Shoulder Pain in the Swimmer

Introduction:

The most common injury affecting the swimming athlete affects the shoulder complex, with about 66% of swimmers reporting shoulder pain at some time. Three main factors lead to this high incidence, including:-

1. the high propulsive demands placed on the shoulder in swimming, with about 90% of the propulsive force coming from the upper extremities
2. the enormous endurance requirements placed on the shoulder musculature due to the repetitive cycling of the arms and the long distances often covered in training
3. the relative instability of the shoulder joint due to its bony geometry. It’s the most mobile joint in the body and is often equated structurally to a golf ball sitting on a tee. Additionally, swimmers frequently demonstrate increased laxity of the shoulder joints on both sides, possibly due to the demands of the sport

 

Anatomy and Pathology

There are a number of structures and pathologies that can cause pain in and around the shoulder…a good reason to get ongoing shoulder pain properly assessed. In the swimmer, however, the mechanism of shoulder pain is frequently due to overuse and impingement of the rotator cuff tendons on the acromion process (figure 1).

Figure 1. Anatomy of the glenohumeral (shoulder) joint – as the arm is raised, the head of the humerus (ball) pinches the rotator cuff tendons beneath the acromion process...shoulder impingement!

 

The impingement itself often results from increased shoulder joint laxity in conjunction with the high demands placed on the shoulder. On top of this, the muscles controlling the scapula (shoulder blade) become dysfunctional and set the shoulder up for problems (figure 2).

 

Figure 2. Common pathophysiology of shoulder pain in the swimming athlete

In English, the joint is a little too loose, the shoulder blade muscles don’t work as well as they should, the muscles and tendons of the rotator cuff fatigue from trying to control the shoulder, and end up getting pinched between 2 bones.

Management

If the shoulder has become painful, eliminate aggravating activities and institute an anti-inflammatory regime as soon as possible. This might include ice, taping, and a short course of anti-inflammatories such as ibuprofen. Get on the bike or run for cardiovascular fitness, and if you have to get in the water with a kickboard, be careful with your shoulder positioning. Once you’ve done all this, make an appointment to have your shoulder assessed by a skilled professional! It’s not worth mucking around with the shoulder complex, so jump on it early.

I’d recommend that you seek out a physiotherapist or sports medicine physician that has a specialised knowledge of the shoulder, and make sure that you receive a complete biomechanical assessment of the shoulder, shoulder blade, and spine. Don’t be satisfied with a bit of massage and ultrasound or electrical stimulation, as this will not fix the problem. A skilled practitioner will understand the importance of the serratus anterior and subscapularis muscles (see Prevention section), and will guide you through an exercise program to address these deficiencies and any other apparent problems.

Prevention

I don’t think I can really stress this idea enough, particularly when it comes to the shoulder. Once the shoulder is painful, it is very easy to slip into a nasty cycle of pain and muscle dysfunction that can be difficult to break out of. The earlier a potential injury is recognised, the better the chance of a quick and full recovery without any serious damage. Failing to address a problem may result in progression of the initial injury to a rotator cuff tear, worsening capsular laxity, or a tear of the passive stabilising structures of the shoulder (eg. labrum). Even if you don’t read the rest of the article, take this section to heart and you’ll go a long way to avoiding a serious shoulder problem!

1. Swimmers frequently associate an increase in distance covered, or an increase in the intensity of their workouts with the development of shoulder pain. Be smart about changes in your routine and allow plenty of time before an event to build your workouts up.
2. Two important muscles have been identified as dysfunctional in the painful swimmer’s shoulder.

 

• The SERRATUS ANTERIOR is incredibly important in stabilising the shoulder blade and allowing for normal shoulder function. It is continuously active throughout the freestyle stroke to hold the shoulder blade in position and to pull the body through. It has been shown to fatigue in the painful shoulder and is therefore a lot less active, creating an unstable shoulder blade. Since there is no other muscle that can effectively compensate for a dodgy serratus anterior, this creates a major problem and often leads to shoulder injury. As such, the prevention regime must include endurance training for this muscle (see exercise section).
• The SUBSCAPULARIS (Rotator Cuff) is another muscle that is continuously active throughout the stroke, and apart from helping to propel the body, it also helps to hold the head of the humerus in place and thus prevent impingement. It too is prone to fatigue and must be addressed in the training regime.

1. Avoid bad stretches!!! The front of the shoulder is often loose already, and any stretches that force the arms behind the body have the potential to make this worse. A safe way to loosen the thoracic spine and stretch the pectoralis muscles, without damaging the shoulder joint, is to lie with a rolled up towel or foam roller between the shoulder blades.
2. Avoid bad weight room habits!!! Bench press is a great exercise, but can be devastating to the shoulder joint if done incorrectly. Make sure when lowering the weights, the elbows don’t go past parallel, as this will lever the head of the humerus forward and loosen the front of the shoulder joint further. Also, lat pulldowns are brilliant, but don’t take the bar behind the head. Same with the shoulder press. A good general rule with these 2 exercises is to ensure the back of the hands are always visible. This will keep the elbows in front of the body and avoid over-stretching the front of the shoulder.
3. Early recognition of a problem can save weeks and months of laborious rehabilitation and psychosis induced by not being able to get in the water! There are a number of things to keep your eye on, and this is where it’s helpful to have a skilled coach or trainer. The key things to watch out for are:-

• Hand entry that crosses mid-line puts the shoulder in the impingement position.
• Thumb-first hand entry has the same effect.
• Asymmetric body roll or unilateral breathing increases impingement on the non-breathing side or the side with less body roll.
• Holding the head too high in the water, as in the “eyes-forward” position frequently taught, makes it difficult for the spine and shoulder blade to function effectively, thus leading to shoulder problems.
• Dropped elbow in the recovery phase – this is often an attempt to avoid the painful position, and hopefully your coach wont simply yell at you for being lazy! The point in the workout where the elbow is consistently being dropped signals time to pull out and evaluate the shoulder.
• Wide hand entry may also be noted for the same reasons.
• Asymmetric pull and/or excessive body roll may make it difficult to stay in the centre of the lane and often signal impending injury.

Although it’s become a bit of a cliché, one of the most important aspects of good technique and solid shoulder mechanics is control of the pelvis and lumbar spine…the all-powerful core!

If you have difficulty controlling the trunk, or lack endurance in this area, then it’s likely the shoulder will suffer. Working in prone with a stability ball is an excellent way to establish control and endurance of the pelvis and spine. In the pool, this control must provide a stable base from which the arms work, allowing symmetrical body rotation of at least 45 degrees. Appropriate body roll equates to rotating on a skewer that passes through the top of the head, down the spine, and out between the legs.