Back in high school, one of my best friends, Jason, was having the season of his life. It was perfect timing, since he was starting to get recruited by colleges all across the country. Jason was a breaststroker and really wanted to win his high school swimming champs that upcoming winter. For that reason, he started to increase his breaststroke training. One day at practice, his knee started to become pretty painful. He tried resting, exercises, but nothing seemed to work. Fortunately, by keeping his breaststroke yardage down his knee pain stayed at a low level, but he was never quite able to return to same level of breaststroke training. While not as common as “swimmers shoulder,” breaststrokers knee is one of the more common injuries in the lower extremity for swimmers.
What is Breaststrokers Knee?
Breaststrokers knee is commonly described as pain on the inside of the knee, but some swimmers may feel it over the front of the knee. Typically a swimmer will feel it during the “whip” of their breaststroke kick.
Who Gets Breaststrokers Knee?
This injury is more common in senior level swimmers, swimmers whose primary stroke is breaststroke, and in training programs that have higher volumes of breaststroke. Just like with Jason, if not treated properly, breaststrokers knee can last a long time and become a significant source of irritation.
What Causes Breaststrokers Knee?
The million dollar question. There are a couple schools of thought on this, none of which have strong evidence. The first theory is poor breaststroke kick technique. A common fault is instead of having a narrow and efficient kick, a swimmer has a wide “frog like” kick. In a wide kick, there a large strain on the ligament on the inner part of your knee, the MCL. If done repeatedly, this can cause micro tears on the ligament, leading to pain and irritation in the area. Given that swimmers naturally are hypermobile, this can further lead to problems as their ligaments are already more mobile.
Another theory is a lack of hip internal rotation. If a swimmer is unable to rotate their hip inwards, the rotation their need from their leg must come from another joint. Typically, this will be the knee joint. While the knee is incredibly strong, but it is not meant to repeatedly rotate. This rotate will stress the muscles, ligaments, and tendons, along the inside of the knee, potentially resulting in pain.
The last theory, which is not stated in the research, but something I have seen is a PT, is an increase an activity outside of the pool that results in knee pain. This could be from increases in running, dryland activities, jumping and landing weird, gym class, etc. While a swimmer may not be feel discomfort during any other parts of practice, they may feel it during breaststroke due to the increased strain placed on the knee.
What Do We Do Now?
The second million dollar question. As a physical therapist, it is my job to assess for any relevant deficits that may be contributing to the problem or deficits that result from the problem itself. Some deficits that I will see in the clinic with breaststrokers knee are….
- Soft tissue tension in the muscles around the knee
- Asymmetrical quadricep strength
- Weakness in the hips (particularly glute med/glute max)
It should be noted that these deficits may be a result of pain itself. When a body part becomes painful, the body inhibits the muscles around the area to help protect the injured body part. This is called muscle inhibition. While this may be helpful for the first 1-2 days after injury to allow the injured area to rest, it can make the injury worse if the deficits are not corrected.
Part one of this blog series discussed why a swimmer might develop knee pain during breaststroke, what are some potential causes, and some of the common deficits I have seen in swimmers who develop knee pain. A quick review of the common deficits in swimmers with breaststrokers knee are…
- Soft tissue restriction in the hip flexors and adductors
- Asymmetrical quadricep strength
- Weakness in the hips (particularly glute med/glute max)
Why is it Important to Correct These Deficits?
Perhaps one of the biggest reasons to work on these deficits, is that it will help a swimmers performance. Optimizing the function of any of the muscles in the legs will help a swimmers kick, leading to improved times in the pool. IFor example, if a swimmers right quadricep is weaker than their left, their kick will be not as strong. This will lead to earlier fatigue and less power. A decrease in power and strength in the legs will also lead to the knee and hip to become fatigued faster. By increasing fatigue, you are leaving the knee to become more susceptible to injury. If a swimmer has a soft tissue restriction, there muscles will not be able to get in the optimal position for their kick. This too will lead to decrease power during your kick, leaving performance gains on the table.
Step #1 Undoing Soft Tissue Tension
One of my favorite ways to decrease soft tissue tension around knee is foam rolling. Decreasing soft tissue tension can be a great way to help keep a swimmer in the water by providing short term symptom relief. Foam rolling will definitely not fix the problem, but it may allow you to keep kicking while working on the other deficits. Some of the foam rolling exercises that I will use for muscles around the knee are…
Tennis ball above the Knee
Quadricep foam Roll
Adductor Foam Roll
Step #2 Restoring Quadricep Strength
One of the first things I focus on is making your quadricep strength symmetrical. It is important to note that the difference in strength is likely due to muscle inhibition. Meaning, the pain around your knee is inhibits the muscles around the area. This is your bodies way to try and protect the area, but it often causes more problems than it fixes. Inhibition to the muscles lowers the amount of force they can produce, making the quadriceps appear weaker.
Here are two of my favorite exercises to help get the quads firing again. For these exercises, it is critical to make sure you feel your quadriceps working. Your body may try and use other muscles groups (hamstrings, glutes, calves, etc.) instead. Really focus on making sure the quadriceps are the ones working.
Single leg wall sit
Lateral Step Down with TKE
Step #3 Strengthening the hips
The muscles around the outside of your hip are also important to strengthen. Specifically the gluteus medius and gluteus Maximus. Why are they important to strengthen? One reason is that also your glutes can also become inhibited from pain in your knee. A second is reason that glutes help stabilize the hips and control the rotation of your femur during the breaststroke kick. Both of which can help take pressure of the knee during breaststroke kick. Three of my favorite exercises for strengthening your glutes are…
Side plank
Single Leg Bridge
Step Down
Can you Still Swim with Knee Pain during Breaststroke?
For the majority of swimmers, yes. Typically I will tell a swimmer avoid breaststroke for a couple of days and encourage them to stay in the water. Once breaststroke is reintroduced, having a little pain is acceptable and expected (<4/10). If your pain goes above a 4, switch to a stroke that is not painful or rest until the pain drops down again. I am strong believer in keeping swimmers in the water while injured. Check out this previous post for my reasons why.
In Summary:
Breaststrokers knee is complex and there is not a one size fits all solution. I have found improving quadricep and hip strength, while using soft tissue techniques to keep symptoms down, highly effective for breaststrokers knee. However, some swimmers may need different exercises or a different approach to help solve their knee pain.
If you are struggling with knee pain and do not know what to do. Let’s get in touch.
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