Shoulder Problems in Competitive Swimming

Scott A. Rodeo, M.D.

Chief, Sports Medicine and Shoulder Service, The Hospital for Special Surgery Chairman, USA Swimming Sports Medicine Committee Team Physician, New York Giants Football

Swimmer’s Shoulder

•

Incidence 40-70%

•

Estimate: 500,000 stroke revolutions/arm/season

•

6-8 miles/day, 5-6 days/week

•

High training volumes overuse injuries “To convert a merely good swimmer into a champion, you must expose him to what he thinks is the ultimate agonizing limits of physical performance and then teach him to go beyond that limit day after day”

James “Doc” Counsilman

Swimmer’s Shoulder

• • • • • Etiology Shoulder kinematics Diagnosis Treatment Rehabilitation and prevention

Factors Associated with Swimmer’s Shoulder

• • • 1) Muscle fatigue / overload 2) Rotator cuff tendonosis 3) Impingement positions during swimming stroke • 4) Shoulder laxity

Shoulder Kinematics

• • • Glenohumeral stability dependent on: - Static stabilizers (capsule) - Dynamic system (muscles) • Controlled by synchronous pattern of muscle firing Balanced force couples to center humeral head - Subscapularis + infraspinatus Rotator cuff functions as humeral head depressor

Glenohumeral Kinematics

• Scapular stabilizing muscles play critical role • Scapula is stable base from which all else follows • Mistake to emphasize only rotator cuff

Swimmer’s Shoulder

•

Rotator cuff fatigue / overload:

Over-training muscle fatigue

In particular, serratus anterior & subscapularis (Pink et al, Amer. J. Sports Med 1991)

• Muscle imbalance Abnormal force couples

Experimental studies demonstrate superior migration of humeral head with rotator cuff fatigue (Chen et al., 1994)

• Altered shoulder mechanics impingement pain

Muscular fatigue Rotator cuff dysfunction Loss of synchronous firing patterns, abnormal proprioception Abnormal kinematics Secondary impingement

Rotator Cuff Tendonosis

• • Shoulder pain in elite swimmers is related to supraspinatus tendinosis Correlation between supraspinatus tendinopathy and training volume (Murrell et al) - hours swum per week - weekly training mileage

Sein, Murrell, et al.

1.2

1.0

0.6

0.4

0.0

0 r = 0.34, p = 0.01

20 35 40 60 80 Kilometres swum per week 100

Specific Abnormalities in Swimmers

• • EMG studies document muscle fatigue and alteration in muscle force couples in swimmers Subscapularis and serratus anterior vulnerable to fatigue, since firing at >20% MMT

Pink et al, Clin Ortho 1993

Serratus Anterior Functions to Decrease Impingement by Scapular Protraction Loss of serratus function exacerbates impingement

Specific Abnormalities in Swimmers

• • Asynchronous muscle forces Serratus  and rhomboids  • The rhomboids try to compensate, but this is antagonist to serratus anterior No muscle can substitute for serratus anterior

Specific Abnormalities in Swimmers

• Asynchronous muscle forces - Subscapularis  - Infraspinatus  • Compensatory increased infraspinatus firing to decrease internal rotation

Force Couple Between Internal and External Rotators to Stabilize Humeral Head Internal rotator External rotator

•

Internal rotators stronger than external rotators in normal shoulder

•

Imbalance between internal and external rotators in swimmers

•

Goal: ER/IR ratio 65%

Pink et al, Clin Ortho 1993

Postural Abnormalities

• Posture of rounded shoulders and forward head leads to weakness of scapular retractors due to elongation of these muscles Weakness of scapular retractors Anterior tilt / protraction of scapula Impingement

• Fatigue of the “core” muscles including abdominal and pelvic muscles can also contribute by affecting scapular kinematics and body position in the water

Shoulder Stability / Laxity

• Stability dependent on: - Static stabilizers (capsular ligaments) • - Dynamic system (muscles forces) • Swimmers often have some generalized laxity Fine balance between stability and laxity

•

The Role of Laxity

• With shoulder laxity on dynamic stabilizers more dependence • If these dynamic stabilizers fatigue abnormal kinematics • Role of laxity in shoulder pain debated but it often correlates with shoulder injury Instability secondary impingement

The Role of Laxity

• • Anterior laxity is typically symptomatic in abduction + external rotation This is the arm entry position in backstroke

Specific Abnormalities in Swimmers

Anterior capsular laxity

+

Tightness of posterior rotator cuff Combination results in anterosuperior translation of humeral head  impingement

Capsular constraint mechanism: Head translates away from tight capsule

Impingement During Swimming

• • • • Certain stroke positions can cause impingement Classic impingement position = forward elevation + internal rotation Position of hand entry in freestyle, butterfly Rotator cuff tendons/bursa impinge on acromion

Impingement During Swimming

• • • Early pull-through : Forward flexion, IR Late pull-through: hyperextension Recovery: Elevation

Anterior Internal Impingement?

(articular side)

• Articular surface of rotator cuff against glenoid and anterosuperior labrum • Responsible for “biceps” pain??

Impingement between cuff & anterosuperior labrum with arm in flexion + IR

Diagnosis and Management

Diagnosis

• Accurate diagnosis begins with a careful history and examination • Recent change in training regimen? Training volume? Dryland exercises?

• Specific attention to – glenohumeral laxity – strength of rotator cuff and periscapular muscles – impingement signs – localizing tenderness – labral signs – acromioclavicular joint pathology • Careful analysis of the swimming stroke

Stroke Alterations with Painful Shoulder

• • • •

Dropped elbow

:

avoids internal rotation

Wider hand entry

:

less forward flexion

Early hand exit with pull

:

avoids hyperextension

Excessive body roll

:

allows less hyperextension Are stroke alterations cause or effect???

Diagnosis

• • • • Radiographs usually normal Obtain an imaging study if symptoms persist MRI: - Capsular thickening (previous instability episodes) - Rotator cuff tendinosis (suggestive of tendon overload) Diagnostic injection may be helpful to confirm the source of pain

Swimmer’s Shoulder Treatment

• • • • • Rest: change stroke, eliminate paddles, more kicking sets Avoidance of strokes and training exercises that exacerbate the pain Ice, NSAIDs Modalities such as electrical stimulation and ultrasound are useful to control pain and inflammation in the initial treatment phase Proper warm-up

Swimmer’s Shoulder Treatment

Stroke corrections:

• Butterfly: wider hand entry, shorten follow through • Freestyle: less internal rotation at hand entry, breathe bilaterally, shorten follow-through

Swimmer’s Shoulder Treatment

The most important part of the rehabilitation program is identification of any deficits in muscle strength, endurance, balance, and flexibilty

Swimmer’s Shoulder Treatment

• Gentle stretching: posterior rotator cuff, scapular stabilizers, posterior capsule, pectoralis major • Generally do not need to stretch anterior shoulder

Swimmer’s Shoulder Treatment

Posterior capsule Pectoralis stretch Anterior capsule stretch

Treatment Considerations

• • • • • Focus on serratus anterior, scapular retractors (lower trapezius, rhomboids), subscapularis Rotator cuff (external rotation) strengthening: goal is ER:IR ratio at least 65% Proprioceptive neuromuscular facilitation (PNF) patterns to facilitate agonist/antagonist muscle co-contractions Development of core strength: lumbar stabilization, abdominals, pelvic girdle Avoid / correct excessive anterior pelvic tilt / lumbar lordosis

Prevention

• • • Comprehensive program to develop muscle strength, endurance, balance, and flexibility Address three important areas: 1. rotator cuff 2. muscles that stabilize the scapula 3. muscles of the low back, abdomen, and pelvis that make up the “core” of the body Emphasis placed on endurance training and strengthening for the serratus anterior, rhomboids, lower trapezius, and subscapularis

Rotator Cuff Exercises

External rotators Full Can Scaption Ball on the Wall

Scapular Muscle Exercises

Theraband Rows “Hitch-hiker”

Scapular Muscle Exercises

Push-ups with a plus

Core Strength Development “Dead bug” Quadruped

Flexibility Exercises

Hamstring stretch Upper back stretch

Flexibility Exercises

Trapezius stretch

Swimmer’s Shoulder Treatment

• Further evaluation if unresponsive to initial treatment • • • • Radiographs Rule out underlying instability Pathologic lesions Injection used sparingly

Surgery

• Operative management is generally indicated only after a comprehensive course of conservative treatment • Surgical intervention is most commonly required to address instability and secondary impingement

Surgery

• • Proliferative, inflamed subacromial bursa • • Subacromial bursectomy Acromioplasty not performed Capsular plication as indicated

Arthroscopic Capsular Repair

Capsular Repair

Post-Surgical Rehabilitation

• • • • • • Post-operative protection 4-6 weeks Gradual restoration of motion Comprehensive strengthening Swimming ~ 12-16 weeks Training semi-normally by 6 months 1 year total for return to full training

Conclusion

• Shoulder pain in swimmers related to muscle fatigue/overuse and altered shoulder mechanics • Shoulder pain in swimmers can usually be improved with a comprehensive rehabilitation program • • Prevention is most important Team approach critical (athlete + coach + parent + therapist + physician)

Thank You

Sports Medicine and Shoulder Service The Hospital for Special Surgery New York, NY

Swimmer’s Shoulder

• • • • Incidence 40-70% Estimate: 500,000 stroke revolutions/arm per season 6-8 miles/day, 5-6 days/week High training volumes injuries overuse

“To convert a merely good swimmer into a champion, you must expose him to what he thinks is the ultimate agonizing limits of physical performance and then teach him to go beyond that limit day after day”

James “Doc” Counsilman Indiana University

Specific Abnormalities in Swimmers

• • • • Imbalance between internal and external rotators Goal: ER/IR ratio 65% Weakness of posterior cuff, serratus anterior, lower trapezius, rhomboids Tight pectoralis minor

Sein, Murrell, et al.

1.2

1.0

YES

0.8

0.6

0.4

No

0.2

0.0

5

r = 0.35, p = 0.01

10 15 20 25

Hours swum per week

30 35

Other Entities Causing “Swimmer’s Shoulder”

• • • • • • Cervical spine Labral tears/degeneration IR + adduction loads superior labrum Biceps tendinitis AC joint arthrosis Coracoid impingement Coracoid apophysitis