Breaststroke swimmers have a fivefold higher risk of knee pain (relative risk, 5.1), although most occurs in the medial compartment, whereas freestyle has a reduced relative risk (0.5) for knee pain.23 The biomechanics of the breaststroke generates high valgus loads due to the adducted hip position. Extreme hip abduction angles at kick initiation can be detrimental. For example, a study of 21 competitive swimmers reported that hip abduction angles of less than 37° or greater than 42° were associated with a higher knee injury rate.46
Increased varus and valgus loads also occur in the knee in addition to rapid knee extension. Due to the kick style in the breaststroke technique, increased tension across the medial compartment and increased compression of the lateral compartment occur.34 Clinical and arthroscopic examination of 9 breaststroke swimmers with medial knee pain found medial compartment synovitis in 7 swimmers.21 Rovere and Nichols proposed that inflammation and fibrosis of the synovial plica cause medial knee pain; they found thickened and tender medial plica in 47% of breaststroke swimmers with medial knee pain.37
There is increased strain of the medial collateral ligament (MCL) due to high valgus loads during the whip kick, which can present with tenderness of the femoral or tibial origin of the MCL.19 Repetitive valgus loads may result in pes anserinus tendinitis or bursitis.35 Strain injuries of the hip flexors and adductors (particularly adductor magnus and brevis) occur in breaststroke swimmers.35