Swimmer?s Shoulder: An Overview
SWIMMERS?S SHOULDER: AN OVERVIEW
Shoulder pain is a typical problem that up to 75% of swimmer?s have had at some point throughout their career. Usually classified broadly as swimmer?s shoulder, it is often an overuse injury related to the repetitiveness of stroking that occurs with competitive swimming. A common problem in swimmers is impingement. In the case of impingement, the tendons of the supraspinatus, the long head of the biceps and the subacromial bursa, a fluid filled sac that provides lubrication to the joint, become impinged or squeezed between the head of the humerus, the coracoacromial arch and anterior acromion. This compression which can occur during every stroke leads to further inflammation of the tendons worsening the impingement. Factors that contribute to this impingement are related to the rotator cuff and scapula, such as laxity and fatigue as well as muscular imbalances. A combination of these factors along with the development of weak external rotators and a tight posterior shoulder capsule change the resting position of the humerus. Consequently, instability increases and often worsens the symptoms.
Some common signs and symptoms of swimmer?s shoulder are:
- Shoulder pain during or after swimming that worsens with high intensity practice sessions
- Pain with shoulder internal rotation and flexion to 90 degrees
- Slouched forward shoulder posture anteriorly
- Tenderness to palpation of the supraspinatus and biceps tendons
- Decreased strength of the shoulder musculature
- Scapula winging
- Positive impingement tests
Biomechanically, the timing of muscle recruitment has been shown to be altered in injured swimmers. A study by Wadsworth and Bullock-Saxton showed decreased consistency of the pattern and timing of the serratus anterior and upper and lower trapezius during bilateral controlled shoulder elevation in the plane of the scapula. Other problems beside impingement can also cause pain in a swimmer which must be ruled out and treated accordingly if present. For example, injury to the rotator cuff, injury to the labrum of the shoulder, or clavicular dysfunction. As in the case of Michael Phelps the winner of six gold medals at the 2004 Olympics, a problem with his clavicle was affecting his gleno-humeral movement and further causing instability and early fatigue. Specifically, the importance of discovering the cause of the pain is crucial to a successful rehab (USAswimming, 2004).
When treating typical swimmer?s shoulder based on impingement and muscular imbalance, rest and rehabilitation is indicated. Focusing on strengthening the rotator cuff as a whole, especially the external rotators is important. Specific attention to the external rotators is key because often in swimmers the external rotators of the shoulder joint are elongated and weak, in contrast to the internal rotators which are shortened and tight. In order to achieve optimal results in any sport, the activity being performed should be carefully analyzed and training thus made specific to the demands.
In addition to strengthening, stretching is also indicated. Stretching of the posterior capsule, not the anterior capsule is imperative. When the anterior capsule is overstretched it further increases the risk of instability that will worsen the condition. In my opinion, many swimmers are unaware that they should not be overstretching the front part of their shoulder and subsequently it is a common stretch seen on the pool deck. In contrast, the posterior portion of the shoulder should be stretched. To stretch the posterior portion, the scapula must be stabilized. This can be performed with the swimmer on their back and rolled partially on the outer border of the scapula. (O?Donnell, Bowen and Fossati, 2005) This type of stretching helps to decrease the forward shoulder posture and lower the high riding humerus often seen in people with tight posterior capsules. This lowering of the humerus and postural alignment of the shoulders increases the subacromial space, which should help a swimmer suffering from impingement.
Some simple strengthening exercises that would be beneficial are resistive rows using a theraband to make the posterior musculature of the shoulder stronger and resistive external rotation with the theraband to strengthen the external rotators. ?Core? strengthening of the abdominals and lower back are also indicated to decrease muscular imbalances and connect the upper and lower body. Many swimmers positively respond to a program of rest and rehabilitation, while a small percentage need surgery. Increased rehab time after surgery decreases the swimmer?s chances of returning to their previous level of performance.
Another very important aspect of swimming to focus on in order to decrease or prevent shoulder pain is stroke technique. In my opinion, only a few coaches that I?ve had have intensely focused on proper technique, while more emphasis was put on the amount of distance performed. Bad habits are exacerbated with fatigue, and can be very difficult to break. A central concept to concentrate on is getting as much glide as possible with each stroke. The lower number of strokes per lap decreases the incidence of impingement and increases overall efficiency. In addition, focusing on sustaining a high elbow in the middle of the pulling phase, maintaining body roll throughout the stroke and breathing bilaterally can help decrease muscular imbalances. (Riewald, 2002) Very importantly, each swimmer is different and should be treated accordingly with a focus on relieving the body of its stress while being as efficient as possible.
In conclusion, swimmer?s shoulder is a condition that is much easier to prevent than treat. Proper stroke technique and a dry land program focusing on stretching and strengthening of the rotator cuff, scapular muscles and core is important to maintain efficiency, health and balance in competitive swimmers.
- Koehler, S. M., & Thorson, D, C,. (1996). Swimmer?s Shoulder: Targeting Treatment. The Physician and Sportsmedicine, 24(11).
- Johnson, J.N., Gauvin, J., & Fredericson, M. (2003). Swimming Biomecahnics and Injury Prevention: New Stroke Techniques and Medical Conderations. The Physician and Sportsmedicine 31(1).
- O?Donnell, C.J.,Bowen, & J.,Fossati, J. (2005). Identifying and Managing Shoulder Pain in Competitive Swimmers: How to Minimize Training Flaws and Other Risks. The Physician and Sportsmedicine 33(9).
- Riewald, S. (2002) Swimming Technique. NSCA?s Performance Training Journal 2(4).
- Wadsworth, D,J., & Bullock-Saxton, J.E. (1997). Recruitment patterns of the scapular
rotator muscles in freestyle swimmers with subacromial impingement. INT J Sports Med, 18(8), 618-24.
- Shoulder Injury Case Study- Michael Phelps. Retrieved Dec 10, 2005, from http://www.usaswimming.org/USASWeb/ViewMiscArticle.