Maintaining Shoulder Health

1. Maintaining Shoulder Health • For coaches?

2. The Hyper-mobile Shoulder Swimmers’ Blessing Swimmers’ Curse Steven Kalandiak, MD, Shoulder and Elbow Surgery University of Miami, Miller School of Medicine ASCA Conference Fort Lauderdale, FL, September 2009

3. Thanks • Google • Yahoo • Scott Rodeo, MD • Chair – USA Swimming Sports Medicine • George T. Edelman, MPT, OCS, MTC • http://www.usaswimming.org/USASWeb/DesktopDefault.aspx?TabId=451&Alias=Rainbow&Lang=en

4. Background • Elite competitive swimmers put their shoulders through millions of stroke cycles over the course of their careers.  • Michael Phelps – 80K/wk • 20 lap/K x 80K/wk x 50wk/yr = 80,000lap/yr • 80K x 13-14cycles/lap = approx 1M cycles/yr • Ouch!

5. Background • The Problem • The same hypermobile joints that allow elite swimmers to compete at the level they do also predispose them to overuse injuries. 

6. Background • Proper mechanics, appropriate therapeutic exercises, and rest and rehabilitation are not only essential to fast swimming, but are also important to maintaining shoulder health.  • This talk reviews the structure and inner workings of the shoulder joint, the injuries swimmers are likely to suffer, and the prevention and treatment of these problems. 

7. Incidence • McMaster and Troup - 1993 - 1262 US swimmers • Prevalence of interfering shoulder pain varied between 10% (age group) to 26% (national team) at any given time and increased with time in the sport. • 50 to 80% have training interrupted at some point in their careers.

8. Incidence • Wolf et al, 2009 - Injury data for University of Iowa swimming and diving team 2002-07 • 94 swimmers • 71% injury rate, 37% resulted in missed time • Shoulder/upper arm was the most frequently injured, followed by the neck/back • Increased number and risk of injuries in freshman • Conclusion: Give particular attention to swimmers making the transition to a higher level of training

9. Anatomy - bone

10. Anatomy – 17 muscles attached to scapula

11. Problem 1 – no bony stability

12. Ligaments – static stabilizers

13. Problem 2 – lax ligaments(collagen)

17. Anatomy – shoulder socket

18. Anatomy – shoulder joint

19. Anatomy – rotator cuff

20. Anatomy – rotator cuff

21. Anatomyscapular stabilizers and principal movers

22. Anatomyscapular stabilizers and principal movers

23. Anatomic causes of shoulder pain • Impingement/tendonitis • Internal impingement • SLAP tear • Anteroinferior instability

24. Impingement/tendonitis

25. Impingement/tendonitis

26. Internal Impingement

27. SLAP tear

28. Anteroinferior Instability

29. Causes of shoulder pain • Multifactorial • Impingement, laxity, instability and labral pathology can all coexist in the same shoulder • Maladaptive movement patterns (scapula) can also coexist

30. Swimmers’ painful shoulder arthroscopic findings and return rate to sports • Brushøj, Bak et al, 2006 • Eighteen competitive Danish swimmers had arthroscopy fortherapy-resistant shoulder pain. • Most common findings at arthroscopy was labral pathology in 11 (61%) and subacromial impingement in 5 (28%). • Nine swimmers (56%) returned to preinjury competition level. • Findings suggest that ‘‘Swimmer’s shoulder’’ covers a variety of pathologies including labral wearing and subacromial impingement. • Arthroscopic debridement of labral tears or bursectomy has a low success rate with regard to return to sport. • Scapular dyskinesias were common in this patient group.

31. Mechanisms of injury • Training (yardage/intensity) • Repetitive microtrauma • “acquired capsular laxity” • ?? Incorrect stretching ?? • Muscle imbalance • Flaws in technique

32. Training (yardage/intensity) • Rapid increase in training distance, intensity or frequency problematic • Pressing on past the point where technique fails either reinforces poor mechanics or causes injury (or both) • Go slow – increase only one per week • Elite athletes need months to years to achieve full fitness

33. Repetitive microtrauma • “acquired capsular laxity” • when baseline laxity increases, it can become pathologic • ?? Can incorrect stretching contribute??

34. Repetitive microtrauma • 1,000,000 stroke cycles a year! • Repeatedly moving through unbalanced shoulder positions can further stretch already loose tissue, creating pathologic instability • Improper mechanics (poor technique or technique breakdown due to fatigue) can worsen this • Could inappropriate (capsular) stretching also contribute to excess laxity? • (Edelman at USA Swimming)

35. Why do we stretch? • Tradition, emulate others • Injury prevention (little real proof) • Relieve muscle soreness • Loosen tight muscle groups • (correct unbalanced joints)

36. Inappropriate stretches?

37. Appropriate stretches • Doorframe stretches (Pectoralis)

38. Latissimus stretch

39. Levator/trapezius stretch

40. Muscle imbalance • Flexibility – Pectoralis and Latissimus tight > • external rotation difficult • Strength – large propulsive adductors and internal rotators vs. abductors and external rotators • Endurance – serratus and subscapularis prone to fatigue > scapular dyskinesia • rotator cuff fatigues faster than large muscle groups > instability > worsening laxity

41. Scapular dyskinesia

42. Flaws in technique or training • Poor body roll • Crossing midline • Too straight elbow during pull • Persisting in the face of failing mechanics • ?? Unilateral Breathing ?? • ?? Hand Paddles ??

43. Poor body roll Scapular plane swimming

44. Poor body roll

45. Crossing midline

46. Arm too straight during pull • Also fingertips not toward bottom, arm timing wrong

47. Pressing on when mechanics fail • Reinforces poor, rather than excellent technique • Puts joints at risk of injury • fatigue accentuates muscle imbalances • scapular control and joint stability decline • Switch stroke, drill, or kick instead

48. ? Unilateral Breathing ? • Bilateral breathe to improve stroke symmetry • ? increase body roll ? ? Hand Paddles ? An error in and of themselves, or do they just aggravate existing flaws ?

49. Nonsurgical treatment • First, second and third line treatment • “You can always operate – • you can never un-operate”

50. Nonsurgical treatment • DO NOT swim through the pain • (But ok to swim with it if mild) • relative rest - vary strokes, • decrease intensity and yardage • NSAIDS, ice when aggravated • gradually re-increase workouts