Common Diving Specific Injuries
During competition divers do have an option of landing feet first, but in modern days, except for high diving, most enter the water hands first (11). During training, divers practice different landing positions from different heights. Therefore lower extremity injuries usually occur with dry-land training or at the take-off phase of the dive. Osteochondral lesions can occur in knees due to overuse, and there is some suggestion to keep kids undergoing a growth spurt from the 10-m platform (3). Jumping from the springboard with poor form or the sheer volume of dives can increase risk of chronic overuse injuries such as: patellar tendinitis, quadriceps tendinitis, patellofemoral compression syndrome, Achilles and posterior tibialis tendinitis (1,28,29). In addition, ankle sprains and fifth metatarsal fractures from awkward landing on the board are not uncommon. High divers competing from the 20- or 27-m platform do enter the water feet first and therefore are not only at risk for the previously mentioned injuries, but due to greater force and velocity, they are at higher risk of ligamentous knee injuries and lower-extremity fractures (21).
Many times, the shoulder is the endpoint of the deceleration forces from water entry impact. The shoulder absorbs much of the water entry axial loading, taking the brunt of the kinetic chain load. It is imperative to stabilize the glenohumeral joint by elevating the shoulder girdle with increased scapular abduction so the glenoid fossa is behind the humeral head, therefore providing better absorption of the axial load impact (32). When the glenohumeral joint is in 180 degrees of abduction and flexion and maximal internal rotation with no inferior support from the glenoid fossa, the shoulder is in a mechanically at-risk position (1,30,31). Decreased scapular abduction impairs energy dissipation and increases the demands on the soft tissue, such as the rotator cuff, biceps, tendon and labrum leading to injury, ligament laxity, and many times to shoulder instability (1,31). A stable shoulder is important for water entry, yet flexibility also is necessary for successful diving to minimize forces at the spine. When there is a lack of shoulder flexibility, a diver will tend to make up for this by placing increased demands and forces on the spine, which can lead to spine injuries. Too much flexibility can lead to microtrauma secondary to exposure to repetitive diving which can lead to glenohumeral joint instability and shoulder impingement of the supraspinatus, bursa, and biceps tendonitis. Another diving-specific injury pointing to the deleterious effects of repetitive stresses in diving is a case report of a midclavicular stress fracture in a 19-yr-old collegiate athlete who had been a former swimmer and was new to diving (34). This example points to the fact that impact forces of entry can cause injury anywhere along the kinetic chain, so a high index of suspicion must be maintained.
For the integrity of the kinetic chain to be preserved, the elbow must remain in extension upon entry. In order for extension to occur, the triceps need to be activated and prevent flexion, and in turn this places the distal triceps at risk for injury, such as tendon ruptures in older divers and triceps tendinitis or strains secondary to overuse (1,12). As in the shoulder, instability can occur, and in the elbow, traumatic hyperextension can cause injury to the ulnar collateral ligament. Shinozaki et al. (32) reported on a 14-yr-old male diver with olecranon stress fracture, which was amenable to conservative treatment. This supports the notion that repetitive stressors placed on the joint can lead to stress injuries.
Only a minority of wrist injuries occur secondary to acute trauma, many times from hitting the board, but most injuries occur from hitting the water repetitively. Case series have described various injuries that can be attributed to the repetitive microtrauma including multiple bone contusions of the carpal bones, triangulo fibrocartilage complex (TFCC) tears, extensor pollicis longus ruptures, microfracture of the radial styloid, and scaphoid stress fractures (5,12,18). Divers are prone to scaphoid impaction syndrome due to the repetitive hyperextension stresses of both the board and the entry phase (6). In terms of wrist injury prevention, although proper technique is vital, wrist loading is inevitable. To prevent acute ramp up in wrist loading, a period of acclimatization with a stepwise increase in the number of dives and height should be considered. Many divers do tape their wrists with modest benefit, allowing training to continue despite injury. As with any other injury or sport, off-season is an ideal time for healing to occur and for the overused, tired body to rest.
Cervical Spine Injuries
Most of the literature on cervical spine injuries and diving focus on recreational, nonorganized diving where lack of experience, shallow water, inadequate supervision, and alcohol ingestion are the greatest risk factors (16).
In general, cervical spine injuries are cervical hyperflexion injuries that occur usually secondary to poor technique. The diver enters the water with a flexed neck with the impact of entry causing hyperflexion of the neck and in turn causing an anterior spine injury with symptoms, such as pain, paresthesias, and radicular symptoms. Proper technique with neck in neutral position, sitting protected in between the two arms, is essential (2,6).
Lumbar Spine Injuries
Lumbar spine injuries seem to be the most prevalent diving injury, except maybe for shoulder injuries, and are the most common reason for retirement from the sport (6,21,24,30). The anterior segments (vertebral body, vertebral endplate, and intervertebral disc) are vulnerable to increases in loads especially during take-off and entry while the posterior segments (facet joints, pars interarticularis) tend to be the more common cause of back pain due to extension. Recent studies have found low back pain incidence to be between 38.4% and 89% (3,23,24). One study found that after age 13 yr, there is a 45% chance of having back pain within a year (3). Another study found that young divers are at risk for lumbar spine issues at a younger age than the general population due to annulus tears from torsional shear forces and repetitive axial loading (2). Many times, divers attempt to correct malrotation with a “save” underwater to correct their form in hope of attaining a splashless entry. When performing a “save,” divers sometimes have extra arching of the lumbar spine to attain a more vertical orientation upon entry (2). Another study found that a breakdown in the kinetic chain in the form of decreased shoulder flexion led to increased truck extension (23). The energy of impact entry must dissipate and the focus of this dissipation tends to be the weakest link in the kinetic chain, and many times this is the spine. One of the concerns with the sport of diving is that most start at a young age and a growing spine is highly vulnerable to trauma especially during the adolescent growth spurt (3). Careful attention must be taken with young divers if they are to last in their sport.
Other Injuries (3)
There are a variety of nonmusculoskeletal diving injuries that are diving-specific in that they are secondary to the large forces applied to the body upon entry.
Brief descriptions of a variety of these conditions described in the literature are provided:
- Tympanic membrane perforations from landing directly on ear (28).
- Vestibular abnormalities are thought to be related to the changes in linear acceleration and rotation and water impact with rapid deceleration. Some forward rotating dives take the diver through 1260 degrees of rotation, and more recently, many divers go through 1620 degrees of rotation with certain dives (29).
- Corneal epithelial injuries can occur from repetitive microtrauma. Fortunately, it is usually reversible (17).
- Scalp lacerations occur from direct trauma to the board and are more common with reverse and inward dives (8).
- Pulmonary contusions can occur from the rupture of pulmonary blood vessels and resultant hemoptysis secondary to landing flat. This usually occurs from 10 m platform dive. The hemoptysis can be very alarming to the diver, coaches, family and team physicians, but fortunately recovery is rapid with most returning over a period of a few days. One way to minimize this from happening is to practice with a bubbler in the water, which allows for decreased surface tension (7,19,30).
- Anxiety and psychological stress occurs not only due to individualized pressure to perform but also due to the complexities of learning and performing dives. Many times, this needs to be addressed before learning more difficult dives (6).
- Concussions also can occur from both direct head impact with the board and from water entry impact. One must have a high degree of suspicion for a possible concussion whenever a dive does not go as planned or any time abnormal vestibular symptoms are reported.
Once again, as with other aspects of diving, little has been written as it relates to diving and nutrition. Although diving is considered an aesthetic-focused sport, there is a need for performance as well, and so there is focus placed on body weight and composition (4,31). Physical characteristics, such as being muscular and lean, do provide some advantage biomechanically. Many times, divers restrict their diet to achieve the desired physique goals. This leads to low-energy availability which can in turn lead to fatigue, increased injury rate, and decreased performance. Athletes who restrict dietary intake are seven times more likely to have musculoskeletal injuries (27). Due to the emphasis placed on body type for performance and appearance, divers also are at higher risk for eating behaviors and disordered eating (4,26).
Current recommendations, in general, for daily energy/diet requirements are 3500 kcal for males and 2650 for females (4). In terms of carbohydrates, divers should consume 2 to 8 g ·kg−1 ·d−1 of carbohydrates and 1.2 to 1.7 g ·kg−1 protein intake divided during the day (4).
Although diving is an ancient sport, available studies and research in the literature are lacking, and the little that is available are mostly case series and observational studies. As with most modern sports, diving does not wait for research to catch up to advance the sport. Divers continue to test the limits of what their bodies can do. This is evident not only from the mere increase in numbers of competition, amount of training load, but also in degree of dive difficulty. As humans continue to push their limits, athletes increase the potential for injury by spending more time perfecting their individual sport. The recent 2016 consensus statement on the methodology of injury and illness surveillance in FINA by Mountjoy et al. (22) will serve as a foundational basis for future research. A surveillance model for accurate collection of injury data among many other things will help define health risks in aquatic sports, develop aquatic-specific definitions, gather information on injury location and causation, and capture out-of-competition aquatic athlete health with the ultimate goal of injury prevention (22). Two areas of possible future research focus would be 1) the large forces that are created and then abruptly dissipated with water entry and 2) the repetitive exposure to these forces. Future research should look not only at how to minimize these forces but also how to reduce the exposure to these forces.
The author declares no conflict of interest and does not have any financial disclosures.
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