Abstract

Management of shoulder problems in swimming

Shoulder pain and injuries are common in swimming since over 90% of the propulsive power in swimming comes from the upper extremity. Contributing factors for swimmer’s shoulder are felt to include 1) overuse and subsequent fatigue of the muscles around the shoulder, scapula, and upper back, 2) glenohumeral laxity, and 3) the mechanics of the swimming stroke, in which impingement can occur in various positions during the swimming stroke. Other associated findings include muscle imbalances and inflexibility, such as tightness of the pectoral muscles, and sometimes inflexibility of the posterior rotator cuff and posterior capsule. Because of their continuous activity during the swimming stroke, the serratus anterior and subscapularis are susceptible to fatigue Although muscle fatigue and/or shoulder instability with excessive glenohumeral translation can by themselves cause pain, it is likely that some element of impingement and subsequent rotator cuff tendinitis is the final common pathway causing shoulder pain in swimmers. Impingement may be caused by the particular mechanics of the swimming stroke as well as altered glenohumeral kinematics due to muscle fatigue and/or glenohumeral laxity. Recent studies demonstrates supraspinatus tendinopathy in swimmers with shoulder pain.

As in any injury, an accurate diagnosis begins with a careful history and examination. A comprehensive examination is performed with specific attention to glenohumeral laxity, strength of the rotator cuff and periscapular muscles, impingement signs, localizing tenderness, labral signs, and signs indicative of acromioclavicular joint pathology. Insight into the cause of pain may be gained from careful analysis of the swimming stroke. MRI may demonstrate thickening of the capsule (supporting evidence of previous instability episodes) and signal change in the rotator cuff consistent with tendinosis (suggestive of tendon overload). Diagnostic injection may be helpful to confirm the source of pain. Treatment begins with relative rest, avoidance of strokes and training exercises that exacerbate the pain, use of ice, and a short course of NSAIDs. Modalities such as electrical stimulation and ultrasound are useful to control pain and inflammation in the initial treatment phase. The most important part of the rehabilitation program is identification of any deficits in muscle strength, endurance, balance, and flexibilty. 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.

Prevention is the most important factor in management of shoulder pain in swimmers. A comprehensive program to develop strength, endurance, balance, and flexibility of the muscles is recommended. These exercises address three important areas: 1) the rotator cuff, 2) the muscles that stabilize the scapula, and 3) the muscles of the low back, abdomen, and pelvis that make up the “core” of the body. A comprehensive program for the shoulder and periscapular muscles is required, with emphasis placed on endurance training/strengthening for the serratus anterior, rhomboids, lower trapezius, and subscapularis.