the basics synchronized swimming and its...

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THE BASICS OF SYNCHRONIZED SWIMMING AND ITS INJURIES

Margo Mountjoy, MD, CCFP, Dip Sport Med

Have you ever jumped into the water and tried to twirl your feet in the air without drowning? How do synchronized swimmers make it look so effortless?

For many, when thinking of synchronized swimming, an image of young women in sequins floating in patterns on the water often comes to mind. Although this may have been true in the 1940s, today at the turn of the century it is far from the truth. Synchronized swimming has evolved into a complex, highly developed, physically intensive sport.

Synchronized swimming encompasses many attributes of sport: strength, power, flexibility, endurance, artistic expression, and performance. As a result of this complexity, the demands on the athlete are numerous, often resulting in injuries unique to the sport itself. As a sport medicine clinician, it is important to understand the basic structure of the sport, the demands on the synchronized swimmer, and the common injuries encountered.

HISTORICAL REVIEW

Synchronized swimming originated in the early 1900s. It was developed first by Annette Kellerman of the United States.17 The sport, then called “ornamental swimming,” was made famous by the Esther Williams movies in the United States. At that time, the focus of the sport was entertainment value,The routines were composed often of many floating patterns and visual effects.

Synchronized swimming left Hollywood and became a competitive sport with the development of International regulations by Federation Internationale de Natation Amateur (FINA) in 1952. Synchronized swimming was introduced first to the Olympics as a demonstration sport in 1948, and became an event in

From the Canadian Synchronized Swimming Team, Synchro Canada, Gloucester; the University of Guelph Sports Medicine Clinic, Guelph; and the South City Sports Medicine Clinic, Guelph, Ontario, Canada

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the Pan American Games in 1969.3 Canada and the United States dominated the sport during the 1970s and 1980s.

Synchronized swimming became an Olympic event at the 1984 Olympic Games in Los Angeles, United States, with the inclusion of the solo and duet events. The 1988 Olympics in Seoul, Korea, and the 1992 Olympics in Barcelona, Spain, also included the solo and duet events. The team event was introduced to Olympic competition at the 1996 Olympic Games in Atlanta, United States. Canada and the United States dominated all of these Olympic Games.

During the 1990s, synchronized swimming has grown and developed in many other countries, resulting in more competition for the strong North Ameri- can countries. Russia recently dominated the 1998 World Aquatic Champion- ships. Japan has traditionally been and, currently is, a medal contender. Other European, Pacific, and South American countries recently have produced elite synchronized swimmers.

Currently, FINA recognizes synchronized swimming programs in 59 countries. In Canada alone, there are approximately 20,000 participants. These competitors range from elite to recreational athletes. There is an active International Masters program in many countries. There is also participation by male athletes in synchronized swimming.

COMPETITIVE STRUCTURE

Internationally, the rules and regulations for synchronized swimming origi- nate from FINA. The FINA bureau is composed of representatives from 21 countries. A division of FINA known as the Technical Synchronized Swimming Committee meets annually to constantly revise and redefine the sport as it evolves. This committee consists of representatives from 12 countries.

The most important international event for synchronized swimming is the Olympic Games. Currently, the team and duet events are scheduled for the 2000 Games in Sydney, Australia. Other FINA events include the World Aquatic Championships, Junior World Championships, and World A and B Cups. Re- gional competitive events include the Commonwealth Games, Pan American Games, and the Pan Pacific Games.

International competitions include three events: solo, duet, and team. The figure event recently has been excluded as a competitive event at the senior level. At international competitions, the solo event is composed of two routines-a technical and a free routine. The technical routine is 2 minutes in duration, and must include approximately 6 to 10 required elements or set movements in a predetermined order. The mandatory technical elements illustrate the athlete’s flexibility, strength, skill, power, and control. Elements chosen include arm movements, boosts, spins, splits, vertical twists, and figure skills. The required elements are changed by FINA every 4 years. The free routine is 3 minutes and 30 seconds in duration. There are no predetermined required elements, thereby allowing the athlete to express her interpretation of the music and skill in any means she chooses (Fig. l).18

The duet event also is composed of a technical and a free routine. The technical routine is 2 minutes and 20 seconds in length. Although the chosen elements for the duet are different from the solo, they also similarly demonstrate the athlete’s strength, flexibility, power, control, and skill. The free routine is 4 minutes in duration, and freedom of interpretation and expression is allowed. In the duet event, unlike the solo event, emphasis is on synchronization with

THE BASICS OF SYNCHRONIZED SWIMMING AND ITS INJURIES 323

Figure 1. Canadian Sylvie Frechette, gold medal soloist at the 1992 Barcelona Olympic Games. (Courtesy of Canadian Sport Images, Gloucester, Ontario, Canada.)

each other as well as the music. Intricate patterns and positions made possible by two people are encouraged (Fig. 2).18

The team event, which tends to be the most popular with spectators, also has a technical and a free routine component. The usual number of athletes in the team event is eight, with one or two alternate swimmers who would compete in the necessity of illness or injury. The technical routine is 2 minutes and 50 seconds in duration. The required elements in the team event are more complex in that they include specific patterns and timed moves. The othe: elements, as in solo and duet, are chosen to reflect skill, flexibility, power control, and strength. The free routine is 5 minutes in duration, and it also has no required elements. Synchronization is a large component of this competition because there are more athletes to coordinate. With the larger number of athletes, there is greater freedom in developing exciting high-risk boosts where one or more athletes is lifted out of the water, while being supported by a network of other teammates under the water (Fig. 3).18

JUDGING CRITERIA

As with other artistic sports, such as figure skating, diving, and gymnastics, synchronized swimming is a judged sport. The judges at international events are selected from participating countries. Each judge must have attained the highest level of judging competence in their respective countries and must be

Figure 2. Duet competitors in an underwater joining figure-a difficult, high-risk move, which is rewarded accordingly. (Courtesy of Synchro Canada, Gloucester, Ontario, Canada.)

Figure 3. The team event demonstrating a modified crane position. It is imperative that the athletes have the same angle of leg, at the same time, while maintaining their pattern underwater. (Courtesy of Synchro Canada, Gloucester, Ontario, Canada.)

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accepted as competent by FINA. Judges are constantly evaluated by FINA to ensure that standards of competence are being met.

At all international events, there are two judging panels, each comprised of seven judges with one alternate judge. One panel of judges is responsible for evaluating and awarding a score for Technical Merit for each routine, and the other panel of judges is responsible for evaluating and awarding a score for artistic impression for each routine.1s

The technical merit score comprises three criteria for evaluation. The first criterion is the quality of the ”execution of strokes, figures, propulsion tech- niques and precision of patterns.” In the solo event, execution is worth 50%, and in the duet and team events, execution is worth 40%. The second criterion is ”synchronization with one another and with music.” This comprises 10% of the technical merit score in solo, 20% for duet, and 30% for team. The final criterion of evaluation is the ”difficulty of the strokes/figures/patterns and synchronization.” Difficulty comprises 40% of the solo and duet technical merit score, and 30% for team.I8

The artistic impression score also comprises three criteria for evaluation. The first criterion is the ”choreography” of the routine. The judge looks for variety, creativity, intricate and unique patterns and transitions, and pool cover- age. This criterion is worth 50% of the artistic impression score in the solo event and 60% in the duet and team events. The next criterion is ”music interpretation,” which is allotted 20% of the artistic impression score in all three events. The final criterion of evaluation for the artistic impression score is the “manner of presentation.” The manner of presentation comprises 30% of the solo artistic impression score and 20% for duet and team.I8

Each judge on both the technical merit and artistic impression panels awards a mark out of 10 based on the above criteria. The highest and the lowest mark awarded for both the technical merit and artistic impression scores are deleted. The mark is then tallied, as a total of the remaining five judges’ numbers. The total score for the event, whether it be the technical or the free routine, comprises 60% of the technical merit score and 40% of the artistic impression score.18

The final championship score for the solo, duet, or team event is determined by the computation of the technical routine marks at 35% and the free routine marks weighted at 65Y0.’~

TRAINING REQUIREMENTS

Most synchronized swimmers enter the sport as young girls at the recreational level. By the age of 13 to 15 years, the athletes who are more serious or talented may choose to train and compete at a more intense competitive level. In many countries, athletes that are at the National Team calibre of competence often train in congregated centers ensuring uniform training, adequate time together to perfect synchronization, and more effective resource use.

The components of a synchronized swimmer’s training include aerobic and anaerobic fitness, strength, power, endurance, flexibility, sport specific skill perfection, artistic expression, and performance skill. Balancing these components to maximize output without producing overuse injuries is a major task for all National Team coaches, in consultation and conjunction with their respective sport science specialists. Most National Team coaches have undergone educa- tional programs to equip themselves with the knowledge in general coaching principles and sport-specific skills.

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As a sports medicine physician, one may be involved at the planning level to facilitate coordination and prevent overuse injuries. One also may be involved in the ongoing monitoring of the swimmers to advise changes in training to prevent overtraining fatigue or to determine early injury intervention, thereby preventing chronic or serious injury. Other experts involved in the planning and training implementation of the elite synchronized swimmer may include sports physiologists, weight-training experts, sports therapists, gymnastics, or dance coaches to facilitate flexibility and artistic interpretation, sports nutritionists, and sports psychologists.

Aerobic and anaerobic fitness are achieved through a variety of means, including running, cycling, aerobic dance, or swimming. Strength and power training are achieved through a sport specific weight-training program. Flexibil- ity training is a daily part of the training regimen of the synchronized swimmer. Sport specific skill acquisition is aequired through direct teaching by coaches and fellow senior swimmers. The types of skills trained are determined by the competitive event and by the level of competition.

Synchronization to each other and the music in the routine events is acquired through repetitive practice, often using a video camera to illustrate errors to the athlete. Many coaches use an underwater microphone to give corrections during training. Synchronized swimmers also acquire synchronization through an exercise called “dry land drill,” whereby the athletes simulate all in-water movements on land, to the music, with various actions.

Artistic expression often is developed with the assistance of dance choreog- raphers. Performance skill is practiced through repetition and experience, often in the format of demonstrations or mock competitions with volunteer judges providing feedback.

At the elite level, the synchronized swimmer would train 6 days per week. One day off is recommended for physical and psychologic recovery. The training sessions run from 3 to 5 hours in duration. Two training sessions of different content per day may occur. For example, sport-specific skill training in the water could follow a pool session of swimming for aerobic fitness. Later in the same day, a dry land training session could occur consisting of flexibility, dry land drill, or a psychology session. A skilled coach must balance the training so as not to overload the athlete, and also not to overtrain a specific body part, which could potentially lead to overuse injuries.

The training components listed previously are then balanced over the training season to produce the desired result., at competition time. This balance is called periodization. For example, early season training includes weight lifting for strength and specific individual body shaping. Flexibility and cardiovascular fitness also are emphasized during the early season training regimen. As the season progresses and the routines are choreographed, more sport-specific skills are trained. Presentation and synchronization occur at this stage of the training. A basic weight-training program is maintained, as is an aerobic fitness program, although they are weighted less in time and priority. Before competition, taper- ing occurs where the athlete trains in more sport specific skills/routines, with less of the other training demands. The intensity and duration of the training sessions also are decreased to allow recovery and maximize competition results.

REVIEW OF COMMON MUSCULOSKELETAL INJURIES AND THEIR MANAGEMENT

As in all aspects of sports medicine, familiarity with the common injuries for each specific sport facilitates the medical management of the athlete. This


knowledge can ensure adequate prevention through a balanced training regimen, or if this is not possible, a regular surveillance program with early recognition and effective treatment to prevent the development of a chronic injury. Chronic injuries in synchronized swimmers can lead not only to missed valuable training time and subsequent substandard competitive performance, but also to advanced personal injury.

Trauma

Synchronized swimming was once thought of as a noncontact sport, where its injuries were acquired from either outside the sport or from repetitive chronic overuse injuries.I7 With the recent advances in high-risk boosts and throws, there is an increase in the incidence of traumatic injuries. To throw or support the athlete above the water, the teammates closely stack under the water, thereby increasing the potential for acute hematomas, contusions, sprains, disc hernia- tions, and fractures. Serious head injuries with post-concussive syndrome also have been seen (Fig. 4).

Acute tears of muscles and tendons occur with the increase in high-speed, ballistic movements. The ”rocket” (a quick vertical thrust followed by an explo- sive move to the split position) is responsible for acute groin, hamstring, and quadriceps strains.

The three most common musculoskeletal overuse injuries encountered in clinical practice among elite and recreational synchronized swimmers are shoulder instability problems, lumbar strains, and patellofemoral syndrome.

Figure 4. The team “boost and throw” is a skill with high potential for trauma owing to the height of the thrown athlete. Note the height of the thrown athlete and the stacked supporting athletes underwater. (Courtesy of Canadian Sport Images, Gloucester, Ontario, Canada.)


cate with the coach and the athlete to educate and to develop a training schedule that is effective yet will not inhibit the healing of the injury. Kicking with the arms at the side is an appropriate in-water activity, along with running or cycling for fitness.'*

To decrease inflammation, icing the shoulder before and after training is recommended. Anti-inflammatory medication may provide symptom relief as necessary. Once the athlete is symptom free and the strength of the humeral and scapular control muscles has been achieved, the athlete can return to sport- specific activities. This should occur in a graduated stepwise, controlled manner. A gradual reintroduction to training will prevent early relapse of this injury.14

Lumbar Strain

As in gymnastics, dance, and diving, synchronized swimming demands great flexibility in the lumbar spine. An important technical element in synchronized swimming is the "walkout" from the split position that requires tremendous lumbar hyperextension (Fig. 5) . Figure 6 illustrates the flexibility demands on the lumbar spine.

The pathophysiology underlying the lumbar pain is unclear. Proposed sug- gestions include facet inflammation, tight or weak abdominal and hip flexor muscles, poor pelvic posture, and overuse. In synchronized swimming, it also is possible that the pain is a result of poor muscular control of the lumbar spine at the speed that activities are performed.8 Split boosts require the athlete to thrust vertically at maximum speed and split at the height of acceleration in a ballistic movement. The development of spondylolysis and spondylolisthesis as seen in elite gymnastics is not common in synchronized swimming.

The athlete will present with aching pain in the lumbar area with an absence of neurologic symptoms. The pain is exacerbated by activity, especially with hyperextension as seen in repetitive walkouts. Physical findings on examination may include palpable spasm of the erector spinae, evidence of facet inflammation on extension, tight iliopsoas and quadriceps muscle groups, hypomobility of the spine, and abnormal lumbar and pelvic posture. It is important to rule out other causes of back pain excluding the presence of boney, discogenic, or intra-abdominal pathologies. Radiologic evaluation most likely will be negative.

Treatment of this injury must include athlete and coaching education. Modi- fication of the frequency, force, speed, and degree of hyperextension while in the acute phase is necessary. Maximizing flexibility of the surrounding muscula- ture is essential as well as strengthening of the appropriate muscle groups to ensure spinal stabilization. Correction of the postural abnormalities and hypomobility is recommended. The use of ice, anti-inflammatory medication, and

b n

Figure 5. The walkout figure from the split position requires extensive hyperextension of the lumbar spine. (From Werner G (ed): FINA Handbook. Lausanne, FINA, 1998, p 276; with permission.)

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Figure 6. Extensive repetition of extreme lumbar spine hyperextension (a position that is required and encouraged in synchronized swimming) can lead to lumbar strain syndrome. (Courtesy of Synchro Canada, Gloucester, Ontario, Canada.)

physiotherapy modalities (including transcutaneous electrical nerve stimulation and ultrasound) will assist in pain control.8

Patellofemoral Syndrome

Anterior knee pain also is present in the synchronized swimmer. There is no published data outlining its prevalence in the sport. In clinical practice with the elite athlete, the incidence of patellofemoral syndrome appears to be declin- ing. This may be due to the increased awareness of the disorder and the subsequent development of intensive and balanced lower limb weight-training programs. Patellofemoral syndrome is still a common finding in the recreational athlete.

The origin of this disorder is controversial and obscure.11 The pathology is reported in the literature by some to be due to the malalignment of the patella." Others believe that vastus medialis oblique weakness occurs secondary to a biomechanical tracking disorder, thus resulting in cartilaginous changes?

In synchronized swimming, patellofemoral syndrome most likely is the result of an overuse injury from excessive repetitive use of the eggbeater kick (a modified whip kick) in the predisposed athlete. Eggbeater also is associated sometimes with a chronic strain of the medial collateral ligament. Eggbeater is used to enable the athlete to raise his or her arms and body above the water. By altering the angle of the hips and legs, the eggbeater kick will move the athlete in all directions (Fig. 7).

Symptoms of patellofemoral syndrome include diffuse anterior knee pain


Figure 7. The eggbeater kick produces tremendous out-of-water height. For the predisposed athlete, overuse of the eggbeater kick can lead to patellofemoral syndrome. (Cour- tesy of Synchro Canada, Gloucester, Ontario, Canada.)

of insidious onset. It is exacerbated by stair climbing and descending, squatting, and prolonged sitting. Intensive eggbeater drills also will increase symptomatol- oev. ",

Examination findings include abnormal patellar movements and location. There may be patellar apprehension and pain elicited on patellar compression. Squatting will exacerbate the pain. Assessment of the strength and flexibility of the quadriceps muscle group may show weakness in the vastus medialis oblique, imbalance in the hamstring and quadriceps, and inflexibility. Examination of the feet may reveal pes planus with pronation. It is essential to rule out other intra- and extra-articular pathologies of the knee as well as back, hip, and ankle di~orders.~

There is consensus in the literature to support the recommendation of initial conservative treatment resulting in satisfactory outcomes at long-term follow- up." Management includes patient education, modification of activity, quadriceps muscle strengthening and balancing, improving flexibility, and bracing or McConnell taping of the patella. The use of ice and anti-inflammatory medication is beneficial for the control of swelling and pain. Correction of malalignment of the foot with orthotics is recommended, if indicated. Surgical arthroscopy is not necessary in the initial treatment of patellofemoral ~yndrome.~

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REVIEW OF COMMON MEDICAL PROBLEMS AND THEIR MANAGEMENT

In addition to the musculoskeletal injuries listed previously, there are also specific medical issues that are common, although not exclusive, to synchronized swimmers. As a sports medicine physician, it is important to approach and evaluate the synchronized swimmer’s medical status and his or her musculoskeletal status. A review of the five most common medical concerns that are encountered in clinical practice follows.

H ypoxia

Synchronized swimmers perform vigorous exercise, often during prolonged periods of breath holding. This can lead to hypoxia resulting in fainting, confusion, disorientation, and dizziness. Swimmers are rewarded by the judges for slowly performed figures during the figure competition, and for long periods of underwater sequences during the technical and free routines. At the elite level, many athletes who have fainted in the water following long periods of submer- sion have had to be retrieved.

One prospective study from Great Britain by Davies et a1 in 1995 studied this issue with the 1992 British Olympic Team. A clear correlation between duration of breath holding and ranking was discovered in the figure competition and in the free routine? Also measured were alveolar gases following the free routine, revealing profound hypoxia with central cyanosis and confusion. There was no hypercapnia found.6

This issue of hypoxia in synchronized swimming is one that demands further study, discussion, and subsequent rule modification to ensure athlete safety.

Eating Disorders

As in other judged aesthetic performance sports such as figure skating, dance, and gymnastics, eating disorders are present in synchronized swimming. Although there is no published data establishing the statistical prevalence of eating disorders in synchronized swimming, it is evident in clinical practice.

Eating disorders tend to occur predominantly in females. Their onset is usually in adolescence or early adult life. Electrolyte imbalance, dehydration, substance abuse, and even death in advanced anorexia nervosa (15%-21%) may be complications of these disorders. There may be a positive family history.’

The two main types of eating disorders include anorexia nervosa and bulimia nervosa. According to the Diagnostic and Statistical Manual IV (DSM- IV), anorexia nervosa is diagnosed by the presence of the criteria outlined in Table 2. The DSM IV diagnoses bulimia nervosa by the criteria outlined in Table 3.

Education of coaches and other professionals regarding the prevention and precipitation of eating disorders is an important role of the sports medicine physician. Erroneous coaching and judging comments or actions can precipitate eating disorders in an athlete who is predisposed. It is also essential to encourage the coaches and athletes to choose weight goals and body fat measurements that are within a realistic physiologic range. Daily weight measurements by coaches should be discouraged strongly. By enlisting the assistance of clinical sports


Table 2. IV DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSA DIAGNOSTIC AND STATISTICAL MANUAL (DSM)

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (i.e., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during a period of growth, leading to body weight less than 85% of that expected).

8. Intense fear of gaining weight or becoming fat, even when underweight. C. Disturbance in the way one’s body weight or shape is perceived; undue influence of

body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

D. Amenorrhea in postmenarcheal females, i.e., the absence of at least three consecutive

Specify type: Restricting Type: During the current episode of anorexia nervosa, the person has not

engaged regularly in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-Eating and Purging Type: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, DC, American Psychiatric Association, 1994, pp 544-545; with permission.

Table 3. DIAGNOSTIC AND STATISTICAL MANUAL (DSM) IV DIAGNOSTIC CRITERIA FOR BULIMIA NERVOSA

~ ~

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period (eg., within any 2-hour period), an amount of food

that is definitely larger than most people would eat during a similar period of time and under similar circumstances

2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. Recurrent, inappropriate compensatory behavior in order to prevent Geight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise.

at least twice a week for 3 months. C. The binge eating and inappropriate compensatory behaviors both occur, on average,

D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify type: Purging Type: During the current episode of bulimia nervosa, the person has regularly

engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Nonpurging Type: During the current episode of bulimia nervosa, the person has used

other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not engaged regularly in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, DC, American Psychiatric Association, 1994, pp 549450; with permission.

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nutritionists, one can assure that the synchronized swimmer is eating an appropriate balance of nutrients as well as an appropriate caloric intake for the energy expenditure.

Further education regarding early recognition of eating disorders is important. By informing athletes, coaches, and parents of the warning signs and symptoms of eating disorders, one can ensure early diagnosis and treatment. When assessing the athlete with an eating disorder, it is important also to assess for the presence of affective disorders. Depression is a common finding in association with eating disorders in clinical practice. Suicide risk assessment is essential, and suicidal ideation must be taken seriously.

When treating the athlete with an eating disorder, it is imperative to enlist the cooperation of the athlete, the coach, and often the athlete’s family (within the boundaries of patient confidentiality). The use of antidepressants may be necessary in the presence of a concomitant major affective disorder. Referral to a sports psychologist or a psychiatrist trained in the treatment of eating disorders often is necessary for the successful treatment of these disorders.

Female Athlete Triad

The female athlete triad is a syndrome where the identified athlete has the following three features:

1. Disordered eating 2. Amenorrhea 3. Osteoporosis

The presence of prolonged abnormal eating with subsequent low body fat can lead to the development of secondary amenorrhea. Prolonged amenorrhea, as defined by the absence of menses for greater than 6 months, can lead to a ”menopausal-like state” from the low levels of circulating estrogen. As in menopausal women, this can lead to the development of osteoporosis, even in the young, active female athlete.1°

When evaluating the synchronized swimmer, it is essential to screen for the presence of eating disorders as discussed earlier. In addition, it is important to elicit a menstrual history to identify the amenorrheic athlete. Upon ruling out other causes of amenorrhea, such as pregnancy, primary ovarian dysfunction, and hypothalamic dysfunction, the diagnosis of female athlete triad must be considered. Evaluation of the athlete’s bone mineral density is essential.

Treatment of the female athlete triad is complex. The eating disorder requires serious attention as described above. A sports nutritionist will be helpful in ensuring that the nutritional needs of the athlete are met. The use of the birth control pill will alleviate the hypo-estrogenic state.l0 The osteoporosis can be treated by a combination of reversal of the cause, the use of hormones (i.e., birth control pill), dietary supplementation of calcium, magnesium and Vitamin D, weight-bearing exercise, and if necessary, the use of biophosphonates such as etidronate or alendronate. Ongoing psychologic support is essential in the treatment of the female athlete triad.15, l6

Iron Deficiency Anemia

Synchronized swimmers, like other female athletes in this age group, are prone to the development of iron deficiency anemia. The causes of iron defi-


Table 4. POTENTIAL CAUSES FOR LOW SERUM FERRlTlN IN YOUNG FEMALE ATHLETES

Poor dietary intake Menstrual blood loss

* Loss of iron through sweat

Gastrointestinal bleeding Intravascular hemolysis

Datafrom Nickerson HJ, Holubets MC, Weiler BC: Causes of iron deficiency in adolescent athletes. J Pediatr 114657459, 1989.

ciency are multifactorial. Table 4 is a list of potential origins for low ferritin levels in young female athletes.

In synchronized swimmers, the two main factors in low ferritin levels leading to iron deficiency anemia are poor dietary intake and menstrual blood loss. Dietary intake is further compromised in the vegetarian athlete and in the athlete with an active eating disorder. More careful surveillance of these two groups of athletes is necessary. Menstrual blood loss is also a significant means of iron loss, and can be treated by iron supplementation and hormonal regulation of the menstrual cycle.

At one time, it was widespread acceptable clinical practice to measure serum ferritin levels in elite athletes to predict performance capabilities. A recent meta-analysis by Garza et a19 reviewed the current scientific research on the effects of serum ferritin levels on physical performance. Conclusions from this meta-analysis revealed that ”low serum ferritin in the absence of frank anemia is not associated with reduced endurance perf~rmance.”~ There was also “no evidence to support iron supplementation for increasing endurance performance in athletes who have isolated low ferritin levels but normal hemoglobin level^."^

It is, therefore, valuable to measure serum ferritin in the synchronized swimmer for the surveillance of iron deficiency anemia but not as an indepen- dent marker of performance capability that once was accepted common clinical practice?

Otitis Externa and Dermatitis

In addition to the medical problems listed above, the synchronized swimmer also is prone to the development of otitis externa from prolonged water submer- sion. This can be prevented by the use of ear drops (one quarter part vinegar with three-quarter parts water) used prophylactically after in-water training. Symptomatic otitis externa is treated with analgesia and antibiotidanti-inflammatory drops as required.

Dermatitis is a common finding also due to prolonged exposure to chlorine, water, and other pool chemicals. Showering after training is an effective preven- tative maneuver. In the acute dermatitis, the use of topical corticosteroid can be effective, although caution regarding drug doping is required.

SUMMARY

Synchronized swimming is a complex, physically demanding sport. It is a challenging and interesting sport for the sports medicine clinician. There is opportunity for involvement in program development and in the treatment of medical illness and injury. There is also great potential for clinical research in

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synchronized swimming because of the paucity of published literature. Greater understanding of the competitive structure, training requirements, and common medical presentations facilitate the management of synchronized swimmers.

ACKNOWLEDGMENT

I would like to thank Dr. Kevin Samson, Dr. David Magee, and Synchro Canada for their assistance and contributions to this chapter.

References

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2. Andrews JR, Wilk KL The Athlete’s Shoulder. New York, Churchill Livingstone, 1994 3. Clark L: Synchronized Swimming. 60 Years to Celebrate. Canadian Amateur Synchro-

nized Swimming Association, 1985, p 8 4. Curwin S Tendon injuries: Pathophysiology and treatment. In Zachazewski J, Magee

D, Quillen W (eds): Athletic Injuries and Rehabilitation. Philadelphia, WB Saunders,

5. Cutbill J, Ladly K, Bray R, et al: Anterior knee pain: A review. Clinical Journal of Sports Medicine 740-45, 1997

6. Davies BN, Donaldson GC, Joels N Do the competition rules of synchronized swimming encourage undesirable levels of hypoxia? Br J Sports Med 29:16-19, 1995

7. Duke P, Wallace WA. Pathophysiology of impingement. In Copeland S (ed): Shoulder Surgery. Philadelphia, WB Saunders, 1994

8. Dyrek D, Micheli L, Magee D: Injuries to the thoracolumbar spine and pelvis. In Zachazewski J, Magee D, Quillen W (eds): Athletic Injuries and Rehabilitation. Phila- delphia, WB Saunders, 1996, pp 465-485

9. Garza D, Shrier I, Kohl H, et al: The clinical value of serum ferritin tests in endurance athletes. Clinical Journal of Sport Medicine 74653,1997

10. Haberland C, Seddick D, Marcus R, et al: A physicians survey of therapy for exercise- associated amenorrhea: A brief report. Clinical Journal of Sport Medicine 5:246-250, 1995

11. Karlson J, Thomee R, Sward L Eleven year follow-up of patello-femoral pain syndrome. Clinical Journal of Sport Medicine 6:22-26, 1996

12. Magee D, Reid D: Shoulder injuries. In Zachazewski J, Magee D, Quillen W (eds): Athletic Injuries and Rehabilitation. Philadelphia, WB Saunders, 1996, pp 529-530

13. Nickerson HJ, Holubets MC, Weiler BC: Causes of iron deficiency in adolescent athletes. J Pediatr 114657459, 1989

14. Reid D: Shoulder region. In Sports Injury Assessment and Rehabilitation. New York, Churchill Livingstone, 1992, pp 934-936

15. Ridout R, Hawker G: Ten frequently asked questions about osteoporosis. The Canadian Journal of DIAGNOSIS 1470-83, 1997

16. Rubin L, Lindsay R, Marcus R, et a1 Osteoporosis: What’s new in prevention and treatment? Patient Care Canada 8:36-56, 1997

17. Weinberg S Medical aspects of synchronized swimming. Clinics in Sports Medicine

18. Werner G (ed): FINA Handbook 1998-2000, pp 276-280 19. Zemek MJ, Magee D Comparison of glenohumeral joint laxity in elite and recreational

Address reprint requests to Margo Mountjoy MD, CCFP, Dip Sport Med. University of Guelph Sports Medicine Clinic

570 Kortright Road West Guelph, Ontario

Canada N1G 3W8

ders, ed 4, Washington, DC, DSM-IV, 1994, pp 543-544

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