Don’t worry about the big words; these are simpler than they sound. Before we dive into these three problems, let’s review some lung anatomy.

Tangent: Yes, chlorine is an irritant and will cause you to cough. There, it’s been said, now we can move on because no one here is going to quit because of a little chlorine!

If you remember from our Lung chapter, the lungs are made of microscopic air filled sacs called alveoli which receive air through a tube called the bronchiole. Think of bronchioles as an air highway that transmits air from your mouth and trachea all the way down to your alveoli. Around these bronchioles is a layer of muscle that can contract and close up if needed.

Asthma is a disease where there is chronic inflammation due to genetics and irritants that cause the little bit of muscle around each bronchiole to hypertrophy and get big. This oversized sphincter is also touchy and tends to clamp down at times when it is unnecessary. That’s called an asthma attack.

Surprisingly, the problem with asthma is that the air gets trapped inside the alveoli and can’t get out. This inability to breathe and the over-inflammation can cause coughing and even reduce the oxygen delivered to the blood. Since the problem is getting air out, testing and diagnosis involves measuring how fast you can blow air out. Doctors will often use a breathed in muscle stimulant or relaxer to test how sensitive the bronchioles muscles are.

Treatment involves attacking the two main problems of over constricted muscles and inflammation with inhaled steroids (again, not the anabolic kind) and inhaled muscle relaxers like albuterol. These help keep the airways open in the short and long term. It is very important to take the steroid every day and the “rescue” inhaler about 15 min before practice.

Let’s say you think you have asthma and cough a lot at practice, but when you went to get tested, the tests showed you didn’t have a problem. Now what? Now we move to our second cause of coughing in athletes: exercise induced bronchoconstriction (as in Broncho = bronchiole, constriction = closure).

Here, the problem is not inflammation that builds up the size of the bronchioles muscles, but instead the muscles are generally normal sized, but react and constrict in response to exercise. It is not clear why this happens. The diagnosis requires a similar test to be done as with asthma, but you perform the test while exercising or voluntarily breathing as fast as you can. Then, the muscles will clamp down and prevent air from escaping the alveoli. This irritation and obstruction causes a coughing reflex just like asthma.

The treatment for exercise induced bronchoconstriction is similar to asthma because we need to send medicine to those muscles that tells them to relax. A rescue inhaler like albuterol 15 minutes before practice is usually enough. In fact, it is a requirement of WADA that you have official testing and diagnosis of either asthma or exercise induced bronchoconstriction before you are allowed to be on albuterol at major competitions. Even with bronchoconstriction, there can be overlapping asthma at the same time which might require more treatment and another inhaler like we talked about before.

You’re still coughing. You have gone through all the testing listed above and came out with nothing. Now what? The third most likely diagnosis is called laryngeal dysfunction. The larynx is your voice box and contains your vocal cords. You can feel your larynx vibrate if you feel your “Adam’s apple” and hum (everyone has an Adam’s apple, not just guys, the technical name is the thyroid cartilage). Normally when you take a deep breath in, the vocal cords have to get out of the way so that air can pass from your mouth to your lungs.

In laryngeal dysfunction, the opposite happens. Instead of opening up when you take a breath, the vocal cords clamp shut during inhalation and cause the throat to get irritated which makes you cough. Not to mention… it kind of blocks you getting any air. The same thing happens when you take a deep breath with cold air and start coughing.

The way this is diagnosed is a doctor will stick a small camera up your nose and down the back of your throat to watch how your vocal cords work while you exercise. It’s called rhinolaryngoscopy.

Tangent: “Rhino” means nose in Greek and is where we get the term rhinorrhea (runny nose) and Rhinovirus (the common cold). Laryngo means voice box and “scopy” means camera.

This is a nervous system problem where the software has gotten mixed up somehow. Medicine won’t help. You need to re-write the software through breathing exercises prescribed by a speech therapist. Speech therapists are people who specialize in diseases of swallowing and breathing in addition to their training in speech problems. In rare severe cases, surgery can be an option, but let’s try to avoid that shall we.

Swimmer’s Ear: Otitis Externa

The final common problem that swimmers experience is otitis externa, or swimmer’s ear. This is an infection of the ear canal and can be very painful. Before we jump in, let’s review some ear anatomy. There are three parts to the ear: outer, middle and inner.

The outer ear is the part you can see without cutting into anything: ear lobe and outer canal up to the ear drum. Past the ear drum you are in the middle ear which houses the three tiniest, cutest little bones in the body that transmit the sound from the ear drum to the inner ear. The inner ear is deeper in the skull and houses the actual nerves and organs that translate sound into nerve impulses before they are sent to the brain for processing.

Tangent: The eustachian canal is the connection between the middle ear and the nose. That’s what helps equalize the pressure behind the ear drum when you are blowing bubble rings at the bottom of the pool or flying in an airplane.

Our problem child in Swimmer’s ear is the outer ear. The canal is usually protected by a layer of wax as well as it’s very own microbiome. Remember the microbiome from our Nutrition chapter? It’s not just the community of bacteria, fungi and viruses that live in your gut, it’s the community that lives on your skin, in your eyes, mouth and your ear. They sever to maintain balance among each other to prevent any one nasty bacteria from outgrowing the others and causing problems. Here is a normal ear canal:

Water, heat and humidity increases the pH of your ear canal and disrupt the microbiome as well as the protective wax coating. Once these safety mechanisms are disrupted, bacteria like Pseudomonas aeruginosa and Stapholoccocus invade and infect the outer ear. This causes an inflammatory response of white cells that creates a red-hot ear canal that is swollen and painful and sometimes will discharge fluid from the ear… which is pus!

Tangent: Pseudomonas is a very feared bacteria in hospitals since it is very resistant to antibiotics and is found in wet warm areas. It is also the main cause of hot tub folliculitis (infection of the hair follicles).


Most of the time, topical antibiotics are enough to get rid of the infection. Over the counter Polymyxin or Neomycin are good options. You can even mix them both together and smear it all over your ear since each antibiotic will kill a specific organism. If these fail, or if you have worse symptoms like fever, hearing loss or you feel big lumps in your neck, you will need to see a doctor and get oral antibiotics and make sure they work against Pseudomonas.

To prevent this from happening again, you need to maintain a nice microbiome as well as keep your wax layer intact. DO NOT USE Q-TIPS EVER! Q-tips disrupt the protective wax and can pierce your ear drum. They are not meant for cleaning your ears.

Keep your ears dry by using ear plugs during swims or by squeezing a couple drops of 70% alcohol in your ears after practice to help dry out the water that’s left inside.


Always remember, the best injury is the one that never happens. Take the time to properly train for prevention and you will never have to hit these common bumps in the road. And if you do, don’t give up. Take a step back, take the time to heal properly and then re-introduce your training slowly while maintaining your pre-hab exercises to prevent future problems.  


Karl Hamouche- Swim Smart founder
© 2017 Swim Smart, ALL RIGHTS RESERVED

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