Inflexibility in the shoulders and anterior chest wall could indicate a strength imbalance. Classic weight training has focused on the anterior chest wall and internal rotators, while external rotators and supportive muscles may have been underdeveloped and unable to stabilize the shoulder. This inflexibility of shoulder musculature may also lead to impingement pain.
Many competitive swimmers often train and compete year-round and very intensely. Elite swimmers often swim up to 11 two-hour workouts per week (Johnson et al., 2003). In addition to pool workouts weight training may be added to the training schedule. Typical daily training distances average between 10,000 to 20,000 yards. The average of eight to ten arm cycles per 25 yards would put the swimmer at over one million shoulder rotations per week (Johnson et al., 2003). This overuse puts swimmers at risk for shoulder injuries.
A major cause of shoulder problems for swimmers is the impingement of the subacromial structures. Identification of impingement has led to determining the technical causes of this shoulder injury. Further analysis of shoulder movements may be able to help the swimmer reduce the risk of developing shoulder impingement by altering the stroke technique (Yanai & Hay, 2000). A study involving 11 male collegiate swimmers who underwent boundary range of motion testing procedures was conducted to distinguish shoulder configurations that indicate impingement. Three characteristics of stroke technique placed swimmers at high risk for experiencing shoulder impingement. The first was a large amount of internal rotation of the arm during the pull phase. The second was a late initiation of external of the arm during the recovery phase. The third characteristic was a small amount of tilt angle, which is an affect of the scapular elevation/abduction on one side and scapular depression/adduction on the other side. Each subject experienced impingement in some of the stroke cycles but avoided it in others. The researchers indicated that there are specific shoulder actions used in each stroke phase, which either induced or prevented shoulder impingement. The researchers suggested that stroke technique accounted for the individual’s susceptibility to shoulder impingement and not just anatomical differences (Yanai & Hay, 2000).
While training competitive swimmers, the occurrence of shoulder pain which interferes with training or progresses during training are important. Although the occurrence of shoulder conditions in swimmers has not been extensively surveyed it is assumed to be common. One study reported on three groups of competitive swimmers where questionnaires were administered to 1,262 subjects that gathered training profiles, types of training and questions regarding shoulder pain.
The survey revealed common responses for training activities that aggravated current shoulder pain such as stretching, tubing resistance exercises, kicking drills using flotation boards, weight training and hand paddles. The results of this study showed that as the skill level and age of swimmers increases so did the percentage afflicted with interfering shoulder pain (McMaster & Troup, 1993). This may indicate that the more training a swimmer has undergone, the likelihood to develop a shoulder injury increases.
Although a number of rehabilitation programs for swimmer’s shoulder have been reported in literature nonoperative treatment has generally been favored. A case study was conducted on the effectiveness of treatment interventions and the in-season management of a NCAA Division I swimmer with unilateral shoulder pain. The 22-year-old swimmer had a history of left shoulder pain and was diagnosed with tendonitis of the long head of the left bicep. It was from the clinical assessment that a direct treatment was generated. The author hypothesized that the athlete had anteriorly subluxed her shoulder and developed rotator cuff tendonitis from overusing the rotator cuff to stabilize the humeral head (Russ, 1998). The treatment approach was team coordinated and used previously prescribed protocols such as medication and physical therapy, as well as the adding and elimination of different exercises. Exercises to strengthen the scapular stabilizer muscles in order to facilitate cocontraction around the glenohumeral joint were substituted for the athlete’s previous dumbbell exercises for external rotation and cardinal plane flexion and abduction. Also part of treatment was a rest period for the irritated cuff musculature and strengthening of the scapular stabilizers. Kicking workouts were performed during practice and treatment focused on symptomatic relief. This case study described the management of a collegiate swimmer with shoulder pain during a competitive season and how an individualized clinical hypothesis and treatment plan led to substantial progress where shoulder pain was eliminated (Russ, 1998).
Another case study found similar results also utilizing physical therapy, medications and strengthening exercises for the rotator cuff and scapular stabilizers. A 14-year-old female swimmer was diagnosed with a left sided impingement, which included a multidirectional instability weakness of the rotator cuff and scapular stabilizers (Koehler & Thorson, 1996). An evaluation of technique and a modified workout plan was constructed through a consultation by a collegiate swimming coach. Kickboard pool workouts made up the shoulder rest period and strengthening exercises for the rotator cuff and scapular stabilizers were added to the training. A gradual progression back into regular workouts with less overall yardage and regular rest periods took place over a 3 week period. Stroke modification was also implemented in order to lessen the impingement by not crossing the midline with the hand during the pull through stroke and lowering of the elbow in the recovery phase. The swimmer was able to achieve personal best times without interference of shoulder pain in the remaining two months of the season (Koehler & Thorson, 1996).
A number of stroke flaws can contribute to shoulder pain in swimmers such as a hand entry that crosses the midline of the long axis or a crossover entry. Both attribute to the impingement in the anterior shoulder, including the long head of the biceps and the supraspinatus (Johnson, 2003). A proper body roll may however resolve the impingement unless the athlete has glenohumeral instability or anterior capsular laxity and concomitant anterior sublaxation (Johnson et al., 2003). Shoulder injuries may be prevented or treated through core stabilization and then by scapular stabilization because the most prominent weakness seen in swimmers with shoulder pain is in the serratus anterior and increased activity of the rhomboids during the pull. The impingement may be increased because of the mechanical imbalance or “floating scapula” (Johnson et al., 2003).
By carefully following an athlete’s condition and by testing the efficiency of a treatment plan it may be possible to change the athlete’s condition. Furthermore, the timing of intervention can have a significant impact on the formulation of the treatment plan depending on where in season the athlete experiences shoulder injury.
An appropriate prevention of swimmer’s shoulder is critical in all intense training programs. In order for the overuse syndrome not to interfere during midseason, a good preventative plan in preseason may be effective (Koeler & Thorson, 1996). The integration of functional exercises into a preventive training program could improve neuromuscular control and force-couple coactivation, as well as decrease the incidence of shoulder pathology (Swanik, Swanik, Lephart, & Huxel, 2002). A study to test the effect of a functional training program on shoulder pain was conducted using intercollegiate swimmers.
The Biodex II Isokinetic Dynamometer test was administered before and after a six week training period. The training period consisted of swim practice six days a week and dry-land training three days a week. The dry-land practice included upper and lower body weight training, cardiovascular training, and lower extremity plyometrics. The isokinetic testing consisted of internal and external rotation, scapular protraction and retraction, and a diagonal pattern where 10 repetitions with a 90 second rest in between were completed for each maximal test. Through out the six week training period an athletic trainer recorded the incidence of injury for both the experimental and control groups. The athletes that where experiencing shoulder pain continued with only the lower body training and kicked with their arms by their side during pool training until the athlete was without pain above 90° of shoulder abduction. The functional training program carried out by the experimental group was performed three days a week for six weeks in a row. The program consisted of seven exercises, four of which used elastic –tubing, two where prone exercises utilizing free weights for resistance and the last exercise was a push-up-plus.
There was no significant difference between the groups but a significant difference within-group increases (Swanik et al., 2002). The results of this study suggest that incorporating functional training exercises into the swimming season could decrease the incidence of shoulder pain.
The shoulder is injuries in competitive swimmers have individual circumstance which bring forth unique problems. There is a need for further research investigating the cause of swimming related shoulder problems specifically related to stroke mechanics and overuse. In order to prevent the muscoloskeltal injuries the area of causation needs to be targeted. Training methods for the shoulder complex of the swimmer also needs further research in order to prevent any subsequent training injuries. Keeping the swimmer in the water is a crucial component to a successful season. Good communication among the swimmer, coach, athletic trainer, and physical therapist are key in rehabilitating the injured swimmer. Each individual case may vary and the communication between the athlete and all persons involved are critical when implementing a prevention or rehabilitation for swimming related shoulder injuries.
BIBLIOGRAPHY
Johnson, J. N., Gauvin, J., Fredericson, M. (2003). Swimming Biomechanics and Injury Prevention. Physician & Sportsmedicine, 31(1), 41-47.
Koehler, S., & Thorson, D. (1996). Swimmer’s shoulder: Targeting treatment. The Physician and Sportsmedicine, 24(11), 39-50.
McMaster, W. (1999). Shoulder injuries in competitive swimmers. Aquatic Sports Injuries and Rehabilitation, 18(2), 349-359.
McMaster, W., & Troup, J. (1993). A survey of interfering shoulder pain in United States competitive swimmers. American Journal of Sportsmedicine, 21(1), 67-70.
Russ, D. W. (1998). In-season management of shoulder pain in a collegiate swimmer: A team approach. The Journal of Orthopedic & Sports Physical Therapy, 27(5), 371-376.
Swanik, K. A., Swanik, C. B., Lephart, S. M., & Huxel, K. (2002). The effect of functional training on the incidence of shoulder pain and strength in intercollegiate swimmers. Journal of Sport Rehabilitation, 11, 140-154.
Weldon, E., & Richardson, A. (2001). Upper extremity overuse injuries in swimming. Clinics in Sports Medicine 20(3), 423-438.
Yanai, T., & Hay, J. G. (2000). Shoulder impingement in front-crawl swimming: Analysis of stroking technique. Medicine and Science in Sports and Exercise 32(1), 30-40.
