There has been some correlation found between the propulsion
phase, (entry to mid pull) and the recovery phase of the stroke
to shoulder pain (King 1985). Technical flaws such as dropped
elbow in the early pull phase (Popov, 1991) and increased body
sway are significant indicators of potential problems. Fig
5. Illustrates a high elbow pull. An initial pull phase that
presses down on the water with a straight arm (Fig, 6) is a
major cause of tendinitis in the shoulder.
Arm recovery is another important factor. The arm should recover
over the water in a laterally orientated position (Thumb or
back of the hand first). By recovering in a laterally rotated
position the possibility of swimmers shoulder is reduced. Fig
7b. shows a correct recovery, thumb first. Fig 7a. shows a
incorrect recovery, little finger leading. An arm abducting
above the head in a medially rotated position will reduce the
Subacromial space and enhance the chance of impingement.
Fig. 8 (Canadian Amateur swimming
Association, 1977. Pg.44)
Butterfly hand entry and initial pull is the main cause of
shoulder tendinitis. Hand entry is thumb first, medially rotated.
A forceful entry or pressure down on the water in the early
stages of the pull is the prime cause of tendinitis in butterfly
swimmers. These principles are similar to that of Freestyle.
Swimmers must attempt a high elbow pull shown in Fig. 8. And
place the hands softly into the water.
Butterfly is an extremely fatiguing stroke to swim. Long sets
at reduced pace that allows stroke correction and skill practice
are extremely difficult. Long butterfly sets are almost impossible
with poor technique. It is difficult to improve Butterfly technique
as the stroke can only be practiced in short bursts. Frequently
Butterfly sets are included to add intensity to a training
session. If poor technique is apparent the swimmer is liable
to develop tendinitis.
If poor technique is the prime cause of swimmers shoulder
then it would appear that the responsibility lays with the
coach. It is the coach’s responsibility to correct poor
technique. However the underlying responsibility for poor technique
lies with muscular imbalances and the swimmer’s inability
to swim with correct shoulder position.
The external rotators are important muscles throughout the
swimming cycle. Their role is to position the arm so that the
muscles of propulsion the internal rotators, triceps and biceps
can generate force across a longer and more mechanically advantageous
sweep. In addition during the recovery phase the lateral rotators
are required to neutralise medial rotation of the arm for optimal
entry position.
Fatigue or dysfunction of the lateral rotators muscles will
increase the likelihood of injury and will reduce performance.
If the lateral rotators cannot neutralize the excessive internal
rotation of the propulsive muscles then impingement is likely.
Likewise fatigue or disfunction of the humeral head depressors
(infraspinatus, teres minor and teres major) during the early
pull phases can cause impingement. If these muscles fail to
stabilize the humerus in the glenoid cavity the humerus will
move within the socket and cause impingement. Despite the joints
flexibility the humerus has minimal slide or displacement within
the articulation. When translation (a small sublaxation, or
dislocation) occurs the risk of impingement is greatly increased
(Sharkey & Marder 1995).
The impingement of the supraspinatus and the long head of
the biceps tendons causes hypovascularity and ischemia (Archambault
et al 1995, Bloomfield et al 1995). Hypovascularity is defined
as a lack of sufficient blood vessels in a particular area.
ischemia, a lack of sufficient blood to the area. The lack
of blood leads to a weakening of the tendons and a lack of
nutrients. This results in reduced lubrication. The avascular
nature of these tendons magnifies the reaction and decreases
regenerative capacity.
Incorrect swimming technique is the main cause of tendon impingement.
Genetics plays a roll. Acromion processes that protrude lower
than normal can cause tendinitis in non swimmers. This can
only be corrected with surgery. Individuals that have extremely
flexible shoulder joints are predisposed to sublaxation (a
minor dislocation) in any direction during every stroke. The
dislocation causes or allows the humerus and the scapula to
press together and reduce the subacromial space. The tilt of
the scapula as it moves in relation to the scapulothoracic
articulation will also have the effected of enhancing impingement.
Swimmers train up to 20km per day, the number of repetitions
of the stroking action of a competitive swimmer is immense.
If this volume of work is conducted with poor technique then
an over use injury is inevitable.
Sharp increases in training volume and intensity can also
cause tendinitis. With sharp increases the body has little
time to adapt. The fatigue that this causes may cause technique
to falter causing impingement. Excessive increases in volume
or intensity may also exacerbate existing technical flaws and
causes injury (Fowler 1995). Coaches often use Butterfly as
a means of increasing intensity. Poor butterfly technique is
a cause of impingement. This factor is compounded by the increase
in intensity of the training.
The overuse of hand paddles have also been associated with
swimmer’s shoulder (Harding 1989). The increased force
that is placed on the shoulder joint can cause excessive fatigue,
that in turn can cause a change in technique. The additional
force that hand paddles exert during the pull phase can also
exacerbate existing problems.
Symptoms
The main symptoms of swimmer’s shoulder are shoulder
pain associated with swimming, either felt on the arm recovery
or the early stages of the pull. Often the swimmer compensates
for the pain by altering the recovery action. This manifests
itself by swinging the arm round with a low elbow. This accentuates
the impingement (Allergic, Whitney & Arguing, 1994).
Other signs include a painful arc on the abduction/elevation
of the arm. A positive impingement sign is a pain felt when
the arm is brought forward across the chest, and then internally
rotated. This action will cause impingement and produce local
pain (Hoerner & Vinger 1986).
Pain is an excellent indicator of an impingement injury. However
the athletes mentality or attitude to pain is important. Most
athletes and a large number of coaches believe in the slogan
no pain no gain. Often the athlete is reluctant to admit to
pain or an injury that will upset their training schedule.
Talking to the athlete and making swimmers aware of potential
signs is important. Often the first a coach will know of a
shoulder problem is the swimmer complaining at the end of a
hard set. Coaches should observe their swimmers in rest periods.
Swimmers unconsciously holding their anterior Deltiod or doing
a range of erratic shoulder stretches that often indicates
discomfort.
The impingement symptoms are a late development of the injury.
The pain is caused by restrictions placed on the rotator cuff
tendons by the surrounding structures of the coraco-acromial
arch and the space between the acromoin process, acromioclavicular
joint, the neck of the scapula and the acromioclavicual ligament
(Harding, 1989).
Inflammation in this already restricted cavity leads to further
impingement of the supraspinatus tendon, long head of the biceps
and the sub-acromial bursa. This space can also be compromised
due to oedema in the supraspinatus tendon, or the growth of
bony spurs (Margary & Jones, 1994).
Rehabilitation of the injury is slow due to the avascular
nature of the tendons. If the tendon has become inflamed and
the space compromised the bursa may of became irritated and
inflamed. Repeated irritation of the bursa will cause scaring
and a long term narrowing of the subacromial space. This narrowing
of the subacromial space will predispose the swimmer to further
impingement and lengthen rehabilitation (Allergic, Whitney & Arguing
1994).
Diagnostic Tests:
Palpation of the area to determine the severity of the injury
is useful. Mild impingement is characterized by a slight response
to pain in the offending arm. A slightly more severe injury
will produce definite pain. If the swimmer is apprehensive
at the beginning of palpation, pain is felt and there is a
slight withdrawal this could be classified as a grade 2. A
grade 3 injury would consist of a swimmer that could not tolerate
slight pressure and withdraw.
Observing the athlete as the swimmers are asked to lift their
arms to the side of their chest. The affected shoulder will
shrug up half way through the lift. If the arm action is slow
and appears difficult this is a good indicator.
The swimmer could also be tested on a swim bench or on stretch
cords. The swimming stoke is mimicked. If pain is felt in the
early part of the pull then impingement is likely.
Dry land manipulation of the swimmers recovery action is also
a good test. If when mimicking the recovery action with the
humerous internally rotated there is pain but this is reduced
when the humerus is laterally rotated then this is strong indicator
of late stages of tendinitis (Magarey & Jones 1994).
Treatment
Prevention is better than cure. However even with preventative
measures tendentious can still happen. Treatment would reflect
the severity of the injury. As a preventative measure and as
treatment, stretching of the major propulsive swimming muscles
and strengthening of the shoulder girdle stabilizers is required.
The underlying causes of the injury must be addressed. These
factors are the causes of the poor technique and are typically
poor flexibility and muscular imbalances.
Initial or instant treatment would include changing the training
regime of the swimmers. Mild or slight discomfort could be
explained by an increase in training load. This could be due
to an increase in volume, intensity, or additional stress on
the joint. This could be caused by an increase in the use of
hand paddles, or a change in stroke priorities that have increased
the percentage of the more demanding strokes, butterfly and
freestyle.
To avoid or treat this mild injury a reduction in over-load
is required. This may include reducing volume and or intensity.
The use of hand paddles or pulling drills must stop or reduced.
A reduction of the volume of Freestyle and Butterfly swam is
also beneficial. Alternatives are more Backstroke, Breaststroke
and kicking drills (Trembley 1995). However this is not always
practical as increased load often occurs in the competition
phase of the season. To start to reduce the amount of Butterfly
for a swimmer who specializes in Butterfly is not ideal. Drill
work can be used, kicking, splitting main sets up with alternative
strokes and limiting specialized strokes to quality set is
preferable (Blanch 1996). Emphasis should be placed on a long
warm up and cool down and focus should be placed on correct
technique. Icing after swimming session is also an alternative
(Booher & Thibodeau, 1994). However the answer lies in
prevention not cure.
More severe pain is normally caused by late reaction to the
early signs of swimmers shoulder. This can be deliberate if
the swimmer is due to compete in the years most important competition.
However volume and intensity must be reduced. Focus must be
placed on technique. Anti-inflammatory medication could be
used, panadole is a mild pain killer and Asprin is a mild anti
inflammatory (Ciullo, 1986). Referral to a physiotherapist
is advisable, treatment could include ultrasound, laser therapy
and inferential / electrotherapy).
With grade 3, or severe injuries no swimming is recommended.
Preventative measures should be used to re-build the mechanics
of the stroke. Referral to a physiotherapist is necessary.
Anti-inflammatory medication is used, and in severe cases Corticosteroid
injections and surgery may be necessary (Strenlund, 1993).
However when elite swimmers are close to competition stopping
or reducing training is not an option. All other injury prevention,
and treatments should be maximized first.
Taping is also a possible treatment. Various results have
been reported (Host 1995). The aim of tapping is to drag the
scapula down away from the humerus. The tape helps the shoulder
girdle adductors and depressors by pulling the scapula into
an adducted and downward rotated position. This helps increase
the subacromial space. Host (1995) reports that taping should
relieve pain immediately. However other reports have reported
relief from pain in daily activity but ineffective whilst actually
swimming (Magarey & Jones 1994). Taping and swimming are
often not compatible. The tape has to survive 2 hours plus
water time, with multiple repetitions. Secondly the range of
motion the swimmer requires is restricted and this feels highly
uncomfortable (McConnell & Allingham 1993).
Again it is worth noting the competitive swimmer’s mind
set. Most elite or highly competitive swimmers would know the
consequences of swimmers shoulder. The swimmer will often swim
through excessive pain before admitting shoulder pain. Swimmers
and uninformed coaches often proclaim no pain no gain. Shoulder
pain can finish a swimmers career. However if treated early
shoulder pain will have a minor impact on a season. Swimmers
must be encouraged to admit to pain, and to communicate with
the coach.
Severe and prolonged cases lead to fraying of the supraspinatus
tendon. Arthroscopic surgery is often required. Server or prolonged
impingement is relieved by scraping away of the underside of
the acromion process. This increases the subacromial space.
Surgery prolongs rehabilitation and is not ideal (Strenlund,
1993).
X-rays give little indication of soft tissue injuries, MRI’s
are a better indication, but very expensive. X-rays however,
do show calcification in the joint, severe swelling, and allow
determination of the distance between the acromion process
and the head of the humerus (Strenlund, 1993).
Prevention
Prevention is the answer. There is no one cure, preventative
measures are required from the beginning to the end of a swimmer’s
career.
Screening is the first and most obvious preventative measure.
Individuals with the following conditions are predisposed to
swimmer’s shoulder: round shoulders, lordosis, kyphosis,
dropped or raised shoulder, muscle imbalances, winged scapula,
weak external rotators.
These swimmers need to take special care. If the condition
is functional then the help of physiotherapy should be used
to correct the condition before training load is too excessive.
If structural the best regime should be to implement a program
that will reduce as much as possible the chances of developing
swimmers shoulder. Appendix 1 indicates exercises that will
aid injury prevention.
Screening should be performed by a qualified physiotherapist.
The majority of competitive squads and coaches would have a
team physiotherapist. If this is not possible or the expense
too great the coach or a sport scientist can perform some basic
tests to identify conditions that predispose swimmers to injury.
Standard postural tests such as the New York Posture test can
identify postural deviations. These tests require a vertical
plumb line, and a horizontal line and a flat wall. These test
can be used to identify lordosis, scoliosis, unequal shoulder
height, unequal hips and winged scapula. This is not a comprehensive
list of tests. However with a little training these tests can
be used to great effect.
Peter Blanch (1996) Australian Swimming Team Physiotherapist
has suggested the following tests to be conducted by a physiotherapist
or trained examiner:
Combined elevation, this is a test of the thoracic spine extension
(strength and range of motion), extension, and the ability
to draw the shoulder blades back. See fig 9. The athlete lays
prone with both arms elevated above head. They are asked to
lock thumbs together and maintain their elbows in an extended
position. The athlete lifts the arms as high as they can while
keeping their head, chest and leg in contact with the bench.
The angle should be measured from the line of the humerus and
the horizontal. A good range is 5-15 degrees. A good range
is important for good swimming technique.
Fig. 10. (Blanch, 1996. Pg. 34.)
Fig. 10. (Blanch 1996. Pg. 34.)
Glenohumeral Internal and external rotation,
this test is designed to measure internal and external rotation
of
the shoulder
joint. The test requires two examiners. The athlete lays
prone on a bench. The arms are at 90 degrees to the body,
with the
elbows bent. The lower arm should be hanging over the
bench. Examiner one stands at the athletes side to support
the
upper arm from below with their fists. The examiner holds
the shoulder
into retraction and applies downward pressure. The athlete
is told to maintain contact with the examiner’s
fist, keeping the elbow at 90 degrees flexion and without
pushing
the examiners top hand.. The athlete is required to rotate
the arm forward and then rotate the arm back. The angle
is measured by the second examiner is the line of the
lower arm
to the vertical. 80-110 degrees is optimal for external
rotation, 40-50 degrees for internal rotation. A good
range of external
rotation is necessary for good swimming techniques fig
10.
Fig.11 (Blanch 1996. Pg. 35.). Abduction with internal rotation; this is to assess if a good
range of motion exists to perform a high elbow recovery. The
swimmer sits on a bench, tester abducts the swimmers arms with
the elbows maintained in 90 degrees of flexion. Ensure that
the forearms are perpendicular to the plane of abduction. As
the arms are elevated they will internally rotate. The angle
should be measured from the humerus to the vertical line of
the body. A good range for this measure is greater than 150
degrees. See fig. 11.
This is by no means an exhaustive list of tests for the shoulder
joint however these tests should identify problems before they
manifest themselves into injuries.
Flexibility and core or trunk strength is also important in
preventing swimmer’s shoulder.
The propulsive muscles used in swimming are trained and placed
under load every stroke. These muscle also cause internal rotation.
Excessive internal rotation is a major contributor to shoulder
impingement.
The major upper body propulsive muscles are Anterior and Middle
Deltoid, Latissimus Dorsi, Pec Major, Teres Major, Triceps
and Subscapularis.
Due to the dominance of these muscles the antagonistic muscle
groups are likely to be stretched and lose power. These muscle
are Infraspinatus, Teres Minor, Rhomboids, Lower Trapezius.
These muscles must be strengthened. Traditional methods have
strengthened these muscles contraction force in relation to
their entire range of motion from their origin to insertion
(Blanch 1997).
However recent research has indicated that the muscles need
to be strengthened as they are used, that is as stabilizers
(Blanch 1997). The muscle’s strength is not only the
important factor, endurance is necessary (Chek, 1997). These
muscles must act as stabilizers for two hours of training twice
a day.
The swimmers are required to relearn scapular control during
swimming. The swimming action of a competitive swimmer has
been performed many thousands of times. Relearning the skill
in a slightly different manner is therefore difficult. However
scapula control is vital if the scapular is to be held in a
retracted position.
Blanch (1996), has detailed strength exercises that are specific
in achieving this aim. These exercises are shown in appendix
2. The exercise goals are also consistent with the treatment
method of taping, that is to hold the scapula in a more adducted
and depressed position whilst performing movement.
Stretching is another important preventative measure. Stretching
the prime movers of the propulsive action of swimming is important
for good technique and thus shoulder impingement. The shortening
and strengthening of the prime movers will cause muscular imbalances
and poor scapular control. The stretches that are beneficial
for stretching the upper bodies propulsive phase Agonists are
included in appendix 3.
Early identification of swimmer’s shoulder is another
important factor in injury prevention. The swimmers should
be educated to identify shoulder injury as important and the
coach should be able to identify the incorrect technique that
causes impingement.
These technique flaws include:
1] No high elbow pull, elbow dropping in early stages of the
pull.
2] Externally rotated humerus on recovery, little finger leading.
3] Insufficient roll in the pull phase of the stroke.
4] Over extending of the shoulder joint after hand entry.
5] Hand pushing down and passed the center line of the body
during initial catch.
The coach must emphasis correct technique, and identify errors
(Volkers, 1997).
Training load, must be planned and prescribed in manageable
increases in intensity and volume. Excessive increases will
place swimmers at risk. Adequate recovery and rest is required
(Richards, 1996).
Training session design, drills, kicking and alternative strokes
can be used to break up large blocks of freestyle and butterfly
(Volkers 1997). Limited use of hand paddles and gradual overload
when using them is necessary (Richards, 1996).
Conclusion.
Swimmers shoulder is preventable in the majority of cases.
Prevention measures such as screening, stretching and strengthening
core muscles is advisable. Correct or even muscle balance will
not only reduce impingement but improve stroke technique.
Stroke technique is a vital factor in the development of swimmer’s
shoulder. Coaches should design programs that spend time on
developing good technique. Large blocks of Freestyle and butterfly
should be avoided. Hand paddle use should be conservative with
swimmers who have less than a perfect technique, and avoided
with swimmers predisposed to impingement.
Program design should progressively over-load in steps that
are inline with a swimmer’s capacity to adapt. Sufficient
recovery is necessary.
Finally education plays a big part, coaches and swimmers must
be aware of the importance of identifying and treating swimmer’s
shoulder early. The swimmers and coaches “no pain, no
gain” attitude to training is not correct in relation
to swimmer’s shoulder. Pain could mean the end of a swimmer’s
career.
Appendix 1: Exercises
for Educating Scapular Retraction
Appendix 2: Stretch
Sheet For: Upper Body Propulsive Muscles Used In Swimming
Bibliography
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