By Al Devereaux and Zhenya Kurashova Wine
Originally published in Massage & Bodywork magazine, December/January 2000.
One of the most gratifying aspects of my work with Williams College swimmers was utilizing Russian Sports Massage when addressing their injuries. This part of the sports massage program can also become one of the most frustrating if the therapist doesn’t obtain the expected results. Most of the time, thank goodness, I am gratified and not frustrated. We, as massage therapists, sometimes expect too much out of what we do and when the outcome is not as quick or as complete as we’d like, we become frustrated.
One of the causes of injuries to swimmers is poor stroke mechanics. At Williams College, coach Carl Samuelson is a master at being able to correct a swimmer’s technique. It amazes me how well he can pick up slight mistakes and communicate to the athlete what needs to be corrected. I can’t tell you the number of swimmers who have come to Williams as “burned out” swimmers never wanting to swim again. The majority of these swimmers have gone on to have successful collegiate careers at Williams, with some becoming All-Americans.
I can recall one such swimmer. Her name was Melissa. As an up-and-coming United States Swimming Association swimmer, she was courted by Division I colleges while in high school. During her junior year, Melissa developed major shoulder problems and had arthroscopic surgery performed on both shoulders. As a result, she was unable to swim in her senior year of high school. The Division I colleges were no longer interested and she ended up at Williams, where I met her during her freshman year. She didn’t plan to swim at all in college because of her shoulders, but eventually decided to practice with the team and was mainly doing kicking workouts. To make a long story short, Melissa worked together with the coach for the remainder of her college career. She was an All-American in her sophomore, junior and senior years. While massage wasn’t the only factor leading to this success, it was certainly an important one.
I feel that part of the success I have had as a therapist is directly related to the positive attitude of the coach and the swimmers. I am so fortunate to have worked in a program where the coach was a believer in, and proponent of, massage. Samuelson’s philosophy about a “low key approach” to coaching is part of the reason for the success of the Williams’ teams and my success with the individual swimmers. I also feel I can relate well with the swimmers because of my swimming and coaching background.
It is important to realize that injuries to athletes are no different than injuries to the general public, as far as the structures involved. A swimmer, for instance, who strains muscles in the rotator cuff has injured the same structures as someone straining the shoulder vacuuming or shoveling snow. The motivation of the athlete to return to sport, however, may be greater than the general public to follow-up with therapy. The athlete is also in better condition and will, in most cases, recover more quickly. Still, we can apply rehabilitative Russian Sports Massage techniques to the general public for injuries similar to those of the athlete.
Let’s consider some of the things swimmers do that contribute to these injuries. The most obvious is the repetitive motion of the shoulder joint when performing the backstroke, freestyle and butterfly strokes. During the course of the swimming season, from Christmas break to the end of winter study, the Williams’ team members might swim up to 14,000 yards per day. This is a time during the school year when they are not heavily involved in academics. Granted, all of the 14,000 yards do not involve using the arms; there is also a portion of the practice delegated to kicking. However, the shoulders do get overused and this directly affects the deltoids, rotator cuff, trapezius, latissimus and pectorals. The actions that occur in swimming are elevation, medial rotation, abduction, circumduction and adduction. These motions, when repeated, cause an overuse syndrome.
Another area of the body that can be negatively affected is the low back. The actions which specifically contribute to low back problems are the butterfly kick and the breaststroke kick. The real culprit in my opinion, however, is practicing starts. At the end of the season, when the swimmers are practicing a lot of starts, is when I see most of the low back pain occurring. Starting is an explosive action and a tremendous amount of flexion and extension occurs in a very short time. Flip turns can also be a cause of low back pain.
The hip and knee can also be problem areas. Breaststroke seems to be the biggest culprit for creating these problems. The medial knee and adductor muscles, as well as the gluteals and lateral hip rotators, are really stressed during the breaststroke kick. As the leg is adducted, it puts a tremendous amount of stress on the medial knee.
Now let’s look at the specific injuries. These are some of the injuries I have dealt with over the course of my career with these athletes. I would like to group the injuries into three categories. Those that occur due to overuse, those that occur as a result of trauma, and those that are related to environment. Traumatic injuries are more apt to occur in team sports, rather than in swimming and diving. However, there can be occasions when trauma does occur. For example: jamming a finger or wrist at the end of the pool when finishing, or hitting the board when diving. Eye, ear and skin problems can also be an issue with swimmers.
Overuse Injuries: Strains and Sprains
Strains – Muscular strains are a tearing injury of the musculotendinous unit. This tearing can occur anywhere. One area is where the tendon attaches to the bone. This occurs more frequently in younger athletes. Another area is at the musculotendinous junction. The third area is in the muscle itself. There are three degrees of muscular strains; a condition that can occur due to continuous muscle strains is tendonitis.
· First degree – A minimal tearing of fibers occurs and activity can usually continue. There is minimal swelling.
· Second degree – Significant tearing of fibers occurs; some continuity of the musculotendinous unit remains. There is significant swelling, and bruising will be evident. Activity may have to be terminated or reduced and rehabilitation, including strengthening and stretching, will be required.
· Third degree – Total avulsion of the musculotendinous junction. This may or may not require surgical intervention. Initially there could be a reduction in function. In any event, the recovery time will be increased over 1st and 2nd degree strains.
Sprains – This relates to injury of ligaments. Ligaments have very little elasticity compared to muscles and tendons. They are not really meant to stretch very much. Sprains are categorized the same as strains.
· First degree – Partial tearing of some fibers.
· Second degree – More fibers are torn.
· Third degree – Total separation of all the fibers either at the attachments or in the ligament.
Sprains may or may not require surgery. Ligaments are also very avascular and therefore require a very specific type of massage for optimum healing to occur.
As far as traumatic injuries are concerned, I have not really treated too many which were directly related to activity in the pool. Most of these have occurred as a result of “dry land” exercises, strength training or other extra-curricular sports activities. Some of these traumas were avulsion of the anterior cruciate ligament, protruding disc in the lumbar spine and possible pectoral muscle tear. The first two of these were diagnosed by physicians using X-rays and MRIs.
Other conditions that are treatable using massage techniques are edema and scar tissue. These injuries are all treatable using massage as one of the components. We are specifically discussing swimming injuries, but these techniques can also be applied to the same type of injury in other sports.
When an injury occurs, edema (swelling) follows. In order to optimize healing, it is important to minimize the swelling as much as possible and as soon as possible. We have all heard of the idiom RICE – rest, ice, compression, elevation. This will help prevent increased swelling and facilitate recovery.
When there is an injury, such as a tear in a ligament or tendon, bleeding occurs. The body then releases a number of chemicals which produce vasodilation. This increased vasodilation brings more blood to the area of injury and fluid begins building up in the interstitial spaces causing edema. If edema remains, the healing process will be lengthened. Massage can be used effectively almost immediately to help keep edema to a minimum and to eliminate it quickly.
I mentioned in an earlier article in this series an anterior cruciate ligament injury to one of the swimmers I was working with. The first time I saw this injury was right after it occurred. The knee was extremely swollen. I spent 12-15 minutes working on the thigh performing effleurage and Russian compression strokes, much like a milking effleurage motion. The swelling was reduced significantly (approximately 80%). I then said to the swimmer that she should do this to herself daily until I saw her again. Four days later, there was virtually no swelling and I was able to work on the knee.
In the acute stage, there will be pain. When palpated, the tissue will feel like a water balloon. Tissue will remain dimpled when pressure is applied and released. Massage is contraindicated directly on the injured area at this time. Massage, however, can be used on the proximal areas. Massage will work both mechanically and reflexively to help reduce edema.
In the example given above, only continuous Russian clasping effleurage and Russian compression were used. These were performed stroking from distal to proximal starting above the swelling. To perform the effleurage, the direction of the pressure is forward toward the direction of movement, not down into the tissues. The reason for this is that if pressure is applied downward, we are shutting down the blood vessels that we are, in fact, trying to open and move fluids through. Russian compression is applied by lifting the tissues, compressing them and then “milking” them. Again the direction of the stroke is forward from the underlying to the upper-lying lymph nodes. Light shaking vibration can also be used in conjunction with the effleurage and Russian compression (these strokes are described in-depth in the Summer 1998 issue of Massage & Bodywork). As the swelling decreases even within the same treatment, you may begin very superficial, continuous effleurage on the knee itself. This will aid resolution of edema in the subcutaneous tissue. Make sure that you do not apply pressure downward at any time, since this will increase the swelling.
In the next article we will deal with other upper body and back injuries.