Swimming and Diabetes by Dr. Jim Miller & Nutritional Supplements by Charlene Boudreau & Swimming Biomechanics and Injury Prevention by Dr. Jim Johnson (2002)


Let me get started, and the second part of this presentation series is related to issues surrounding swimming and Diabetes.  Diabetes is a difficult problem.  It is widely spread and I am sorry to say that the instance of Diabetes is on a tremendous rise in the United States today.  We have several different categories of Diabetes.  There is Type I.  It has some old terms associated with it.  One term is the old “Juvenile Diabetes;” the second one is “Insulin-Dependent Diabetes.”  Type I is a result of an auto-immune destruction of certain cells that produce insulin and has several genetic errors that actually set-up this environment so that this happens.  There are several different metabolic links; this is genetically driven and what happens is that there is a miss-identification.  Genetically, they are set-up not quite right, they miss-identify the virus that is bound to the cell and their own immune system turns on and destroys their own insulin-producing cells.  The viruses that are most commonly associated with this is, first, Viral Hepatitis and all the different forms of A, B, C, and now there are non-A, B, C, kinds and D’s.  Next, there is a Cytomegalovirus called CMV, Anti-Coccyxoci Virus.  This is a fairly common virus that can be associated even with the common cold-type of statement.  There is a higher incidence of Diabetes in those diets that are heavy in dairy products, and there are also certain environmental toxins that can increase the incidence of the formation of the Type I diabetic.  The highest incidence occurs between the ages of 8 and 12.  After adolescence, this type of Diabetes tends to decline as far as incidence, and it is replaced by the second kind, as you might guess, Type II.  There is the old prior terms, non-insulin dependent or adult type.  This one actually has two metabolic defects.  There is a metabolic defect whereby the cells are not as sensitive to the insulin that is being produced and therefore you require higher concentrations of insulin for the same effect.


The second defect is that the cells themselves are unable to respond so, they are not as sensitive, they need more and the cells cannot make it, so there are actually two metabolic defects that create the Type II.  There is a higher incidence in all adults-women are a little bit more common than men.  This is the problem that we are facing today, and the reason that I am talking about Type II to you.  When I gave this lecture to a group of swim coaches ten years ago, Type II was not even discussed, but as we see an increased incidence of obesity, increased percentage of body fat in the kids today, this is the highest rising form of Diabetes in adolescence today.  So, as percentage of body fat increases, the sensitivity of the insulin declines, behold, we have a “adult-type-child-Diabetic.”


This is what we are seeing; with the increasing sedentary behavior in the youth of today, there is increasing body fat.  Diabetes Type I; here are some symptoms that can actually alert you to Type I occurring (these are things that would give you an indication of something to maybe this athlete isn’t quite right.)  Now, how you are able to determine emotional ability in an adolescent (male or female), is beyond me, but you know what I’m talking about.  A lot of the same symptoms, however, in your Type II’s; you will frequently see them getting overweight, and then as they slide into Diabetes, the see a weight drop-off.  Increase in appetite-these guys will frequently show a decrease, though they may also see an increase, too.  Once again, weakness, and fatigue, you will see is common between the two and a huge increase of infections here.  There will be a little bit more in Type I’s for some reason.


Diabetes in swimming:  the question of course, is why are we having this discussion today.  Why has it received so much attention and there is your answer.  This gentleman, of course, did not follow the routine.  He was not diagnosed as a diabetic and disappeared into obscurity, but continued fighting on, and is, of course, an incredible athlete as we all know today.  Diabetes treatments:  When I guess the series of inquires that are sent to me fairly frequently on Diabetes and Diabetes management-here is where I spend my time.  That is number 1-DIET!  Number 2-consistent patterns of eating and eating with balance-a balanced diet, okay?  Sweets-GONE!  You have got to get them to accept that!  Weight control-CRITICAL!  Exercise improves the sensitivity of the cells to the insulin.  That is all cells, muscle cells, fat cells, and the whole nine yards and allows the same dosage of insulin to go farther and do more.  Hydration:  CRITICAL TOPIC!   Once again, during the course of your training, be sure and hydrate your athletes in general, but in particular, your diabetic!   Basic continued: rest makes a difference.


All your diabetics need to be testing.  They need to have reproductive testing.  Your diabetics need to be able to predict how they respond in certain circumstances.  We have diabetics that are open water athletes doing a 25K.  Crossing a channel with Diabetes is quite a challenge, as much as a 50 freestyle or 100 freestyle, well; their needs are different, also.   Your athlete’s needs: remember, every athlete is different.  Just because their sugar is at a certain level an hour before their particular race, doesn’t mean that they will necessarily all produce the same drop in blood sugar over the course of those races.  So, each athlete must be individualized and we encourage them to be doing testing of their blood before practices, even during practices, and after practices, as their Diabetes changes.


Many of your TypeI’s go through what is characteristically called, a honeymoon period, whereby their Diabetes will be severe, and then it will almost disappear.  In some cases, it does disappear and they will think that they are cured, and sadly, they are not.  It will come back full force, and then will resolve again.  So, during these times of new diagnosis, and fluctuations of sugar, remember that you coaches are really on the front line.   As far as working with your athlete, and getting feedback as to where they are in the course and being able to make this as predictable a disease as possible.  This can be done, but reproducibility, reproducibility of diet in teenagers; adolescents are a real marvel to try to work with.


Stress includes psychological stress, just as real as the other.  Health care team:  the athlete, you can’t go anywhere without this person.  The doctor, the coach-everybody in the world can want it, but if this one doesn’t, you are going nowhere.  Medicine, physician, diabetic educators, dietitians, availability is the key.  You may have great people, but if you can’t find them {they are off lecturing at ASCA}, and you can’t get them anyway, so availability of these individuals-if the coach is willing to learn and be flexible, you are just going to have to be flexible.  Parents are on the team with you, and they can make or break you, okay?  This is your health care team.  If any part of this team is missing, you will not do well.  Notice who is number 1?  The swimmer!


The question was, the younger the athlete, are there more risks to them, should they have troubles later on, and the answer is, no-absolutely not!  They should be-if you control them well (and that is the newest literature in the world of Diabetes), is that your young athletes, if you control them well, will do quite well.


Diabetes by the way is more than just blood sugar, but we seem to feel like if we control the sugar, the immune system and all the other systems will work quite well and your risk of Diabetic Eye Disease, Diabetic Kidney Disease-all of those are reduced tremendously.  Where we are getting to is medications that are used and here we go…


When we look at medications and what we can do with medications-these are things they accomplish oral agents; they can increase insulin secretion and increase sensitivity of cells to the insulin you make.  In other words, they change absorption of carbohydrate and how you absorb them and decreased production of sugar by the liver, raise the production of the good form of cholesterol and problems you have to realize that can occur with any of these compounds.   If you go overboard with any of these compounds, you can increase hunger making Diabetes hungry and this never helps anybody.  If you are not careful, if your sugars get too low, you can have seizures.  Weight control is in this stage a disaster and therefore gastric distress can also be a problem.


For those of you who are nutritionists and physicians in the area of Diabetes-#1 those compounds that increase insulin secretion are indicated there.  #2-those increasing sensitivity of cells are shown in number 2.  #3-starch blockers; these are not used much anymore.  #4-in increasing the production of sugar, there is a decreased production of sugar by the liver.  #5-is accomplished by the same group.  Note that there are oral combinations that are also now made to utilize several different things, so concentrate-for those of you who are coaches-that these are different ways that we interact with Diabetes by way of medications.  Those of you in the physicians panels and nutritionists and trainers; here is the medication categories that cross over with these.  The sole exception of course, being #6-does not correlate with #6.  The other thing is, insulin, (we are seeing that we are using all kinds of insulin now), the short acting forms of insulin that last for just an hour or two.


There are regular forms of insulin such as #3 and #4.  Intermediate acting ones, long acting ones, and there is a 24 hour injection.  You will see insulin mixes of combinations of different forms of these.  In the world of swimming, you will not see much use of insulin pumps; in fact, the creation of Iletin insulin is great.  Sooner or later, we think this is going to really affect the number of people on pumps and now there is something new that is coming which we are exceedingly excited about.  It is an inhaled form of insulin which should be out within about a year, allowing people not to have to use shots.  The problem being, at this moment, the inhaled insulin is only a short-acting insulin.  It is not a sustained release form.  So, new hot topics are combination therapy, insulin and oral agents together.  Warning signs for you are low sugars, sweating, hunger, forgetful, confused, headaches, nervousness, dizziness, drowsiness, and rapid heartbeat.  Those are the things that you look for in emergency actions; what you do for low blood sugars?


There are various forms of the jell products that come in secreted forms for you to use.  They will come in prepackaged doormats (in fact this is one of them), you just tear off the end of it and rub it on the gum, and it is absorbed very quickly.  There are injected forms which I doubt you see much of, unless it is a severe Type I diabetic.  You will see some of those and then there is the old method that you have all heard of using orange juice combined with sugars and sodas and all kinds of other things.  The problem with any of these is, if you enact any of those, there is a likelihood of a rapid rise of sugars, followed by a rapid drop so you have to make sure that you are protected on the back-side of that, should anything like that occur.  So, in summary, basics are your key.  Try to make your diabetics as predictable as possible, by adhering to the basics.  Insulin and oral agents are being used by both Type I and Type II, and you can approach this disease with an entire approach to individualize the athletes, as I mentioned before, we have members of open water teams that are using this.  The only changes that we have is an escort craft-a kayak or something that goes with them in those settings so there are some things that we will do specifically for them in those situations.


Next question:  What should the trainers and the coaches, who travel with diabetic athletes, do to be prepared for that setting?  That little tube I showed you, (I’ve got several in my bag), I think ideally, the trainers and physicians who travel with an athlete such as that, need to be very comfortable, or need to be very accustomed to those symptoms.  They can’t just go off on a trip and try to get ready on the way, okay?  So, you have to really be with-it and be comfortable with that knowledge, because as you get higher in your elite levels-higher in your performance, their percentage of exercise exertion increases, and that is a bigger problem-not a smaller one.  Be aware and be comfortable on how to care for your swimmer.


Yes sir, (in the back), I have a whole pile of things to say about a carbohydrate loading period.  I think that your key to success is a balanced diet period.  I think it depends upon the athlete that you are talking about, and the type of exercise that they are going to be doing as to how much carbohydrate loading is indeed appropriate.  In your diabetic, as we have indicated, you have to have a predictable diabetic that knows his or her disease and knows how they tend to respond.  If you change that base, chances are that it will not be a help to you, it will be a hindrance.  So, if they are not used to that type of scenario, and you haven’t, and you haven’t practiced that scenario, I would not do it.  Don’t say, okay, we have all these meets, but we are going to treat this one differently because you are going to have a different response and you will have an athlete that cannot perform.


Yes sir, in the back, that is correct, but once again, predictability is key.  It also depends on the length of the workout.  I mean, you are going to have a sugar that is this low and it is going to drop to there over two hours.  Okay, your athlete gets in the water and has a sugar of 180; if you are going to go for two hours,  that athlete is going to have to do something different that if they wake up and their sugar is 110.  It all will depend on the athlete and it depends on the level of exertion.  I know I have had some one mile open water swims that I have done in 15 minutes and some I’ve done in 45 minutes for the same course.  These conditions are so different.


Okay, there is a question right here.  The predictability of your athlete, most athletes are that, in the situation of a big meet, multiple competitions during the course of the day, we have most of them stay very simple, mostly liquids, mostly things that are readily absorbed-not a lot of gastric load.  I would not change that recommendation with your diabetics with the single exception of having your diabetic testing sugars because you have to remember stress is a big deal.  You cannot tell me that march down the Olympic corridor is the same as standing up on the pool deck in a dual meet.  It is not the same, so that athlete is going to respond differently in that setting.  What they are used to (and I know that is a kind of a cop-out, but you have got to know what your athlete is accustomed to), what their stomach will handle, what they absorb, and how they absorb.  It has got to be very reproducible.  Whether you are using fructose sugars (which are fruits and those sorts of things), or whether you are using synthetic sorts of things to get the carbohydrates, so just individualize your athletes.  They are all very, very different on how they respond.


The question up here was that she does have a swimmer who is on a pump and obviously they are going to attach the pump, or are doing something before she gets up to do her races, and then she reattaches it  and heads on and goes her own way.


She swims with it on?  Okay, that is different.  The statement is that her athlete actually is swimming with the pump in place.  I would probably see, from the standpoint of the physicians, whether or not they have considered some of these other modes we have discussed, to get her through swim race days.  Currently, what we are using is reusing Lancets in the evening and then short-acting insulins during the day to kind of equal what the pump does, as opposed to the issue of surrounding the pump.  The pump is difficult to work with in our sport, it just is.






Okay, I will turn the podium over and let Charlene go from here.


Anybody want to take a stab at the figure for dietary supplement sales in 2001?  Anyone?  15 billion dollars!  That is about on billion dollars for every minute that I have to talk I have to talk to you about supplements today.


A dietary supplement is a vitamin/mineral, herb or other botanical or amino acid which are dietary substances used by man to supplement their diets today.  It is a very concentrated metabolite constituent extract or some combination of those things.  It sounds very technical.  It is also intended for ingestion as a pill, capsule, tablet, liquid or a powder, a very common form of dietary supplement today.  Dietary supplements are not represented for use as conventional foods, nor are they represented to be the sole item of a meal or a diet.  They are labeled as dietary supplements and that is actually a requirement by our government.  If you are selling something that you are calling a dietary supplement, it is supposed to be labeled as one.  Right now, the American Diabetes Association, which is one of the major, if not THE major, nutrition advocacy agency and the United States, says that vitamin and mineral supplementation is appropriate when well accepted.  Peer reviewed scientific evidence shows safety and effectiveness.  I would also like you to keep that statement in mind as we talk about this for the next 12 minutes and maybe for the next 12 years.
In 1994, our government passed the Dietary Supplements Health and Education Act, also known as DuShay.  Upon that Act, it became very evident to many companies that the claims made by the manufacturers and distributors of dietary supplements, regarding the effectiveness of their product, do not require strict evaluation by the Food and Drug Administration.  Rice Krispies do.  Oral Contraceptions do.  Dietary supplements do not.  Back in January, I attended a conference at the National Institute of Health.  The conference was supported by the Office of Dietary Supplements and the Council for Responsible Nutrition, so my plan today, is just to share with you some of the items that we discussed at that conference, and to maybe bring you up-to-speed on some things they you didn’t know, or didn’t realize.  The goal of this conference was to examine the evidence that we have that addresses the safety and efficiency of dietary supplements, and also some of the policy concerns related to the youth.  As you can imagine, (based on the last two slides I just showed you), there are a lot of concerns and a lot of concerns about policy.


Because dietary supplements are not regulated by the FDA, there are some issues with labeling and claims that open the door for some of our athletes, not only for health and safety reasons, but also for drug testing reasons.  Basically, what we are showing here (and this is based on research in 2000-2001), is that one in eight brands did conform to DuShay requirements.  One in eight is not very many.


So, a question came from the audience.  Who and how much is being paid to audit DuShay’s implementation of checking supplements? (Because we know we need somebody to regulate this industry.)  We know we need somebody to check on it so what is the FDA doing?  What is the National Institute of Health doing to promote this procedure?  The answer was that most dietary supplement companies have their own QC companies.  What does this mean to us?  As I mentioned to you, the failure of the supplement’s ingredients to match the product’s content is 100%, which open the door for some things:  mostly, it is a safety issue.  The problem that we run into when it is not being checked or examined very carefully by the FDA or somebody, is that the ingredients list that you see on the outside of the supplement (that I would encourage you always to read to make sure there is nothing prohibited or anything harmful in the product), there is no guarantee that what is listed on the outside is going to match what is on the inside 100%.  A lot of times it will match, but it only takes one.  This opens the door for safety hazards.


If you are allergic to an ingredient that is not listed on the outside, which is actually inside the product, you put yourself at risk for a reaction.  If there is something listed on the outside of the product, which is actually not on the inside of the product:  #1 you have just wasted your money.  #2, if the ingredients listed on the outside do not match what is on the inside, and there is something in there that is not listed on the outside do not match what is on the inside, you have just opened the door for a positive drug test.  Now, let me remind you that, that door may be opened this much, or it may be opened this much.  It doesn’t matter; a positive drug test is a positive drug test.  What you have to decide is, which supplements open the door this much and which ones open the door this much.  You would probably want to stay away from these, and we have an analogy that we can use to help you make that decision.  This has become such a prevalent issue in sports, that there are some very prominent organizations in North America that have taken a stand on this.  Obviously, I work for USA Swimming, and our position right now states that we do NOT advocate the use of supplements, unless there is a medical condition which would warrant its use.


If someone is iron deficient, I would not say absolutely to not take an iron supplement.  I would never tell someone to stop taking their Flintstones or Centrum or One-a-Day.  I might not tell someone to take those of they are iron deficient, or if they don’t have a nutritional deficiency in something that is a basic vitamin or mineral.  I would probably not recommend a dietary supplement if their diet is adequate in nutrients.


The NCAA has a position, but what it boils down to is, you cannot recruit anyone based on the promises that you are going to give them something like Creatine.  The NCAA, according to their rules, you can offer them a carbohydrate supplement, power bars, Gatorade, that kind of thing, but you cannot make promises of protein powders and shakes and that kind of product.  FINA has supplements, and basically, what it boils sown to is, that they classify dietary supplements as: take at your own risk.  The responsibility is on the athlete, not the teammates, not the parents, only the athlete.  They have to be responsible for what goes into the mouth.  In addition to that, the American College of Sports Medicine promotes the concept of good nutrition.  The American Dietetic Association does that as well, and in fact, the American Dietetic Association and the same organization of Canada and the Coaching Association of Canada got together and wrote a position statement together.  This group of Organizations had though that this issue was important enough that they had to get together and say something.  All of these physician statements you can find references to in the USA Swimming Supplements Database, if you are interested in reading those in more detail.


The National Athletic Trainers Association basically said that high schools have a statement, but nobody really follows up on it and this is to me, from trainers who are placed in the high school system to work and cover their athletes.  As I mentioned, let the buyer beware that the representatives said that they hold their athletes to strict liability, and one point they wanted to make, was that natural does not always mean safe.  If it says natural on the label, it doesn’t always mean it is safe.  And of course, they are talking about a dose response.  The Council on Responsible Nutrition gave a red, yellow and green analogy , or red light, yellow light and green light category, which basically means, stop, caution, or go ahead.


I would put protein powders closer to the yellow or red category, depending on what ingredients they have in them.


Another issue, and this is something that has come up (it is pretty new), we don’t give a lot of thought to, but people who tend to take dietary supplements usually aren’t just using one.  They are using 2,3 12, 19 0r even 32.  You walk into some places and it looks like a pharmacy in there.  This element of stacking, basically, what it boils down to is 1+1 does not always equal 2.   The fact is, there is research on individual supplements, some long-term and some sort-term, but there is not a whole lot of research on putting two supplements together and the net effect is zero.  Soy protein for example, interferes with the absorption of iron, so if you are having those two things together you may be actually negating the purpose.  Iron and Zinc, magnesium and phosphate; same situation.  Synergism is a case where the sum of two parts is greater than their individual effects added together.  1+1=3 or 4 or 5.  Vitamin C and Iron;  Vitamin C actually enhances the absorption of iron, so if you are recommending someone supplements with iron, it is usually in conjunction with a vitamin C or a glass of orange juice.  Same thing with ribos and Creatine (this is something new that has come up), I haven’t read a whole lot about that, but there is some reports that indicate the effect of Creatine are actually enhanced if you are ingesting ribos along with it.


Potentiation is similar to synergism, but you are looking at 1+1=10.  That is kind of a strange way to represent that, but if you look at the effect of ginseng and caffeine, or something that is becoming even more popular, ZNA and Terestros, they actually recommend stacking those products together, saying that if you take those two together, the effects are almost amazingly astronomical.  If it sounds too good to be true; what did your mom always tell you?  It probably is.  That may be a good thing to keep in mind too, that and along with 15 billion dollars, and you will start to question which industry you want to be in.


Here is another interesting profile that came up:  You have supplements like DHEA, which is considered a dietary supplement, but when it gets into the body, it is converted to Testosterone, which is a controlled substance and requires a license from the Drug Enforcement Agency.  That has been converted to Estrogen, which is a prescription drug.  You have got one dietary supplement on the outside, a controlled substance and prescription drug on the inside, well; you’ve got three different laws governing each one of them.  Reginald Washington is a pediatrician and he basically summed it up and said “Anything above what is necessary to correct a deficiency, is not necessary.”


The lady from Blue Cross/Blue Shield said that a lot of people are now using and abusing performance enhancing drugs and supplements, and they are not the same thing as dietary supplements.  It all depends on how you are looking at it; but technically, they are not the same thing.  Supplements are not drugs.  Drugs require licenses by the Drug Enforcement Agency.  Dietary supplements do not fit in either of those two categories, but right now supplements are NOT drugs, according to our law.  Supplements are an ongoing problem and are an on-going issue with Blue Cross/Blue Shield.  Her point being that a lot of people are trying to get coverage under their insurance for the supplements they are being prescribed from naturopathic physicians and from health-food stores.


Here are some things to think about-education-information on the internet-research-interaction with foods, drugs and other supplements and a coordination of prominent groups, these are all major topics and major areas that need to be addressed within sports and within swimming.  We are trying to address those as well as we can.  We are trying to promote an education program that has accurate and balanced information.  We have begun to do that for the dietary supplements on the market today.  We provide as much information as we know on the different types of key ingredients or general categories of dietary supplements so that athletes  who wish to, can read about them and to take away their own opinion, and make them more informed.  We can’t tell you to take this or don’t take that.  We have to let you be responsible, or your athletes be responsible for what they are doing, and this is a good was to teach them to make their own decision and to account for their own action.


Look for the right answers to those really important questions before you are considering recommending a dietary supplement.  Have the answer for those parents who are asking you questions about them, too.  For example:  Do the proposed effects apply to the swimming sport?  Will this product keep your athlete from testing positive?  Are they legal?  Are they harmful?   Look for the answers to these questions before trying to talk to your athlete or parent.


I did want to touch on energy bars, drinks and powders because they are so different.  These all fall under different categories of supplements.  There are protein bars, energy bars, high-carb bars, glucose bars, and each has something of value.  Which one to use?  Read the ingredients first.  For a diabetic, they will not want the high-carb bar, because of the rise in blood sugar, but the glucose bar has benefits in maintaining blood glucose.  High-carb bars are great for a burst of energy, but is all that sugar supposed to be good for you?


Drinks are a whole new ballgame because drinks used to be just like Gatorade and Powerade, but now-a-days with added ingredients like amino acids and additives, they, too fall into a different category.  These drinks come in fancy bottles with different colors like black, silver, red, and orange.  There are cans, (really skinny ones!), and bottles that you can pop the cap off and you can drink right away.  There are plastic ones that you can re-use as a water bottle.  No, sports drinks are not just for sports anymore.  Mind you, they are convenient and a quick way to get replenishment and have their thirst quenched during exercise or competitions.


Given the choice, a lot of athletes prefer to drinks a sports drink rather than water to negate thirst and that is fine, provided it is tolerated.


At the beginning, the claims made by dietary supplement companies are always evaluated by the FDA.  You always have to remember this and be aware of what you are buying; knowing what is in it may be untrue.  A lot of our products today contain caffeine and that may not hurt your gastrointestinal tract, but drinks like Coke to rehydrate the body after a tough workout may have an adverse affect on your electrolyte balance.  Since caffeine does appear to increase magnesium and calcium absorption, we can’t count it out, but it is not something that we would recommend for your athletes to have on a regular basis.  Drinks and bars that claim to be fat free and the like, just remember that these are dietary supplements, too.  What it says is in them, may not be true.  Choose them cautiously!  All that is truly needed by your athlete is water for rehydration, there is nothing better, and it is 100%.


About added herbals; not a lot of researching on herbals, which means there is not a lot to tell me that we need them, just enough to tell me that they could be harmful.  Protein powders again; ask your athletes to put them in a caution category.  Use the yellow light because, if you think about the companies who produce protein powders, they produce a lot of other products, too, that are touted for their muscle boosting effect, or their strength effect or their testosterone boosting effect.  If there is any cross contamination between the equipment that is filling those containers, you have just contaminated a perfectly good substance with something that they are not allowed to have.  That would be a perfect example of as case that your label does not match the ingredients 100%, and of course, we wouldn’t recommend any of these.  If you see the work adro on something, put it back.  Do not buy it!  If you see the word “energizer”, “weight loss”, “muscle builder”; think about that, it should have a red light on it-stop-put those ones back.


Stimulants like caffeine is not totally bad, but it is often included in some of these energizers and then you have to go back to the stacking issue 1+1 does not equal 2.  We want to make sure you have access to this information.  Of course, we want you to go to USA Swimming.org.  Check on the dietary supplements data base-see what you find there.  Hopefully it will help in your education process, not only for you, but your parents who are wondering what to do, and your athletes who keep arguing with you.  They say; “Well, Johnny is taking it!”  “This person is taking it and they won a medal!”  Educate them!  Help let them make wise decisions.  Of course the FDA, the USDA, the ADA and the Gatorade Sport Science Institute, American College of Sports Medicine and the Government Nutrition Agency all have web sites dedicated in some states to dietary supplement information.  FINA and the US anti-doping Agency have web sites that have specific statements that are specific to our sport on the use of dietary supplements.  I would urge all of you to check those out and be familiar with them.  Consumer Lab is about the only organization that exists right now that does any sort of testing.


There are some independent agencies, but the nice thing about Consumer Lab, (and I can’t be an advocate for them because you still just never know), but they actually so examine certain products and they will examine certain brands.  If you go to their website and look around a little bit, they will show you the reports and studies that they have done on particular products.  It will show which ones passed and which ones failed their test.  They set the standard for them.  If you are looking for laboratory evaluation of powders and drinks, if you are looking for papers just on carb-protein and recovery, hydration or caffeine as a dietary supplement, these are the links that you can use.  These last three are available through the USA Swimming web site as well, and in the nutrition section, of the coaches section, of the program and services section.  Did you get all that?  Go to programs and services, hit coaches and hit the button and you will find it.


A question?  Yeah, flat Coke and going on a run, that is the sugar thing.  They are looking for a quick carbohydrate source to maintain those blood sugars, especially if it is a long distance event.  They use flat Coke to just eliminate the GI discomfort of having the air.  Another question?  Red Bull?  Is it prohibited?  Red Bull itself is not a prohibited substance, but it is not the product, it is what is in it.  So, what I would recommend is to call and check on that.  Call the Drug Reference Line, it is an 800 number.  1-800-233-0393.


Another question?  Adverse effects of Creatine?  Creatine has been studied a lot.  That is one of the few that has actually been studied a lot and most of the adverse affects of using Creatine have to do with the physiological effects that it has.  A lot of people are suffering water retention, cramping-that type of thing.  There were some cases where they said it can really stress the kidneys and have adverse effects in that regard, but studies after that were indicating it would take a lot of Creatine to have that effect and some really chronic use of Creatine.  I think part of the problem with the Creatine is that it is, you know, they use it for this amount of time-this dose for three months or however many weeks and then you stop, and then you use it again and then you stop.  Some people do not pay attention to that and they use it and they never stop.  I think that is when you are getting into cases and there are not any reports.


The last question is about Enduroxin and if it accelerates speed.  The real physiological reason for promoting Endurox is primarily its 4:1 ratio of carb to protein as a recovery drink.   My research or my investigation into the literature has suggested that if you take three carbs and one protein, versus three carbs and one carb, you get the same results, but with Endurox, now it has other things.  It has Glutamine added and it has others that I can’t pronounce properly, like an herbal ingredient that sets an alarm off in my head.  It is not that the product is not good, it just doesn’t work.  I have never seen any research on Endurox products to stop.  I know they have a few references on the label.  Glutamine is not prohibited, but check our website.






I am Jim Johnson.  I am the team doctor at Stanford and with USA Swimming.  I want to talk about injury incidents before I get into the preventative rehabilitation and swimming biomechanics, because the injury incidence data that I have tabulated over the last couple of years gives us a clue into some of the exercises that we should be doing to prevent injury in swimmers.  I wanted to identify the common injuries in swimmers.  I wanted to try to correlate that injury type with age, sex, volume of training, time and level of conditioning, and identify some future directions of study to prevent injury, which, maybe, some of you all will take off with from today and start looking into.  An injury questionnaire was distributed to 325 age group, high school, college, and masters swimmers.  It was asked to detail training and injury history over a one year period.  It was not pretested, but 100% of the surveys were returned.  It looked at a 12 month injury incidence.  It showed that shoulder, knee, and back injuries are very common, and the interesting finding was the back injury data.  Rick Eagleston was instrumental in collecting this data a few years ago, and it has been sitting in a box needing to be tabulated, because we need to know what kind on injuries our athletes are having.


The age and sex difference in injury rate was insignificant, which is good because, then we can make some generalizations about injuries in swimmers.  The injury types seem to be related to level of conditioning.  It seemed to be most related to back injury, and it was a bi-modal peak of back injury as related to level of conditioning.  Those that were the least conditioned had the most incidence of back injury, and those who were the most conditioned on the opposite end of the volume and hours of training, had an equal amount of back injury to the lower conditioned athlete.  But the athletes in the moderate to moderately high intensity training programs (we are talking amount anywhere from 40,000 to 80,000 kilometers per week), had very low incidence of back injuries.  You had injury to the back less than 20,000 and greater than 80,000 meters per week.


Of the 325 swimmers, 214 had an injury which was defined as missing one week of training due to that injury.  That is 66% of those athletes.  That is a very high incidence of injury.  If we look at data a little more closely, knee injury data almost exclusively came from either breaststroke swimmers or dryland activity and most commonly related to non-swimming activities rather than swimming activity.  Elbow, ankle, foot, wrist, and hip injuries are also common.  Hand injuries are not common at all.  Going through each part of injury data (the sex related injury incidence), there was no significant difference between males and females.  The findings did suggest however, that men were injured more often.  Females had more shoulder injuries and males had more back injuries.  I cannot explain why that was at this time, but it was not statistically significant.


There was a relationship of back to age as people advanced in age, especially including the master’s swimmers.  There was an increased incidence of back injury, causing missed training.  Shoulder injury increased mainly from the teens to the twenties and then leveled off from the twenties forward.  The perceived level of conditioning seemed to be the most significant factor.  The perceived level of conditioning and this not only correlated with increased mileage or yardage, but shoulder injury increased in the more highly competitive and highly elite type athletes.  That correlated more with the level of conditioning for shoulder injury, so conclusions from this study is that shoulder and back injuries are the most common reason for missed training.  The injury type is related to the level of conditioning.  One may be inversely related and one directly related and other injury patterns may be suggested, but are not statistically significant.  So, what this led me to do was to study and review the literature to try and develop stroke teaching and training progressions which emphasize injury prevention.  Also, to explore the relationship of shoulder and back injury to see if there was some way to develop a set of preventative exercises to effectively link the kinetic chain and link the scapular stabilizers through the core (what we are calling the core now), into the low back, so that gets into the swimming biomechanics and injury prevention topic.


The main thing I wanted to talk to the coaches about today was some stroke correction tips that I have found to work as both a physician and a coach, and preventive exercises that US Swimming shoulder injury task force put together in April.  You can find all this on the USA Swimming website with pictures and very detailed instructions on how to do those exercises.  I am not going to go into those exercises in detail, because Rick Eagleston will go into some of them in his talk later on, as will Dr. Rodeo as he explains some of what we did at the Shoulder Injury Prevention Workshop.  So the goals of an article that I am getting ready to publish, have to do with just to review and update the literature on swimming injury and try to develop some kind of common ground between coaches and physicians when we are talking to swimmers if what we are teaching them is correct stroke mechanic.  First, obviously, swimmer’s shoulder is very common as you saw from our data.  30% of all swimmers in a year missed a week of training because of a shoulder injury.  Add onto that the other 23% that missed because of back injury, you can see that, that is very significant.


You need to understand normal freestyle biomechanics and the pathomechanics, or flaws, in the stroke and then you need to know some tips and some dry land exercises that can maybe prevent some of these injuries.   What is very interesting about the biomechanics of a powerful freestyle pull is they overlap a little bit with the pathomechanics or flaws in a stroke.  The most powerful movement, or moment in a stroke is the maximal internal rotation in adduction as you catch the water.  That is also the most common position to cause impingement, so the key is to find a balance between those two, one productive and one counterproductive result of that movement.  What we have shown recently, thanks to some research done by Barry Bixler and Scott Riewald, and also by Brent Rushell in 1994, and earlier that the pull pattern is not really an S-shaped pull, it is more of a straight-line pull.  So what does that mean?  Well, what that means is that we are looking at the stroke in 3-dimensions and from the point in which the hand approaches the water until it exits.  It is really in the same place, moving along the same place in a straight line.  It is not an S-shaped pull pattern as originally shown by some 2-dimensional stroke photographs back in the 1960’s and 70’s, so propulsion is primarily from drag forces, not lift forces and we are not talking about drag like body here type drag.


We are talking the neutonian force of drag and equal actions provokes an opposite and equal reaction, so that is where our propulsion is coming from, and from this we have also determined that propulsion, the range of propulsion which Scott Riewald has gone into (probably in a lecture here), but talking about an early catch, early recovery being the phase of the arm stroke that provides the most propulsion.  So you want to maximize the amount of time you are in that propulsion phase of the stroke, added to a stroke rate that provides the fastest velocity.   We also have talked a lot about it in the last few years, since ’94, the concepts of body rotation and balance.  Bill Boomer stated that, but if you look back in the literature to many, many years ago, Silva was talking about his in the ‘50’s.  Also, in some of his articles in the 1960’s, so it is not a new concept.  It is just a concept that we understand better because we have been able to see more accurate photographs of the correct swimming stroke in 3-dimension.


Then, I want to talk about the prime movers in the scapular motions, which I just alluded to a minute ago, in terms of the internal rotation in adduction being a prime mover.  Just talking more in terms of coaching terminology, hand entry and pull across the midline can cause impingement.  Asymmetric body roll of less than 45 degrees can cause impingement.  Unilateral breathing can sometimes cause impingement.  Thumb-first hand injury, which is a new stroke technique that a lot of people are trying to adopt, I believe can cause biceps stress and I have seen some degenerative labril pathology in people that have been doing the straight arm freestyle recovery at high volumes.


Improper high head position can cause neck origin-type shoulder pain and also, just provide a mechanical impingement and cause some posterior capsular impingement.


Then, you have the anatomical abnormalities of the young swimmers with the over-developed adductors, because that is the most important propulsive movement, but have under-developed stabilizers so the forward sloping shoulders are probably a clue to you to look into developing the scapular stabilizers in that swimmer to develop more balance in their stroke and their strength.  The common denominator in all of the studies that have been done, all the EMG studies of swimmers, is a weak serratus anterior.  The serratus anterior fires maximally through the whole propulsive phase of the stroke, and it can easily succumb to fatigue and it is the muscle that seems to fatigue the fastest.  The rhomboid is also overused in the swimming stroke, and also fatigues.  So, some of the stroke corrections that I recommend in trying to crossover between two worlds are the early catch/early recovery straight line pull pattern with no crossover.  Trying to link the (what I call the scapulohumeral link), trying to keep that scapulohumeral link at 80 degrees, while rotating on a very stable spine at about 45 degrees in each direction.  The body roll is augmented by bilateral breathing.  I believe in little finger, fifth finger first hand entry, so that you can perform an early catch and avoid some of the stressful positions of the thumb-first injury.


I would say avoid straight arm recovery, though I know that is a new technique that some people are exploring, but I am talking here in terms of injury prevention and maximizing speed.  Whereas, a coach may be just looking at maximizing speed and I think we need to combine both to look at long-term development of the best speed.  Neutral head position is, and then, developing the body balance and core strength which is addressed on the USA Swimming website in terms of the scapular stabilization exercises and abdominal exercises and stretches that you can look up when you get home.   So, my general dry land recommendations would be total body conditioning, muscular strength endurance being the emphasis of your strength program with scapular and trunk stabilization and trying to link those two and then advanced stroke specific strengthening in the water.  Scapular stabilization should focus on the endurance strength of serratus, lower traps and subscapularis muscles which are emphasized on our web site task force recommendations.


My recommendations tend to be a little different.  I think in an uninjured athlete, it recommends three sets of two minutes, or three sets to fatigue.  I like to start people out with five sets of 5 repetitions with 10-15 seconds between each group of repetitions to allow blood flow to get back into the rotator cuff muscles between each bout of exercise, progressing to 10 sets of 10 repetitions increasing by 10-20% per eek.  Once they reach those 100 repetitions, they have developed pretty good muscular strength endurance, and then they could go to the more advanced three sets to failure.  This could be a progression that you could start in an age group program and go all the way up through until they are elite athletes ready to go on to the national/international level.  Finally, I want to refer you to exercise demonstrations on the USA Swimming web site that incorporates the exercises that have been validated by electrical studies done in the lab and with swimmers in the water.  The stretches and abdominal exercise listed there have also been verified, so I would refer you there as a place to start.  As you get more advanced any swimmers you have that are developing that stabilization and want to get stronger and stay injury-free, I would suggest consulting any one of us in the Sports Medicine Society, or with a local Sports Medicine physician in your ares.


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