Swimming is a highly popluar sport in many countries. Up to 12% of the population of the United Kingdom regularly take part. Epidemiological data suggest that overall injury rates are very low in comparison with other sports. Swimming is often promoted as an ideal activity for the acknowledged benefits of exercise for both those in health and with disease. The spectrum of swimmers, therefore, cover those individuals wishing to improve their health to the committed elite swimmer. It is this latter group that suffer from the preponderance of injuries. The swimmer needs to contend with the fact that they perform in an alien, fluid environment that offers considerable resistance to forward motion and relies largely on the uppper limbs for propulsion. The four strokes differ subtlely in their injury patterns. Swimming injuries may be either acute or due to overuse. Acute injuries are relatively rare due to the lack of bodily contact and the relatively slow speeds. Discipline in and around the pool, avoidance of over crowding and caution when diving are important. Acute muscle strains can occur following failure to perform an adequate warm-up. Blunt injuries for the majority are minor in nature and self-limiting. The majority of injuries that affect training and performance are overuse in nature. The anatomical and biomechanical demands are far in excess of normal design which, with insufficient preparation and recovery, can result in injury. Training errors are factors in the development of swimming injuries but these can be minimised by individualised, responsive programmes with in-built recovery periods for each physiological system. Shoulder problems are most common, accounting for approximately 60% of all musculoskeletal problems and are felt to relfect a secondary impingement syndrome due to instability. Swimmers have high levels of flexibility and the shoulder joint relies heavily on dynamic control of the rotator cuff muscles. Strengthening programmes particularly focussed on balancing the internal and external rotators and the scapular stabilisers muscles can lead to lower injury rates. Three dimensional video analysis suggest that some swimmers spend upto 56% of each arm cycle in an impingement position. The knees of Breaststrokers are vulnerable to the combination of flexion, valgus and rotational stresses applied. Quadriceps strengthening programmes should concentrate on closed-chain and terminal range exercises. The streamline position encourages repeated extreme hyperextension of the lumbar spine particularly in Butterfly and the 'undulating' style of Breaststroke. Such actions repetitively load the posterior structures of the spine, which may result in a stres injuries. Kick drills, with the upper body relatively fixed with an arm board, have been noted to exacerbate symptoms. Developmental poor postures with an increased thoracic kyphosis and rounded shoulders are not uncommon. Optimising technique and avoidance of provocative positions and drills are important. Core stability programmes concentrating on the endurance of the major muscle masses are also key. Understanding the causes of injury allows physicians to work with coaches to minimise risks and allow prompt early intervention to prevent chronicity and underperformance.
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