Shoulder Problems in Competitive Swimming

1. Shoulder Problems in Competitive Swimming Chief, Sports Medicine and Shoulder Service, The Hospital for Special Surgery Chairman, USA Swimming Sports Medicine Committee Team Physician, New York Giants Football Scott A. Rodeo, M.D.

2. 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

3. Swimmer’s Shoulder • Etiology • Shoulder kinematics • Diagnosis • Treatment • Rehabilitation and prevention

4. Factors Associated with Swimmer’s Shoulder • 1) Muscle fatigue / overload • 2) Rotator cuff tendonosis • 3) Impingement positions during swimming stroke • 4) Shoulder laxity

5. 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

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

7. 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

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

9. 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

10. r = 0.34, p = 0.01 YES No 35 Sein, Murrell, et al.

11. 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

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

13. 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

14. Specific Abnormalities in Swimmers • Asynchronous muscle forces • - Subscapularis  • - Infraspinatus  • Compensatory increased infraspinatus firing to decrease internal rotation

15. 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

16. 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

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

18. 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

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

20. The Role of Laxity • Anterior laxity is typically symptomatic in abduction + external rotation • This is the arm entry position in backstroke

21. 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

22. 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

23. Impingement During Swimming • Early pull-through : Forward flexion, IR • Late pull-through: hyperextension • Recovery: Elevation

24. 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

25. Diagnosis and Management

26. 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

27. 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???

28. 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

29. 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

30. 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

31. Swimmer’s Shoulder Treatment The most important part of the rehabilitation program is identification of any deficits in muscle strength, endurance, balance, and flexibilty

32. Swimmer’s Shoulder Treatment • Gentle stretching: posterior rotator cuff, scapular stabilizers, posterior capsule, pectoralis major • Generally do not need to stretch anterior shoulder

33. Swimmer’s Shoulder Treatment Pectoralis stretch Posterior capsule Anterior capsule stretch

34. 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

35. Prevention • Comprehensive program to develop muscle strength, endurance, balance, and flexibility • Address three important areas: • rotator cuff • muscles that stabilize the scapula • 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

36. Rotator Cuff Exercises External rotators Full Can Scaption Ball on the Wall

37. Scapular Muscle Exercises Theraband Rows “Hitch-hiker”

38. Scapular Muscle Exercises Push-ups with a plus

39. Core Strength Development “Dead bug” Quadruped

40. Flexibility Exercises Hamstring stretch Upper back stretch

41. Flexibility Exercises Trapezius stretch

42. Swimmer’s Shoulder Treatment • Further evaluation if unresponsive to initial treatment • Radiographs • Rule out underlying instability • Pathologic lesions • Injection used sparingly

43. 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

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

45. Arthroscopic Capsular Repair

46. Capsular Repair

47. 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

48. 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)

49. Thank You Sports Medicine and Shoulder Service The Hospital for Special Surgery New York, NY