SWIMMERS SHOULDER

What is it?
 
Swimmers shoulder refers to pain in either one or both shoulders.  It is often hard to pin point the location of the pain and is described as a vague ache associated with swimming.  In its initial stages it presents as an ache during swimming but can progress to being a sharp pain at points throughout the stroke, typically in the first half of the pull and early recovery.
 
The symptoms are usually associated with an inflammatory response surrounding the rotator cuff group of muscles and the bursa (a sack of fluid lying between structures to decrease friction).  Often in the early stages it will respond to rest from swimming and anti-inflammatory medications but symptoms frequently return when swim training resumes.  If you consider that in an average 4000m swim set you turn over your shoulder in excess of 2500 times this presents a great deal of stimulus for the shoulder if not injury free.
 
Why do you get it?
 
There are a number of reasons for developing swimmers shoulder with faulty mechanics playing the biggest part.  When we assess athletes in the clinic we look at each of the areas below:
 
Flexibility
 
In order to achieve good stroke mechanics you must have sufficient flexibility to get good reach at the front of the stroke, internal rotation through the pull and extension of the shoulder for the recovery.
 
Looking at each of these in turn beginning with reach we want to see that the latissimus dorsi flexibility allows the wrist to rest on the floor when the athlete is lying on their back and raises their arm above their head as far as they are able (without arching the back).  If not they may have a lack of flexibility in their latissimus.
 
When looking at the degree of internal rotation we again assess this with the swimmer lying on their back but with the arm out to the side level with the shoulder.  In this position we want to see them able to internally rotate the shoulder so that the forearm stops at less than 30^o from the floor without the shoulder girdle raising from the resting position it started at.
 
The required amount of shoulder extension is easy to see in standing as the athlete needs to be able to extend the shoulder backwards so that the upper arm is at greater than a 30^o angle to the trunk.
 
Posture
 
Posture can have quite an effect on perceived flexibility and can easily bias your results when looking at the three tests described above.  A good guide you can try poolside is to stand with your back to a wall resting your heels, buttocks, shoulders and head against the wall.  If you can maintain these four points of contact and distance between the small of your back and the wall is no greater than the size of your knuckles you are about right.  We use some progressions on from this position to get a more accurate picture but this will provide you with a good starting point to work from.
 
Rotator Cuff Strength
 
This is critical to maintaining good shoulder function and staying injury free as a swimmer.  The most obvious area that athletes look at is how strong they are in their rotator cuff but we are less interested in this than we are in scapular (shoulder blade) stability.
 
It is however important to have good rotator cuff strength in balance.  If you consider that most swimming utilises the front portion of the rotator cuff there is a tendency to weaken the back portion.  This does not negate the importance of weakness in the front but does mean the most common deficit we see is weakness of the lateral rotators of the shoulder which run over the back of the shoulder from the shoulder blade to the upper arm.  Secondary to this sometimes the primary internal rotator of the shoulder in the front of the joint is not sufficiently strong to undertake all the work asked of it by swimmers.
 
Most of our strength programs for swimmers then have a lateral rotation exercise as the mainstay.  This is easily done with a Theraband or other stretchy band held in both hands with the elbows at the sides and rotate the shoulders outwards keeping the elbows in.  Remember this must be a functional exercise towards swimming so must have higher repetitions of 15-20.
 
Scapular / Shoulder Blade Stability
 
As mentioned above this is where we identify most deficits and poor mechanics.  If the platform that the upper arm works from is not stable then the arm cannot be used well.  The shoulder blade must be positioned and controlled well during the swim stroke otherwise more irritation is created in the shoulder joint leading to swimmers shoulder.  This isn’t as simple as just rowing type exercises in the gym to strengthen the muscles that draw your shoulder back but requires a balance between the often neglected pushing type muscles controlling the shoulder blade.
 
Thoracic / Trunk Rotation
 
Without sufficient trunk rotation you must either rotate the hips further around with your body roll or have a flat body position requiring greater shoulder extension backwards or a round swinging arm during recovery.  Both of these mechanics increase the irritation of the rotator cuff and bursa at the shoulder.
 
Swim Technique
 
The most common technique flaws contributing to swimmers shoulder are:
Increased internal rotation of the shoulder with a thumb first hand entry.
Crossing over the arms at the front of the stroke.
A deep straight arm pull.
An S shaped pull.
 
If we identify any of these actions in video footage of a patient’s swim stroke we first identify if there is a biomechanical reason why this may exist and correct that deficit.  If the problem is more related to poor technique we encourage them to get swim coaching aimed specifically at technique.  We believe our role in this is to identify the biomechanical deficit and correct this but to utilise specialised swim knowledge to do the actual technique correction.
 
People often relate their thoughts to us around paddles provoking their shoulder pain and putting blame on the paddle use for the development of the injury.  This is slightly incorrect as the paddle merely unmasks the lack of strength and control at the shoulder and if anything we like to see people do a portion of their swim sets with paddles as it ensures they have sufficient strength to control shoulder movements through the swim stroke.
 
Signs and Symptoms
 
Non specific aching pain around the shoulder joint relating to swimming activity is usual.  It comes on with swimming and may persist after your swim session has completed.  The pain may increase  in the first half of the pull or during the first part of the recovery.  Mechanical symptoms of clicking etc are not usually present.
 
 
What You Can Do
 
Self Trigger Point
 
Trigger points are areas within a muscle that when pressed into produces pain distant from that site in addition to local tenderness where pressed.   These are regularly seen in the back of the shoulder  in swimmers either over the shoulder blade or just lateral to this closer to the shoulder joint.  Physiotherapy regularly targets these as they alter the shoulder mechanics and can limit rotation and reach.
 
You can treat these yourself by lying on your side over a tennis ball with the ball on a trigger point as described above.  You may have to explore the muscle a little to find them.  Putting the ball in an old sock so you can hold the ends of the sock to place the ball where you want in can help with positioning.  Remember to maintain the pressure on the trigger point until the pain eases and there is no referral of the pain away from the site.  This may take several minutes.
 
Stretches
 
The two most important stretches are the pectoralis minor and the latissimus dorsi.  Hold each stretch for a minimum of 20” and repeat 4 times.
 
Pectoralis Minor
Stand in the corner of a room with your elbows bent and hands immediately in front of the shoulders on the two walls.  Lean into the corner and pull your shoulder blades back feeling a stretch in the front of your shoulder / chest.
 
Latissimus Dorsi
Standing in a doorframe with your arms above your head lean forward with a straight back until you feel a stretch under the shoulder and down the side of the trunk.