SPORTS MEDICINE KEEPING THE WATER POLO PLAYER OUT OF THE CLINIC AND IN THE WATER

– Written by Andrea Mosler and Rod Whiteley, Qatar

ABOUT THE SPORT Only a few descriptive injury epidemio- and match play is required before we can Water polo is a high-intensity team logy papers and one retrospective review fully appreciate the true injury burden in sport that originated in England in the have been published on water polo injuries1-4. this sport. This paper will therefore present 1860s as an aquatic form of rugby. It is The Fédération Internationale de Natation level 5 evidence with reference to clinical particularly popular in Europe, but is (FINA) has conducted injury surveillance reasoning and available literature as rapidly growing in popularity in other at major international competitions since appropriate. continents. Water polo is the oldest team 20045-7. While FINA should be applauded for sport included in the Olympic programme this initiative, unfortunately this data does TRAINING LOADS – WHY DO WATER POLO with the men’s tournament featuring at not capture information regarding injuries PLAYERS GET INJURED? all Olympic Games since 1900, while the sustained in regular training as players Water polo requires the combined women’s tournament was first conducted that are excluded from national team actions of throwing, swimming, defending, at the Sydney Olympic Games in 2000. selection due to injury do not attend these wrestling and tackling, making it a very The sport is considered safe to play at tournaments. Accordingly, this survivor bias physically demanding and full contact the recreational level, but there is a high underestimates the burden of injury at the sport. A typical training week comprises injury burden when played at the elite highest level. Prospectively recorded injury up to five water polo-specific sessions, two level1. surveillance and exposure during training to three swimming-specific sessions and

434 shorter arm strokes, higher elbows and a much less streamlined body position. This results in reduced efficiency of the swimming stroke and extra load being placed on the cervical spine and shoulders.

The eggbeater

© Al Bello/Getty Images © Al Bello/Getty The eggbeater kick is used by water polo players to support their body in an elevated Figure 1: Typical head-up swimming pattern of a water polo player. position for extended periods and then raise the body out of the water in an explosive action for defending, tackling, passing or shooting (Figure 2). The eggbeater kick is a biomechanically and technically complex movement pattern that involves a cyclical motion with the right and left limbs opposite in phase (Figure 2)9,10. Repetitive rotational hip motion occurs at high ranges of hip flexion, abduction and internal rotation, coupled with a dynamic boost action when shooting, tackling or defending a shot. These repetitive and dynamic loads can place the hip and groin region at risk of injury. Additionally, large valgus moments are placed across the knee during the downstroke, putting the medial structures (such as the medial collateral ligament) under tension.

Shooting The water polo throw and shot are highly complex biomechanical actions which © Ryan Pierse/Getty Images © Ryan combine the familiar throwing motion of the baseball pitch (albeit using a ball Figure 2: Eggbeater kick action. weighing 400 to 450g) with an eggbeater boost kick11. Despite the biomechanical three weight training sessions1,8. Playing WATER POLO-SPECIFIC BIOMECHANICS disadvantage of throwing in the unstable elite level water polo therefore requires the Apart from the high training loads environment of water, the speed of the athlete to cope with high training loads. required for the sport, there are sport- water polo shot can reach up to 95 km/ Repetitive motions involved in swimming, specific biomechanical demands involved hour. There is, therefore, substantial load throwing and the ‘eggbeater kick’ can result in the game which are unique and can place placed on the glenohumeral joint with the in overuse injuries, while training and the athlete at greater risk of injury. repetitive throwing action, as the shoulder match play creates risk for acute, contact is commonly the most vulnerable link in the injuries. Heavy weightlifting is an essential Head-up swimming kinetic chain. There is significant variation part of training for most elite water polo Swimming freestyle is often performed between coaches on what is considered programmes and can also result in injuries with the head up out of the water, either the ‘perfect’ shooting technique, however as athletes strive to optimise their upper swimming in possession of the ball or all agree that to shoot fast and accurately, and lower body strength to assist in pushing looking around to follow the game play plus deceive the goal keeper, considerable around their opponents and shooting with (Figure 1). Head-up freestyle swimming skill and co-ordination is required. Shooting power. involves extension of the cervical spine, with minimal load on the shoulder requires

AQUATIC SPORTS TARGETED TOPIC 435 SPORTS MEDICINE

the optimal transfer of kinetic energy from clinician closely monitors symptoms suggests that these athletes can often the boost of the leg action via the pelvis during throwing as well as swimming, suffer exacerbation of pain with repeated and trunk to the upper body and eventually ensures internal rotation range of motion is injuries when performing bench press the ball. If there is dysfunction at any maintained and that the ratio of internal to exercises and we have noted some success component of this kinetic chain, such as: external rotation strength is <1.5. To achieve in avoiding performing bench press below reduced range of motion at the hips, reduced this, the clinician needs to be prepared to the horizontal. thoracic rotation or poor core stability, the work with the coach to modify throwing The physical nature of the sport means shoulder and elbow could quickly become and/or swimming load as dictated by signs that acute traumatic injuries to the shoulder overloaded from the demands of throwing and symptoms13. are common, with glenohumeral instability and shooting. Biomechanical factors that may a relatively frequent finding. These injuries contribute to inefficient shooting or may require a prolonged rehabilitation time Goalkeeping swimming technique could include: as recurrence of instability is a significant The goal keeper in water polo is very reduced hip motion, poor co-ordination risk when returning to this contact sport. close to the action, often defending shots of the eggbeater kick, reduced thoracic Surgery is often required if there is a at short range – as little as 2 metres or less. or pelvic rotation, incorrect timing of the significant structural injury resulting in They are therefore particularly vulnerable kinetic chain and poor scapular or core mechanical instability, with the restoration to acute injuries to the face, elbows, fingers stability. These biomechanical deficiencies of adequate range of motion a particular and thumbs. should be discussed with the player’s concern if surgery is required on the coach (and other technical staff involved throwing shoulder. INJURY PATTERNS with the sport) as potential influencing From the available literature, the most factors to the clinical presentation of any Wrist/hand injuries commonly injured part of the body is the water polo player with overuse-related Wrist injuries seen in the water polo play- shoulder, followed by the wrist/hand, head/ shoulder pain. Our experience also er include acute injuries to the triangular face, elbow and hip/groin1. a b Shoulder injuries Water polo shoulder injuries can be a unique mixture of conditions due to the repetitive loads of throwing and swimming, combined with contact injuries that can occur in the act of throwing, tackling or blocking in front of goal. It is therefore challenging for the treating clinician to determine which loads from the sport are contributing to the pain presentation and therefore represent the greatest risk when returning to play following injury (Figure 4). The typical mix of throwing-related injuries such as SLAP (superior labral anterior and posterior) lesions, rotator cuff and long head of biceps tendinopathy, postero- c d superior impingement are commonly seen in water polo players. However, these can be complicated by the presence of multi- directional hypermobility that is commonly associated with the swimmer’s shoulder. The water polo player’s shoulder has higher range of motion in the dominant compared to non-dominant shoulder12, which is likely to be due to the extreme ranges of external rotation required to throw hard (analogous to the baseball pitcher’s shoulder), plus the high range of internal rotation range required for efficient swimming. In these athletes it is essential that the managing Figure 3: Eggbeater kick action.

436 fibrocartilage complex or carpal ligaments, the injured player must be brought to the the blocking action of defending the goal. sustained either while tackling a player or side of the pool by the other players in the Strengthening the elbow flexor-pronator blocking a shot. Finger and thumb injuries water to allow for medical evaluation. The muscles and eccentric biceps action are are very common and typically include most common types of head/facial injuries important components of the rehabilitation acute, ligamentous strains when blocking are skin lacerations, bone fractures and programme17. Taping for prolonged periods a shot, catching a ball, tackling a player or eye lacerations, but concussion or retinal may also be required to protect the elbow when the fingers get caught in the swim suit detachment can also occur and the clinician joint once returning to training and match of the opponent. If these injuries are in the caring for these athletes needs to have play. Bracing is not usually recommended dominant hand, they can often be difficult in place appropriate training and clear as the loss of terminal extension can to manage due to the ongoing pain and pathways for these critical injuries3. interfere with the player’s reach and inhibit dysfunction with ball handling. Therefore swimming and throwing action. These optimal acute injury management using Elbow injuries elbow hyperextension injuries can often ice and local compression are essential in Two patterns of injury to the elbow are be difficult to manage and recurrence the early management of these injuries. commonly seen in the water polo player, is common. Technique training, in Strapping and splinting, preferably without similar to that described for the handball consultation with the coach and technical interfering with the fine motor function of goalkeeper’s elbow14-16; acute traumatic staff, is therefore an important part of the hand, may be required for an extended strain injury to the anterior capsule and management and prevention of these period to prevent recurrence. ulnar collateral ligament and overuse injuries. This should focus on maintaining medial/posterior/lateral elbow pain the arm in front of the body where possible Head/face injuries comparable to valgus extension overload and defending against shots using: leg Otitis externa (swimmer’s ear) is common spectrum of injury. Acute ulnar collateral work, trunk motion, scapular protraction in water polo players3. Head and face injuries ligament injuries occur particularly in water and horizontal flexion/internal rotation are also unfortunately quite common in polo goalkeepers, but also in field players, as of the shoulder, particularly for the the sport and can be life-threatening as a result of a hyperextension injury during goalkeeper.

My shoulder My shoulder My shoulder My shoulder hurts since my hurts when hurts when hurts since my arm was hit I throw I swim arm was pulled

Subjective while shooting

• Throwing load • Swimming load • GH anterior instability • GH instability • IR/ER strength ratio • Thoracic rotation • Scapular dyskinesis (anterior or posterior) • GIRD • Hip extension range • Check kinetic chain • Scapular dyskinesis • Thoracic rotation • Technique faults • IR/ER strength ratio • IR/ER strength ratio • Hip IR range in • IR/ER strength ratio • Thoracic rotation • Core-stability

Key points exion/abduction • Scapular dyskinesis • Hip IR range in • Check kinetic chain • Technique faults • Core-stability exion/abduction • GH instability • Check kinetic chain

Figure 4: Flow diagram for key features in planning the assessment of a water polo player presenting with shoulder pain. Note that each of the three presented subjective features may co-exist providing a mixed presentation which will need to be individually examined. IR=internal rotation, ER=external rotation, GIRD=glenohumeral internal rotation deficit, GH=glenohumeral.

AQUATIC SPORTS TARGETED TOPIC 437 SPORTS MEDICINE

5a © Jamie Squire/Getty Images

5b © Rfabrice Coffrini/AFP/Getty Images © Rfabrice Coffrini/AFP/Getty

Figure 5: Optimising goalkeeper defending technique to protect against elbow injuries. (a) The goalkeeper maintains their arm in front of their body and reaches the shot by jumping powerfully to the side. (b) The goalkeeper’s arms are behind his body, with the elbows at greater risk of hyperextension injury.

438 Overuse injuries to the elbow as a References result of throwing may require extensive 1. Annett P, Fricker PA, McDonald W. 14. Tyrdal S, Olsen BS. Hyperextension technique correction and a rehabilitation Injuries to elite male waterpolo players trauma to the elbow joint induced programme that addresses deficiencies in over a 13-year period. N Z J Sports Med through the distal ulna or the distal the entire kinetic chain. Control of throwing 2000; 28:78-83. radius: pathoanatomy and kinematics. load, improved eggbeater efficiency, timing 2. Colville JM, Markman BS. Competitive An experimental study of the ligament of the shooting technique and a more water polo: upper extremity injuries. Clin injuries. Scand J Med Sci Sports 1998; elevated elbow position relative to the body 8:177-182. Sports Med 1999; 18:305-312. (ideally between 90° and 110° of shoulder 15. Tyrdal S, Bahr R. High prevalence of 3. Franic M, Ivkovic A, Rudic R. Injuries in abduction) are essential components of elbow problems among goalkeepers in water polo. Croat Med J 2007; 48:281-288. injury management and will typically be European team handball - “handball done in conjunction with technical coaching 4. Brooks JM. Injuries in water polo. Clin goalie's elbow". Scand J Med Sci Sports staff. Sports Med 1999; 18:313-319. 1996; 6:297-302. 5. Junge A. Injuries in team sport 16. Popovic N, Lemaire R. Hyperextension Hip/groin pain tournaments during the 2004 Olympic trauma to the elbow: radiological The load of eggbeater kick means Games. Am J Sports Med 2006; 34:565-576. and ultrasonographic evaluation in that intra-articular hip joint lesions, 6. Junge A, Engebretsen L, Mountjoy ML, handball goalkeepers. Br J Sports Med chronic adductor-related groin pain and Alonso JM, Renström PA, Aubry MJ et 2002; 36:452-456. acute adductor muscle strain injuries are al. Sports injuries during the summer relatively common in water polo. The 17. Tyrdal S, Pettersen OJ. The effect of Olympic Games 2008. Am J Sports Med management and prevention of these strength training on “handball goalie's 2009; 37:2165-2172. elbow" – a prospective uncontrolled injuries requires the maintenance of range clinical trial. Scand J Med Sci Sports 1998; of motion – particularly hip abduction/ 7. Mountjoy M, Junge A, Alonso JM, 8:33-41. internal rotation range – and strength of the Engebretsen L, Dragan I, Gerrard D et al. abductor, adductor, internal and external Sports injuries and illnesses in the 2009 18. Mosler AB, Blanch PD, Hiskins BC. The rotator muscles plus optimal core stability18. FINA World Championships (Aquatics). effect of manual therapy on hip joint In conjunction with a biomechanist and Br J Sports Med 2010; 44:522-527. range of motion, pain and eggbeater kick coach, technique training using underwater 8. Webster MJ, Morris ME, Galna B. Shoulder performance in water polo players. Phys cameras can sometimes be required for pain in water polo: a systematic review of Ther Sport 2006; 7:128-136. improving the efficiency and effectiveness the literature. J Sci Med Sport 2009; 12:3- of the eggbeater kick. 11. 9. Sanders RH. Analysis of the eggbeater Knee pain kick used to maintain height in water Lastly, medial knee pain similar to polo. J Appl Biomech 1999; 15:284-291. breaststroker’s knee is quite a common 10. Sanders RH. A model of kinemaic injury seen in water polo players due to the variables determining height achieved in training and playing loads of eggbeater kick. water polo boosts. J Appl Biomech 1999; The managing clinician should assess range 15:270-283. of motion and strength around the hip, as reduced abduction/internal rotation range 11. McCluskey L, Lynskey S, Leung CK, of motion and weakness of hip abduction Woodhouse D, Briffa K, Hopper D. Andrea Mosler B.App.Sc. (physio), M.App.Sc. commonly creates excess valgus stress at Throwing velocity and jump height in female water polo players: performance (sports physio) the knee and consequent pain in the medial predictors. J Sci Med Sport 2010; 13:236- knee structures. Senior Physiotherapist 240. In summary, this exciting sport can be challenging for the treating clinician to 12. Witwer A, Sauers E. Clinical measures of Rod Whiteley Ph.D. shoulder mobility in college water-polo maintain an injury-free water polo team. Assistant Director of Rehabilitation However, as in most contact sports, many players. J Sport Rehabil 2006; 15:45-57. Aspetar – Orthopaedic and Sports water polo players play with discomfort 13. Wheeler K, Kefford T, Mosler A, Lebedew Medicine Hospital from overuse injuries. These require A, Lyons K. The volume of goal shooting Doha, Qatar ongoing close monitoring, management during training can predict shoulder and prevention which can help reduce the soreness in elite female water polo burden of overuse injuries to the team. players. J Sci Med Sport 2013; 16:255-258. Contact: [email protected]

AQUATIC SPORTS TARGETED TOPIC 439