Swimmer’s Shoulder: Assessment, Treatment and Prevention

1. Swimmer’s Shoulder: Assessment, Treatment and Prevention Marketing Submission Project EIM 105_4 Upper Extremity Team Bravo

2. Outline • Define what “Swimmer’s Shoulder” is and some symptoms of its’ presentation. • Review some of the more common risk factors that cause this condition, and how these factors present in swimming. • Describe how a PT would assess for this condition in the clinical setting. • Describe what a PT could do to treat this condition • Review what coaches, trainers, and athletes can do to prevent the development of swimmer’s shoulder in the future.

3. Definition • “Swimmer’s shoulder” is an umbrella term for a painful presentation due to repetitive impingement of the shoulder in swimmers. 1 • This condition is thought to be due to multiple pathologies including: • Subacromial impingement • Tendinopathyof the rotator cuff and long head of biceps, • Shoulder instability, • Possible labraltear, or • AC joint pathology 2

4. What is meant by “impingement”? • Normally shoulder movement relies on muscles to both move the arm and stabilize the humeral head within the center of the joint. • Primary impingement occurs through repetitive overhead activity (ie swimming) which narrows the subacromial space, and can result in tendon injury.3 • Secondary impingement occurs when there is too much mobility within the shoulder joint from excessive motion and weak support muscles, which if it happens excessively can also cause impingment.4

5. Common Reported Complaints • The athlete will complain of pain in the subacromial region (ie front and lateral side of shoulder). • No single event precipitating.4 • The pain is usually low or not present when starting the swim, but worsens with repeated use in swimming.4

6. Common Reported Complaints • Swimmers can spend up to 80% of time in freestyle no matter what stroke is used competitively5 • In freestyle, the highest incidence of pain reported during mid pull through of with arm in the water • Pull through phase places high stress on RTC and supporting scap stabilizer muscle groups5

7. Incidence • In monitoring the injury pattern of Division I collegiate swimmers, Shoulder/upper arm was most frequently injured body part: 31% of injuries for males, 36% of injuries for females. • Shoulder was also most frequent injury to result in lost time. 6 • In one study, 55% of the shoulder injuries in the female athletes occurred during swimming related activities, but only 9% occurred during cross training injuries. 6

8. Risk Factors • There are a multitude of both intrinsic and extrinsic factors that may influence the development of Swimmer’s Shoulder. • Extrinsic factors include: • Training volume—absolute and sudden increases • Technical errors in performance of stroke • Use of hand paddles “The main factor in the development of a swimmer’s shoulder seems to be the high training where swimmers are subject to early fatigue due to the high training volume.” 7

9. Risk Factors • Intrinsic factors include many structures that a physical therapist will assess and possibly treat. They include: 7 • Posture increased thoracic kyphosis, • Excessive laxity/general joint hypermobility • Scapular dyskinesia • Core stability • Rotator cuff muscular imbalances • Lack of flexibility/stiffness in the shoulder, cervical, and thoracic spine.

10. Risk Factors • Also, a past history of a traumatic injury to the shoulder, such as a dislocation, fracture, or fall, may be reported more frequently in the groups with shoulder complaints.8

11. Assessment • A physical therapist can provide a comprehensive examination that may include assessment of the following: • pain and disability through interview and questionnaires • posture • ROM and strength assessment • palpation and manual assessment of bones, joints and soft tissues, • special testing that may help in identification of what structures in the shoulder are affected. 2

12. Interview and Questionnaire • Determine the location, severity, and duration of the reported pain. Record the aggravating and easing activities. • Record the functional restrictions both in swimming (length of time before pain, style of stroke which provokes, recovery time after completion of swim)7 and in general everyday activities. • Identify any other affiliated symptoms such as stiffness, weakness, locking, or giving way. • Generate a preliminary diagnosis as to structure or mechanic at fault to guide further testing.

13. Posture • It is not uncommon that swimmers will present with both a forward head posture and rounding of their shoulders. • This may also be affiliated with a rounding of their mid-back which is known as a thoracic kyphosis. • This adopted posture can increase the likelihood of impingement. 1

14. Scapular Mechanics • The scapula (shoulder blade) may present as winging out , and during active movement its’ expected mechanics may be altered. This is defined as scapular dyskinesia. • The scapula may present with increased angulation and forward position, which can lead to reduction in the subacromial space and increased risk of primary impingement. • The presence of scapular dyskinesia may due to altered posture and/or muscle imbalances. 1,9

15. Range of Motion • Range of motion is assessed to see if there is any restriction or excessive movement which may alter the swimming pattern. • A small weight may be added to evaluate the swimming stroke on land, and see if an inappriote movement pattern develops. 8

16. Strength • Muscle imbalances may alter overall posture and change the position of the scapula: • Muscles that tend to become weak (example: rotator cuff, lower trapezius and serratusanterior) are assessed for both their strength and endurance.

17. Core Stability • Strong core muscles not only stabilize the low back, they also provide better transfer of forces. • Core weakness may contribute to upper extremity overuse injury. 1,8

18. Further testing • Further passive testing in and around the shoulder joint will be performed to selectively test specific muscles, tendons, ligaments and the joint itself.7 • Passive assessment of the neck, mid-back, and elbow may also be warranted.

19. Treatment • A physical therapist will implement a wide range of different treatment interventions based on the subjective and objective findings of the initial assessment: • Once a diagnosis can be established and the stage of healing can be identified, then a treatment plan can be developed and implemented. • There may also be alterations in training so as to prevent further damage to the shoulder, and give it a chance to recuperate.

20. Treatment – Phase 1 Patient is most likely to have issues related to pain, limited movement, and reported weakness. • Modalities for pain control (ice, acupuncture, etc..) • Address range of motion limitations with appropriate stretching and manual therapy.

21. Treatment – Phase 1 • Rotator cuff strengthening may be initiated (painfree) • Scapular training – meaning training the muscles in and around the scapula against gravity. • Postural education and maintenance strategies.

22. Treatment – Phase 2 • Progress rotator cuff strengthening into combined movements. • Progress scapular training – push ups, proprioception training with ball on wall. • Include muscular engagement over ball to recreate swimming activity 10, as well as core exercises. • Aerobic conditioning, avoiding direct load on shoulder like cycling on recumbent bike.

23. Treatment – Phase 3 By this point the patient has little to no concern related to pain, and may be performing a portion of their sport. • Stroke specific exercises and education on appropriate muscle engagement. • Plyometrics

24. Treatment – Phase 4 Return to sport! • May require some continued active treatment or ongoing use of an appropriate home exercise program. • The physical therapist should have the opportunity to communicate with the athlete’s coach and physical trainer when returning to sport to prevent further shoulder injuries.2

25. Prevention • Whether it is prevention of a first time incident, or avoidance of Swimmer’s shoulder reoccurring there are things to know whether you are the coach, the trainer, or the athlete: • There are findings that suggest that swimmers with previous injuries or instability should be assessed to determine whether they have deficiencies that could be addressed to reduce the risk of shoulder pain. 8

26. Prevention • Technical stroke analysis and correction should be completed by the coach.7 • Development of a well-designed and balanced dryland training program.7 • Think beyond just the work of the shoulder, and include core muscle exercises. 1

27. Prevention • Consider altering the stroke style you use more often. Four typical strokes: freestyle, backstroke, butterfly, breaststroke all have different biomechanics.4 • Meaning this will load muscles differently, putting less consistent load of the same tissues.

28. Thank You! • Thank you very much for your interest in this topic, and allowing us to provide this presentation. • Acknowledgement and thanks to Michael Stillitano who acted as model for this presentation. • Handouts and a reference list for this presentation areavailable upon request.

29. References 1 Brumitt J, Dales RB. Integrating Shoulder and Core Exercises when rehabilitating athletes performing overhead activities. N Am J Sports PhysTher. 2009;43(3):132-38. 2Almeida GPL, De Souza VL, Barbosa G, Santos MB, Saccol MF, Cohen M. Swimmer’s shoulder in young athlete: Rehabilitation with emphasis on manual therapy and stabilization of shoulder complex. Man Ther. 2011;(16): 510-515. 3Pyne SW. Diagnosis and current treatment options of shoulder impingement. Curr. Sports Med. Rep. 2004. 3, 251-255. 4Tovin, B. Prevention and Treatment of Swimmer’s Shoulder. North American Journal of Sports Physical Therapy. 2006; 1(4): 166 – 175. 5AllegrucciM, Whitney S, et al. Clinical Implications of Secondary Impingement of the Shoulder in Freestyle Swimmers. JOSPT. 1994; 20(6) 307-318.

30. References 6 Wolf BR, Ebinger AE, Lawler MP, Britton CL. Injury Patterns in Division I Collegiate Swimming. AJSM. 2009;(37)10:2037-2024. 7Bak K. The Practical Management of Swimmer’s Painful Shoulder: Etiology, Diagnosis, and Treatment Clin J Sport Med 2010;20:386–390 8 Tate A, Turner G, Knab G., Jorgensen C, Strittmatter A, Michener L. Risk Factors Associated With Shoulder Pain and Disability Across the Lifespan of Competitive Swimmers. Journal of Athletic Training. 2012:47(2):149–158 9Madsen PH, Bak K, Jensen S, Welter U. Training induces scapular dyskinesis in pain-free competitive swimmers: a reliability and observational study. Clin J Sport Med. 2009;21:109-113. 10 Lynch SS, Thigpen CA, Mihalik JP, Prentice WE, Padua D. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. Br J Sports Med. 2010;44:376-381.