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Competitive Diving Principles and Injuries

Jones, Nathaniel S., MD, CAQ-SM1

doi: 10.1249/JSR.0000000000000401
Sport-Specific Illness and Injury: Section Articles
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Competitive diving is a sport that has evolved over time to become an admired present-day aquatic sport, especially in the Olympic setting. Despite its popularity, sparse research has been written as it applies to our understanding of competitive diving injuries. This article attempts to discuss common principles of competitive diving as they relate to the sport, especially as it relates to the extreme physical forces encountered by the diver and also the repetitive nature of diving. Next, these principles will be applied in the context of musculoskeletal and medical diving specific injuries.

Competitive diving injuries closely linked to overuse and large impact forces sustained by the diver.

1Department of Orthopaedic Surgery and Rehabilitation and Department of Family Medicine, Loyola University Medical Center Maywood, Chicago, IL

Address for correspondence: Nathaniel S. Jones, MD, CAQ-SM, Department of Orthopaedic Surgery and Rehabilitation and Department of Family Medicine, Health Sciences Campus, 2160 S. First Ave., Maywood, IL 60153; E-mail: jonen@lumc.edu.

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Introduction

Competitive diving has been described as “a sport that requires strength, agility, balance, timing, courage, and quickness” (28). The high level of execution the diver must have to safely complete a dive is nothing short of amazing. It is an aquatic sport with its own set of sport-specific injuries, vastly different from swimming. Diving deserves special attention in that, although swimming is the aquatic sport with the most participants, diving has the highest frequency of injuries while swimming has the lowest (25). This should be no surprise when one considers the difficulty of dives being performed and striking speeds upon water impact. Even when a dive is perfectly executed, injuries can occur, whether traumatic or from overuse. Despite the high frequency of injuries, current available literature on the medical aspects of springboard and platform diving is sparse compared with similar sports, such as gymnastics. In addition, much of the literature on diving injury pertains to nonorganized, recreational diving in outdoor settings. This is not the same as the competitive sport springboard and platform diving, in an official pool, under qualified coaching supervision. This article intends to cover not only general competitive diving principles but also competitive diving-specific injuries in the context of current available literature, which is sparse.

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History

One of the earliest historical accounts of diving is found in the painting in the Tomb of Hunting and Fishing from the late 6th century, where young men are climbing rocks and jumping off a cliff (2). The Tomba del Tuffatore (Tomb of the Diver), built in about 470 BC, also depicts a young man diving into waves. Some of the early roots of modern day diving can be traced to the mid-1800s in Germany and Sweden with the advent of “fancy diving,” in which gymnasts performed acrobatics over water (1). In 1904, during the St. Louis Olympic Games, men's springboard (elastic board) diving was introduced as part of the aquatics program with platform diving being added in the 1908 London Olympic Games. In the 1912 Olympics, women's “plain diving,” without acrobatic feats, was added with springboard diving following suit in 1920 (4).

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General Principles and Terminology

Most diving competitions involve 1- and 3-m springboard and 10-m platform diving (10,33). The Olympics do not have the 1-m spring, but instead added in the year 2000, synchronized diving of the 3-m springboard and 10-m platform. Most recently, high diving of the 20-m (females) and 27-m platform (males) has been added to the Federation Internationale de Natation (FINA) World Championships. The degree of difficulty of dive is a rating, which takes into account the number of somersaults, twists, and particular details of execution. It can be taken from a list of tariffs and for new dives can be calculated with a formula, which is publically available. The range of the degree of difficulty of the dives performed currently in competitions is 1.0 to 4.1, but there is no upper limit if new dives are invented. Each judge on a panel awards a single score from 0 to 10 per dive, and the following elements of the dive are taken into account: approach, take-off, elevation, execution and entry. The dive rating is multiplied by the sum of the judges’ scores (after the highest and lowest scores are dropped) to obtain a final score for a dive. Basic definitions of diving terminology are listed in Table 1 and Table 2.

Table 1

Table 1

Table 2

Table 2

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Epidemiology

Most data on diving are not based on large populations of divers, but rather from case studies, case series and observations from world championships and Olympic events (2,3,12–14,20,21,26). Recently, consensus has been established in regard to methodology of data and injury collection during aquatics championships (22). This newly accepted injury collection standard could now be used to track training injury information, which at this time remains sparse. Of the most recent available data, Kerr et al. (15) looked at the National Collegiate Athletic Association’s (NCAA) swimming and diving injuries from 2009 to 2014. They found an injury rate of 1.94 injuries per 1000 athlete exposures (AE) for males and 2.49 injuries per 1000 AE for females, with more injuries happening during practice over competition (15). Junge et al. (14) found that 2.1% of divers were injured in the 2008 Olympics and Engebretsen et al. (9) found 8.1% of divers were injured in the 2012 Olympics. Most recently, Prien et al. (26) compared injury during the (FINA) World Championships of 2015, 2013, and 2009 and found that older athletes in the diving, high diving, and water polo groups were in the highest risk group for injury. It is of note that divers spend greater than 50% of training time doing dry-land training which includes activities, such as gymnastics, strength and conditioning, trampolining, and dance. Therefore, much of the epidemiologic injury data in each of these respective activities can be partially extrapolated to the sport of diving.

The typical age of an Olympic caliber diver is between 14 and 30 yr of age with competitive diving at senior international events beginning at age 14 yr (4). The average age at the 2012 Olympics was 22.9 yr of age (4).

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Physics of Diving

A 10-m platform diver can reach up to velocity of 16.4 m ·s−1 (59.2 km ·h−1) before entering the water with quick deceleration to 33 km ·h−1 on impact with water, with a force of about 400 kg ·N−1 (18). Thus, the impact at the water surface on the diver can reach 2.0 g to 2.4 g (18). A 1-m springboard dive reaches an average peak velocity of 8.4 m ·s−1 (30.1 km ·h−1) (18). Upon water impact velocity is decreased by greater than 50% within a fraction of a second (3). These incredible velocities and impact forces are thought to be large contributors to competitive diving injuries. With such forces, injuries can occur not only in the setting of a dive gone wrong but also more commonly secondary to an accumulation of exposures to repetitive forces. These principles of the physics of diving are vital to understanding the nature and cause of many competitive diving injuries.

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Diving phases

A basic understanding of a dive, including a stepwise breakdown, is vital for the understanding of the divers susceptibility to different types of injuries during each phase of the dive. Competitive divers train on average 40 h·wk−1 with springboard divers averaging 100 to 150 dives per day and platform divers averaging 50 to 100 dives per day (4). The high number of exposures places the diver at risk for multiple individual injury opportunities and at times may lead to overuse injuries.

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Take-off

The take-off includes the approach, hurdle (jump on to the end of the board), and press (depression of board and upward acceleration of body). Timing the descent of the board with the descent of the diver onto the board is essential for maximal acceleration of the body and the production of an efficient and successful press. If this timing is not just right, a diver is more prone to injuries, most often lower-extremity injuries affecting the extensor mechanism of the knee (28). These injuries commonly include patellar tendinopathy, quadriceps tendinopathy, and patellofemoral compression syndrome. The eccentric overload produced by the board in conjunction with overtraining, dry land training, and high impact can lead to Achilles and posterior tibialis tendinopathy (1,28,30). At times, the diver may be out of position and compensates by hyperextending the lumbar spine, many times leading to back pain. Lastly, when divers are performing armstand dives off of the platform, they are at risk for upper-extremity injuries. The armstand dive requires tremendous strength and balance placing large weight-bearing demands on a dorsiflexed wrist (12). It is of note that many of these injuries can occur or be compounded by dry-land training activities, especially as dry-land training can comprise greater than 50% of training volume.

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Flight or Midair Maneuver

The flight phase begins as soon as the diver leaves the board or platform and ends with initial water contact. Possible injuries that can occur during flight include spine and longhead of biceps injuries due to torsional overload during a twisting dive where one arm is thrown against the chest and the other behind the head (28). Though not common, divers can strike the board or platform in midair and cause a concussion, laceration, contusion, or fracture. Only two reported fatal head injuries are reported from competitive diving and both occurred in divers from a 10-m platform dive while attempting a reverse 3½ summersault tuck (28).

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Entry

The entry phase begins upon the diver’s impact with the water and is the moment when most injuries occur. The decelerating forces (greater than 50% decrease within a fraction of a second), in addition to a less than perfect dive execution, can lead to either acute traumatic injury or overuse injuries (3). In addition, in a diver's attempt to produce a splashless entry, underwater dive “save” maneuvers are necessary and many times can lead to injury. One example of a “save” maneuver would be during a backward rotating dive, to avoid a nonvertical entry, a diver’s shoulders are hyperflexed and spine hyperextended, therefore increasing injury risk (1). The shoulder is at increased risk for glenohumeral subluxation and the spine to injury of the posterior elements (1,28,31).

To protect the head and dissipate energy of impact, divers enter the water with arms extended and hands overlapping which requires great upper-extremity strength and control to maintain form. Forces are transmitted along the kinetic chain from hands to wrists to elbows and more proximally shoulders (29). Injuries can occur at any portion along the kinetic chain, due to large forces, repetitive stress, and overuse during practice and competition (29).

Hand positioning upon entry is important to create a rip entry — or minimal splash (11). Certain hand positioning can allow a diver to better execute a swim out or save. Two main hand positions exist, one older and one new. The older, is the thumb-in-palm position (Fig. 1), and the newer and most widely used one is referred to as the flat-hand grab position (Fig. 2), which allows larger surface area to contact the water, in turn spreading the impact forces over a larger surface area, but also can increase risk of wrist injuries (11,18).

Figure 1

Figure 1

Figure 2

Figure 2

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Common Diving Specific Injuries

Musculoskeletal injuries

Lower-extremity 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).

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Shoulder Injuries

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.

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Elbow Injuries

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.

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Wrist 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.

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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).

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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.

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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.
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Nutrition

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).

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Conclusions

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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