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Sports Medicine Congress



Shoulder pain in swimmers

“Swimmer’s Shoulder” is a term that is used broadly to describe pain in and around the shoulder in association with swimming activities. The pain in “Swimmer’s Shoulder” is typically described as being anterior and is often in the region of the biceps tendon.  Contributing factors for the development of swimmer’s shoulder include:

1) Inadequate strength and endurance of the muscles around the shoulder, scapula, back, pelvis, and abdomen
2) Glenohumeral (shoulder joint) laxity or looseness
3) Poor stroke mechanics such as a dropped elbow and a lateral hand entry that may lead to impingement.
4) Muscle imbalances and inflexibility – specifically of the pectoral (chest) muscles and the posterior rotator cuff.

Etiology or Cause of Swimmer’s Shoulder

It is felt that there are three main causes for the shoulder pain.

1) The first factor in the development of swimmer’s shoulder is overuse leading to subsequent fatigue of the muscles around the shoulder, scapula, and upper back. Shoulder function is highly dependent on the coordinated function of many muscle groups. These include the muscles around the shoulder, those that control the scapula, muscles in the upper and lower back, as well as abdominal and pelvic muscles. The shoulder does not act in isolation during swimming. Muscles of the back, trunk and even legs are used to help stabilize the body and to assist in the pulling movement. Since the shoulder is an inherently unstable joint, muscle forces are critical for maintaining stability, proper motion, and painless function. The repetitive overhead activity of the swimming stroke can result in fatigue of these muscles.

2) The second factor in the etiology of swimmer’s shoulder relates to the biomechanics of the swimming stroke. Impingement of the supraspinatus or rotator cuff tendon can occur in various positions during the swimming stroke. Such impingement may be subacromial (the bursal surface of the rotator cuff against the anteroinferior acromion) or intra-articular (the articular surface of the rotator cuff and/or biceps tendon impinging on the anterosuperior glenoid and labrum). Glenohumeral laxity also causes secondary impingment during overhead activities.

3) The third factor is laxity. Many swimmers have an element of shoulder laxity or “looseness”. In fact, a certain degree of laxity is likely advantageous. There is a fine line between laxity (normal, physiologic) and instability or “too loose” (pathologic). Normal laxity may increase over time and eventually become pathologic. Shoulder stability is controlled by static (glenohumeral ligaments) and dynamic (rotator cuff muscles) factors. Loss of the static component (glenohumeral capsular laxity) requires a greater contribution from the rotator cuff, which can result in muscle overload and eventual muscle fatigue, as described above. The challenge for the medical practitioner is to distinguish between normal laxity and abnormal instability.

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Stroke Mechanics

Subtle stroke alterations may be seen in the swimmer with a painful shoulder. These include:

- a dropped elbow (this position avoids internal rotation),
- a wider hand entry (avoids impingement due to forward flexion)
- early hand exit during pull-through (avoids hyperextension position)
- excessive body roll (allows less hyperextension).

Such stroke alterations may be causing shoulder pain, or alternatively, may be compensatory changes to relieve and/or avoid painful positions.

Based on these findings, stroke corrections can be suggested. For example, the coach/physician may suggest that the arm be held in less internal rotation during recovery, hand entry may be made more lateral to the midline at the entry phase, or body roll may be increased to the side of the painful shoulder during the recovery phase. However, it must be emphasized that stroke alterations should only be suggested in conjunction with careful discussion with the coach. The physician/trainer should not make technique suggestions without careful analysis of the individual swimmer’s stroke.

Treatment Considerations

The following table summarizes the initial treatment plan for the athlete complaining of shoulder pain:

- avoid strokes & positions that cause pain (butterfly/freestyle)
- ice the shoulder daily
- warm-up slowly prior to training
- modification of distance and frequency of training
- stop using paddles and avoid pulling sets
- kicking drills may be performs – avoid the impingement position
- use of fins to assist in maintaining good body position
- use of pull buoy to decrease drag
- avoid dry land upper extremity weight training
- correction of stroke biomechanical errors

After a period of rest, the athlete may gradually try to resume training. If there is recurrent pain upon resumption of more swimming activities, then the athlete should consider staying out of the water entirely for three days time. Use of non-steroidal anti-inflammatory medication may be considered. After this three-day period of rest, the athlete is reassessed, and if clear, he/she can once again resume a normal training regimen. If the shoulder pain rapidly recurs, then the team sports medicine physician should evaluate the athlete. The physician will perform a thorough physical examination and radiological evaluation to rule out any other shoulder pathologies, and to ascertain the severity of the problem. It is important to note that other bone or soft tissue lesions, although uncommon, can present in the athlete as sports-related pain.

Other factors that should prompt the coach or athlete to seek evaluation by the team physician include:

- pain that persists outside of swimming
- pain that persists at night
- pain that is present during everyday activities and while at school
- if the athlete feels that the shoulder “slips” or “feels loose’
- if there has been distinct trauma (a fall, etc.)
- if the athlete reports a new and painful click inside the joint
- if there has been recurrent periods of missed training due to shoulder pain over several seasons.

Treatment Pearls:

- avoid the stroke allowing rest of the tendon
- use of ice
- training modifications
- avoid use of paddles, pulling sets & dry land training
- correction of stroke mechanics
- consult the team sports medicine physician for assessment & treatment

Prevention and Rehabilitation

The principles of prevention and rehabilitation are the same. It is essential that a comprehensive program be devised for the athlete to develop muscular:

- strength
- endurance
- balance
- flexibility of the muscles

These exercises must address the three important anatomical areas:

1) the rotator cuff
2) the muscles that stabilize the scapula
3) the muscles of the low back, abdomen, and pelvis that make up the “core” of the body.

Although a comprehensive program for the shoulder and periscapular muscles is required, emphasis should be placed on endurance training/strengthening for the serratus anterior, rhomboids, lower trapezius, and subscapularis.

Gentle stretching of the rotator cuff and periscapular muscles is reasonable, but aggressive stretching may be deleterious. In particular, swimmers should generally avoid positions that stretch the anterior capsule as such stretches can exacerbate shoulder laxity. Gentle stretching of the pectoralis major muscle and posterior capsule may be required.

It is important to design an individualized program for the athlete’s specific needs. Each individual swimmer should be assessed to determine that individual’s strength, endurance, and/or flexibility deficits. This will allow precise, effective preventative and rehabilitation prescription. Rehabilitation/strengthening exercises should be performed after swimming training or several hours before practice. These exercises should not be performed right before swimming training as this may fatigue these muscles before swimming.

Rehabilitation Pearl:

Designing an individualized rehabilitation program for the athlete taking into consideration their specific needs is essential for successful rehabilitation.

Future Study

There is great need for further study of the swimmer’s shoulder. Our understanding of shoulder pain will be aided by identification of the relationship between shoulder pain and physical characteristics such as:

- posture
- glenohumeral laxity
- scapular kinematics
- sternoclavicular joint
- ribcage kinematics

We also need to explore the relationship of shoulder pain to pathology in other areas. For example, we need to define the relationship between neck, back and shoulder injury, and the role of sternoclavicular joint mobility and ribcage mechanics in swimmers with and without shoulder pain.It is also important to define the exact stroke mechanics that may lead to impingement and pain. This will aid in identification of the anatomic source of pain. This information can lead to the development of an effective preventative training program.

Since muscle overuse and resultant fatigue is associated with shoulder pain, there is a need to develop objective measures of muscle fatigue immediately after intense swimming.

Summary

In summary, it is evident that the health of the swimmer’s shoulder is an integral part of the aquatic athlete’s success. There are many factors involved in the development of this disorder. The potential causes, including the various stroke mechanics have been reviewed. In addition, identifying features have been discussed as well as treatment regimens. Areas requiring further scientific research have been discussed. As the body of scientific research improves, so will our understanding of the complex swimmer’s shoulder. Subsequent to this knowledge, our treatment regimens and preventative protocols will become more effective thereby allowing our athletes to compete to their fullest potential.

*Dr. Scott Rodeo works extensively with USA Swimming. He holds the following positions:
- Chief, Sports Medicine and Shoulder Service, Hospital for Special Surgery
- Associate Professor of Orthopaedic Surgery, Weill Medical College of Cornell University
- Associate Attending Orthopaedic Surgeon, Hospital for Special Surgery, New York City
- Associate Attending Surgeon (Orthopaedic Surgery), The New York-Presbyterian Hospital, New York City
- Assistant Scientist, Department of Research, Hospital for Special Surgery
- Associate Team Physician, New York Giants Football

Ask the Doc

I am a water polo player and I have just been diagnosed with swimmer’s shoulder. My doctor says that I shouldn’t be swimming. How will I stay in shape?

It is important while you are rehabilitating your shoulder that you maintain your cardiovascular fitness and strength. You can cross train with running or cycling. In addition if you want to be in the water, you can do laps of kicking – remember to keep your arms by your side as your shoulder should not be kept elevated over your head for extended periods of time. Shooting is also not a good idea as this requires your arm to be extended above the shoulder. You can take this opportunity to work on your eggbeater skills.

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