Researchers Urge FINA & Feds To Get To The Heart of The Matter On Athlete Health

Sun Yang - by Patrick B. Kraemer

Should all who race in FINA competition carry a certificate confirming that they have passed a fitness test that has included cardiovascular investigation? A question worth asking in light of the following:

Swimming and those governing the sport at international and national levels have failed to implement Olympic health and safety recommendations designed to recognise cardiovascular diseases that afflict leading athletes and ensure that no-one trains and competes at risk through lack of a medical-fitness test.

In a study covering 2,352 Olympic athletes spanning Athens 2004 to Sochi 2014 and entitled “Are Olympic athletes free from cardiovascular diseases?” – published in the British Journal of Sports Medicine – the Italian research team of Antonio Pelliccia, Paolo Emilio Adami, Filippo Quattrini, Maria Rosaria Squeo, Stefano Caselli, Luisa Verdile, Viviana Maestrini, Fernando Di Paolo, Cataldo Pisicchio, Roberto Ciardo, Antonio Spataro, state:

“Implementation of the Olympic programme in Italy was a decision of the National Olympic Committee, to prevent and resolve any medical issue that might impair the athlete’s physical performance, with the aim to maximise the athlete’s chances to succeed. Since 2009, the IOC has introduced and supported the concept of periodical health evaluation in elite athletes.

“However, at present time, only few international federations (FIFA, UCI) have implemented this programme for their elite competitors and, as a matter of fact, no medical evaluation was universally required for athletes, prior to their participation in the Rio de Janeiro 2016 Summer Olympic Games. We trust that our observations support the concept that medical evaluation of Olympic athletes is appropriate and necessary.”

Health in focus – photo by Patrick B. Kraemer

Many leading programs around the world do indeed include medical checks, especially when it comes to those making national teams. Many of those working in leading programs and at performance centres are under the regular supervision of a doctor and other health experts, including dieticians and others, while nations such as Italy have long insisted on medical checks for leading athletes. That tradition goes back a long way: annual medical checks were a prerequisite to competing when this author was a boy and young swimmer growing up in Portugal, for example.

FINA has just one overriding prerequisite to an athlete competing in international waters and competitions held under FINA rules: ” GR 1.1 All competitions shall be registered with their National Federation to be eligible to compete.”

FINA also has Medical Rules, covering such issues as athlete rights, medical consent, confidentiality and privacy, as well as extending to recommendations that injury data and other issues related to sports medicine be a part of the culture of the sport, and that related work should be conducted ethically.

However, the section covering “Fitness to Practise Sport” specifically rules out the need for a fitness test:

“8. 8.1 – Except when there are symptoms or a significant family medical history, the practice of sport for all does not require undergoing a fitness test. The choice to undergo such a test is the responsibility of the personal physician.”

Basically, that adds up to FINA accepting no responsibility for the health of an athlete at the point where that athlete arrives to compete without having undergone a fitness test specifically designed to rule out the kind of conditions that can lay hidden for decades, among athletes just as they can among the general population, the references, such as this one, to such things to be found in abundance.

Swimming’s Experience

The career of Italian double Olympic breaststroke champion Domenico Fioravanti came to an end when medical tests revealed a heart condition. Although Fioravanti, understandably, did not want to quit swimming, he ultimately accepted the advise of doctors  who suggested his health could be at serious risk if he continued to train as an elite athlete.

Early diagnosis is critical to survival rates among those who have congenital and other heart conditions, as this article focussing on new detection technology in the United States points out.

Among leading swimming nations, some have checks and balances in place at domestic and program level. Olympic champion Kyle Chalmers was forced to withdrawal from a showdown with Cameron McEvoy in the 100 metres freestyle at short-course nationals in Brisbane late last year after suffering a sudden attack of supraventricular tachycardia (SVT). Doctors were quick to examine Chalmers and ruled him out of the final.

From right, Rebecca Soni and Dana Vollmer with teammates Missy Franklin and Allison Schmitt after they claimed Olympic gold in the medley relay at London 2012 – by Craig Lord

Dana Vollmer by Craig Lord

Olympic champions Rebecca Soni and Dana Vollmer, both Americans, are among others whose sporting tale includes treatment for heart conditions.  Vollmer has served as an ambassador and spokesperson in American Heart Association campaigns to highlight the face that heart problems that are not often associated with Olympic champions include conditions that affect otherwise perfectly healthy young people.

The issue is one that has been largely ignored by those governing swimming at international level in so far as the sport having no rules that insist on regular medical checks designed to assess whether an athlete is fit to train and compete.

Swimming has a big case in point on its hands. It was November 2014 when Chinese news agency Xinhua revealed that Sun Yang* had waived his right to have his ‘B sample’ tested after testing positive for a banned substance, the heart regulator Triamterene, six months earlier in May. Sun, it would later be revealed, had defended himself at a hearing in July, saying he had been prescribed the drug for heart palpitations he had suffered since 2008. Effectively, he had been on medication for the heart condition for the entire duration of his international career.

Triamterene, added to the WADA banned substances list in 2014, is described as a potassium-sparing diuretic (water pill) that “prevents your body from absorbing too much salt and keeps your potassium levels from getting too low. Triamterene is used to treat fluid retention (edema) in people with congestive heart failure, cirrhosis of the liver, or a kidney condition called nephrotic syndrome.”

Medical websites also note that Triamterene is used to treat edema “caused by using steroid medicine or having too much aldosterone in your body. Aldosterone is a hormone produced by the adrenal glands to help regulate the salt and water balance in your body”.

Sun Yang – a FINA star who has got no stripes for good behaviour of late – by Patrick B. Kraemer

Birthday boy Sun Yang and Dr Ba Zhen, back working with the swimmer in 2016 after serving two anti-doping suspensions – social media, Twitter, screen shot

Chinese authorities tried to bat off the controversy inherent in a woeful lack of transparency by stating that “this is huge bad news but we will not cover it up. We announce positive cases and test statistics in our quarterly reports just as WADA requires”.

The argument in favour of Sun was that the Chinada and Chinese version off the WADA Code and banned substances had not been updated with the latest list when it should have been in late 2013. Sun’s doctors – four were cited in the Chinese media – were, therefore, working of an outdated list.

The delay in revealing the case, as well as the fact that there was no quarterly reporting of Sun’s case before he raced at the Asian Games in 2014, led to a breakdown in trust. Five months after Sun’s test, the World Anti-Doping Agency had still not been informed of the full details of the Sun case, while FINA was forced to insist that China impose a penalty on the swimmer, the rules clear when it came to an offence having been committed. A warning simply would not do.

The 2012 Olympic 400 and 1500m freestyle champion from China received a retrospective ban (one never actually served). Sun raced to three gold medals at the Asian Games four months after testing positive and two months before the world was told that he had fallen foul of anti-doping rules earlier in the year.

At the time the story broke – and before Dr Ba Zhen received a second suspension from WADA for having worked with Sun on the deck at the Asian Games at a time when he should have been serving a year-long ban, Sun told the Chinese media that he had taken Triamterene for the bulk of his young swimming career to cope with a heart condition.

The issue raised serious questions about whether Sun’s coaches, when setting the swimmer some of the hardest training sets you will find anywhere in the world of elite swimmers, knew that the swimmer was taking medicine for the heart condition he had been afflicted by since his days as a youth swimmer.

Coach Denis Cotterell talks to Grant Hackett during his comeback for Rio 2016 – courtesy of Swimming Australia

Those coaches included Grant Hackett‘s mentor Denis Cotterell in Queensland before he was told in 2015 to drop Sun as Australia adopted rules that bar any athlete who has tested positive for a banned substance from training at a funded performance centre such as that in operation at Miami at the time.

In 2015, Sun withdrew from the 1500m freestyle final at the eleventh hour after he was seen to having a blazing row with China team officials in a locker room the Chinese delegates sought to evacuate so that they could have their showdown with the Olympic champion heading for the defence of the 1500m world title. In his rage, Sun was seen to kick a locker in during the altercation with officials.

A FINA statement explained that Sun, according to the Chinese delegation, had been forced to withdraw because heart problems.

A medical check and accompanying health check is not specifically stated as a condition of eligibility to compete. Further to that, FINA has a questionable record when it comes to taking a strong anti-dopig  stance.

In 2016, Sun lost the 400m freestyle Olympic title to Mack Horton after the Australian had lit the fuse to a week of anti-doping protests among the world’s leading swimmers and coaches. The Chinese swimmer then claimed the 200m title and was hugged on the poolside by FINA director Cornel Marculescu as Star Wars raged.

Come the 1500m freestyle heats as the swimming in Rio drew to its conclusion, Sun clocked 15:01.97, 26th on his list of performances topped by the world record of 14:31.02, set when he claimed London 2012 Olympic gold. Sun had not swum so slowly in global waters at anytime since a 15:05.12 in the Olympic final of 2008 at 17 years of age, when his treatment for heart palpitations began.

“Are Olympic athletes free from cardiovascular diseases?”

Go! but get checked first  – by Patrick B. Kraemer

The Italian research paper comes to this:

“In conclusion, this study shows an unexpected prevalence of CV abnormalities in Olympic athletes, including a small, but not negligible proportion of conditions at risk of SCD/CA. This observation suggests that Olympic athletes, despite their astonishing performance, are not immune from serious CV disorders and legitimates the concept of a tailored screening programme for the prevention of cardiac events and appropriate medical care.”

The key points:

  • This study provides important new information on the prevalence of cardiovascular diseases and abnormalities in Olympic athletes.
  • Olympic athletes are a population that is, mistakenly, always considered healthy and free of life-threatening conditions.
  • Relevant cardiovascular abnormalities and diseases were identified during the preparticipation evaluation. How might it impact on clinical practice in the future?
  • The preventive approach adopted in this study, resulting from our experience, strongly supports the adoption of a specific evaluation model for Olympic athletes aimed at the prevention and reduction of fatal events.
  • Considering the effort that the cardiovascular system of Olympic athletes has to sustain a specific approach is recommended in this group of individuals.
  • Findings from our Olympic athlete population suggest that the preparticipation evaluation protocol of these athletes should be tailored to their characteristics.
  • Read the Research Paper in full


Should all who race in FINA competition carry a certificate confirming that they have passed a fitness test that has included cardiovascular investigation? A question worth asking in light of the following: Swimming and those governing the sport at international and national levels have failed to implement Olympic health and safety recommendations designed to recognise cardiovascular diseases that afflict leading athletes and ensure that no-one trains and competes at risk through lack of a medical-fitness test.



Certainly, moves in this direction are both advisable, and in the longer term, essential but the reality is that even should there be the will to pursue; the roll-out would be some years in realisation.

Should said certification eventually cover a wide cross-section of medical issues …. certainly but in the short-medium term; cardio-vascular and respiratory should be the spearhead …. especially the latter which is the prime source of TUEs

The issues I see as needing to be addressed are:

– what will be the accepted level of certification ? From a duly accredited sports med practitioner PLUS a duly accredited specialist in the particular field (cardiologist/respiratory medicine) would be my view.

– the eternal bugbear of “who’s paying ?” Such checks are all part of “due diligence” these days for professional team sports but for Olympic sports where “trade teams” are nigh non-existent; where does the buck stop ? If one says the national federations; the counter-argument is that an ever-increasing majority face a constant existential battle to survive financially let alone asking the question of ability/competence to “police” said matters. The international body ? OK, but who will they be devolving the operational side of things to ?

Craig Lord

CW, I would imagine that sport would have to be looking at a similar model to that which exists in the better models of private healthcare. The role of FINA et al would be to change their rules and accept the good practice of at least writing into their rules that a medical test and fitness are prerequisites to competing. Precisely what those tests and measures would be is a matter for medical experts in consultation with sports medicine experts and folk from the anti-doping realm – but none of that is new to the world and many leading swim nations already have such things in place and well-established.
As for funding, there are many sources of potential funding, including obligatory contributions from the IOC and intl federations from that fat pot of IOC/broadcast and other revenue. As a child growing up in Portugal and a member of a swim club I was obliged (my parents were obliged on my behalf) to undergo a medical test. There was a small fee that helped pay for that service. There are a number of ways such things could be handled, through club fees, etc. There are also models the world of sport could look at, including cross-sport aid programs. Again, going back many decades, football clubs in Portugal, such as Benfica and Oporto, contributed funds to the other sports operating in facilities alongside them in multi-sport programs (they had handball, basketball, swimming and other teams under the banner of the football club name) … club members/fans could buy an ‘associate’ membership to the club and those funds went into a general pot that helped funds flow from the richer end of the sports pool (football) through to other sports that required subsidisation. There are, of course, many models in the USA (and some elsewhere) that tell us that swimming programs can not only be self-sustaining but thrive beyond that position.
Beyond all of that, the question this article poses is the simple principle of what responsibilities FINA and the like should accept in their very well-feathered world. If they are guardians of a world in which kids cover 50 to 100km in water a week, lift weights and do a great deal more than that in order to qualify for national and international competition, then a rule saying ‘no fitness test required’ is not, I would suggest, ideal. The Sun Yang case is cited because it is fundamental to the argument: who, beyond Sun’s doctors and his local coach and family, knew that he spent at least 7 years taking a substance to correct a heart condition while undertaking an extremely rigorous training regime? Was his Australian coach made aware? Who would have taken responsibility had Sun dropped dead in the water? FINA? Miami? Chinese Swimming? Well, as we know from the death of a 17-year-old of late on official training camp in China, the answer is: none of those federation entities took any responsibility nor did they provide any clarification nor explanation. The dots are deliberately left unjoined, it seems to me. As I say in the most mild manner I can muster: not ideal.

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