Swimming 101 for EDS

Dr. Amber Walker is a previous collegiate swimmer and coach who now specializes in working with swimmers and individuals impacted by conditions like MCAS, POTS and EDS through her practice, Origin Wellness. Over the years she’s noticed several trends in terms of important aquatic considerations for individuals with hypermobility spectrum disorders (HSD)/Ehlers-Danlos syndrome (EDS).

Within the EDS community, the sport of swimming has been heralded as great by some, but others voice concerns for its appropriateness in light of hypermobility concerns. The topic of swimming and EDS is similar to the concept of yoga and EDS, where many factors are at play and there’s a large spectrum of individual considerations (and potential adaptations) to keep in mind.

In determining whether swimming is the right form of physical activity for you, you’ll want to ask yourself a few questions:

• What do you plan to do in the pool? Water walking and aerobics are very different from swimming laps, which is very different from water polo/contact water sports.
• If you do plan to swim laps, how is your technique? How much experience do you have in the water with the different strokes? Do you have someone who can watch your technique and give you pointers?
• What is the anticipated frequency and duration? These are easy factors to modify in order to come up with the proper dosage to avoid repetitive stress or overuse to the tissues. Most individuals with EDS find that 3 days per week or less is appropriate. The total yardage depends on the individual’s background with the sport.
• What type of pool environment is an option for you? Chemically sensitive individuals may find themselves flared from chlorine or bromine, but many can tolerate saltwater pools. Open-air settings such as an outdoor pool have better ventilation and less concerns of chemical or mycotoxin inhalation. Lakes may or may not be a good option, because swimming in a lake requires greater head movements in order to keep a line of sight. Water temperature may also need to be factored in.
• Do your shoulders dislocate or subluxate easily and often? Do you have a rotator cuff or labral tear in the shoulder? Do you have craniocervical instability that’s flared from head and neck movements? None of these issues are a “hard no” for swimming, but they may require more attention to detail before starting an aquatic exercise plan. In some cases, swimming may provide more stability over time to assist with these types of issues.
• Do you plan to use your legs in the pool while swimming laps? Using a pull buoy (buoyant device that you hold between the thighs so that you don’t kick) increases stress on the back and upper body and, in some cases, should be avoided. Most people think that swimming is primarily an upper body sport, but when it’s done properly, the legs should be the main drivers. That being said, some individuals who experience leg weakness or paralysis find that swimming with a pull buoy is an excellent form of exercise. If it’s not obvious by now, decisions about swimming should be made on a customized basis, and a physical therapist and/or EDS-savvy coach is an asset for determining the appropriate individualized plan.

 

 

Swimming has four main strokes: freestyle, backstroke, breaststroke, and butterfly. The majority of lap swimmers stick to the first three, with the latter (butterfly) being the most difficult. Beginner swimmers tend to gravitate toward freestyle and backstroke; sometimes breaststroke is also tolerated, though the kicking movement of breaststroke (the frog leg part) can flare up the spine, hips and knees of some individuals with HSD/EDS. You can also try modifying breaststroke by using a dolphin kick or flutter kick instead of the traditional kick if this is the case. For the purpose of this basic overview, in this section we’ll mainly be talking about considerations for freestyle. Be sure to consult with a coach or trainer who can assist you in learning the other strokes if you are new to the sport.

Swimming freestyle consists of several phases: the initial catch when the arm is overhead and reaching in preparation to start the pull, the power phase where the underwater pull occurs, and a swing phase where that same arm is moving out of the water toward the front of the body again.

Proper technique is essential, particularly in this patient population. Below are some common technique mistakes that I note with swimming the front crawl (freestyle).

Common Mistakes Observed with Freestyle Swimming:

 

• Breath holding:

You should never hold your breath in swimming. There should always be a steady stream of air flow out of the nose and/or mouth into the water. If you hold your breath, when you go to “breathe” by bringing your face out of the water, it will take twice as long because you will have to pause your head to exhale and then inhale. This extra pause can trigger rotational issues with the spine and timing issues with the arms and legs. It’s better to exhale slowly while you’re moving and then to focus on the inhale when you turn your head to breathe.

• Lifting the head instead of rotating it:

Many beginners are fearful of running into something and lift their head to look forward when they breathe. By following the lines on the bottom of a swimming pool, you’ll be alerted to when you get close to the wall. The flags and lane lines can also help with this. You can also count your strokes if you’re extra concerned. But the bottom line is that every time you lift your head, your legs drop, creating poor biomechanics and increased stress on the shoulders, lower extremities and spine. You want to think about your head staying in line with your spine as the body rotates around it when you are not breathing. Some people find it helpful to visualize that the head and spine are the pole surrounded by a rotating rotisserie chicken that’s going back and forth. When you do need to breath, rotate your head with your body instead of lifting it.  Keep the forehead pressed down gently when you’re not turning to breathe so that the neck is in neutral in the water.

 

When you rotate your head to breathe, only one eye should come out of the water and the head should not lift. The movement is just enough to take a breath before putting the head back in neutral. 

 

• Asymmetrical breathing:

When you always breathe to the same side, this creates muscular imbalances and biomechanical issues that can lead to inflammation over time. Get in the habit of breathing every three strokes, that way you alternate between the right and left sides of the body. Remember to exhale underwater in between breaths!

• Hyperextending the elbow at the catch phase:

When you first place your hand in the water you should avoid a pause with the arm overhead and you should avoid hyperextending your elbow. Instead, you should have a slight soft bend in the elbow and you should move right into that power phase without delay. Hyperextending the elbow and having the fingertips angle up toward the water surface before you start pulling increases strain on the wrist, elbow and shoulder and can lead to overuse issues.

• Having the hands cross midline:

At the catch phase and as you pull, you want to avoid having your hand cross an imaginary line that shoots out from the middle of your forehead and body. A video taken from the pool deck can help you to determine if you are doing this. If your arm crosses under, this can increase strain on the rotator cuff and neck and is more likely to trigger shoulder impingement issues.

• Hyperextending the shoulder at the end of the pull:

Many people stroke too far behind them with the arm pull in freestyle. Not only is this inefficient but it also increases strain on the shoulder joint and neck and can throw off the timing of the body rotation. As the hand approaches the hip during the pull, the elbow should start to come out of the water for the swing phase.

• Having the hand above the elbow in the swing phase:

This is one of the most common issues I see that can lead to shoulder flare-ups. When the arm is out of the water and swinging back to the front of the body, the elbow should be higher than the hand in the air. During the swing, the hand should not move out in a wide arc; it should stay near the body but below the elbow.

 

The elbow should stay above the hand in the swing phase of freestyle. 

 

• Under-rotation of the hips and core:

The hips should move synchronously with the trunk as it rotates like a single unit. Many beginners don’t realize that the hips are lagging behind the rest of the rotation in terms of timing and/or magnitude of movement, leading to a torsion force that can influence the spine and other joints. Think: shoulders and hips rotate together!

• Poor kicking technique:

Practice kicking on your back or stomach with your arms overhead in a streamline position (or at your sides if the overhead position is aggravating). Do you feel a fluid forward movement in the water? Kicking should be initiated from the hip’s gluteal muscles. The ankles also go through quite a bit of motion when kicking which helps propel the body forward. If you find yourself bobbing up and down instead of moving with forward momentum, you may have too much bend in your knees, or you may be locking them out. (It helps to have someone watch underwater to tell you what you’re doing.) Imagine the power coming from your hips and core when you kick. Make sure that your kick stays continuous as you swim freestyle (try not to let the legs pause). For every one arm stroke you should have 3 kicks, so with every cycle of 2 arm pulls (right and left arm) you should count 6 kicks when you are lap swimming at a mild or moderate pace. (Obviously, the kicking rate increases when you are sprinting).

• Using kickboards, paddles, fins or a pull buoy too much:

This type of gear is usually fine in small doses but should not exceed 20% of the total yardage for the day, particularly in individuals with HSD/EDS. For example, if you swim 1,000 yards in a session, you’ll want to make sure you’re not using paddles for more than 200 yards total. These types of equipment can alter technique and put added stress on the joints and soft tissue structures. The exception to this would be use of a snorkel device which can be helpful, particularly if rotating the head to breathe is irritable.

A few more words of wisdom: Unless you’re an advanced swimmer or have a background in competitive swimming, you may want to use caution with flip turns and (especially) diving as these are more advanced high-impact movements that require significant coordination. Be aware of your joint positions as you swim as best as you can and consider having someone film you with a smartphone so you can determine if your technique needs adjusting.

Water walking and water aerobics are other good options for pool exercise. Many individuals with EDS have poor kinesthetic knowledge of where their body is at in space (termed proprioception) and this awareness can be even more difficult in the water. Aim to avoid going into the hypermobile range (for example, locking the elbows or knees out) while swimming. You can also experiment with putting waterproof tape on the skin or wearing tight gloves in the water to get more feedback on joint positioning as you are learning the technique.

Swimming is an incredible sport and when approached properly it can be a huge asset for individuals who are looking to improve their endurance and stability. Many individuals with EDS also experience dysautonomia/POTS and swimming can be a great way to build stamina in a non-upright position.

If you’re interested in a swimming technique consultation with Amber in person or via video, reach out to originwellnesscolorado@gmail.com

The information on this website is for educational purposes only, and is not intended to be used for diagnosis, treatment, or cure of any disease, symptom, or condition. Users needing medical advice should consult their doctor or other medical provider.