What is Swimmer’s shoulder?
Swimmer’s shoulder is an umbrella term covering a range of painful shoulder overuse injuries that occur in swimmers. Because there are various parts of your shoulder that can be injured from your swimming stroke, your pain can be anything from a local pain near the shoulder joint, to a spreading pain that travels up your shoulder and neck or down into your arm.
Being an overuse injury, it is caused by repeated trauma rather than a specific incident. Over 1/3 of top level swimmers experience shoulder pain that prevents them from normal training.
Your shoulder is a ball and socket joint, with a rim of cartilage that goes around the socket to make it deeper and more stable.
A number of muscles, and the tendons from these muscles, run around and over your joint. The muscles that have the most effect on your joint stability are called the rotator cuff. The ‘cuff’ is made up of four muscles which work together to help keep your shoulder centred in the socket.
What Goes Wrong in Swimmers Shoulder?
The shoulder is a very mobile joint, and being so mobile, it needs to be well controlled by the muscles and ligaments that surround the joint. Over-training, fatigue, hypermobility, poor stroke technique, weakness, tightness, previous shoulder injury or use of hand paddles can lead to your muscles and ligaments being overworked. If this goes on, injuries such as rotator cuff impingement and tendonitis, rotator cuff tears, bursitis, capsule and ligament damage, or cartilage damage can occur.
Diagnosis of Swimmers Shoulder
Getting the correct diagnosis is very important in order to get the best treatment, and to get you back in the pool quicker.
Treatment for Swimmers Shoulder
Your rotator cuff is an important group of control and stability muscles that maintain “centralisation” of your shoulder joint. In other words, it keeps the shoulder ball centred over the small socket. This prevents injuries such as bursitis, impingement, subluxations and dislocations.
We also know that your rotator cuff provides subtle glides and slides of the ball joint on the socket to allow full shoulder movement. Plus, your shoulder blade (scapular) has a vital role as the main dynamically stable base plate that attaches your arm to your chest wall.
Did you know that your arm only has one bony joint articulation where your collarbone (clavicle) attaches to the acromion (tip of shoulder blade)?
The rest of your attachments are muscular, which highlights the importance of retraining and strengthening of your shoulder muscles.
Researchers have concluded that there are essentially 7 stages that need to be covered to effectively rehabilitate these injuries and prevent recurrence – these are:
Phase 1 – Early Injury Protection: Pain Relief & Anti-inflammatory Tips
As with most soft tissue injuries the initial treatment is RICE – Rest, Ice, Compression and Elevation.
In the early phase you’ll most likely be unable to fully lift your arm or sleep comfortably. Our first aim is to provide you with some active rest from pain-provoking postures and movement. This means that you should stop doing the movement or activity that provoked the shoulder pain in the first place and avoid doing anything that causes pain in your shoulder.
You may need to be wear a sling or have your shoulder taped to provide pain relief. In some cases it may mean that you need to sleep relatively upright or with pillow support. Your physiotherapist will guide you.
Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.
Anti-inflammatory medication (if tolerated) and natural substances eg arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as a pain reducing medication.
As you improve, supportive taping will help to both support the injured soft tissue and reduce excessive swelling.
Your physiotherapist will utilise a range of pain relieving techniques including joint mobilisations, massage, acupuncture or dry needling to assist you during this painful phase.
Phase 2: Regain Full Range of Motion
If you protect your injured rotator cuff structures appropriately the injured tissues will heal. Inflammed structures eg (tendonitis, bursitis) will settle when protected from additional damage.
Symptoms related to swimmers shoulder may take several weeks to improve while we await Mother Nature to work her wonders. During this time it is important to create an environment that allows you to return to normal use quickly and prevent a recurrence.
It is important to lengthen and orientate your healing scar tissue via joint mobilisations, massage, shoulder muscle stretches, and light active-assisted and active exercises.
Researchers have concluded that physiotherapist-assisted treatment will improve your range of motion quicker and, in the long-term, improve your functional outcome.
In most cases, you will also have developed short or long-term protective tightness of your joint capsule (usually posterior) and some compensatory muscles. These structures need to be stretched to allow normal movement.
Signs that your have full soft tissue extensibility includes being able to move your shoulder through a full range of motion. In the early stage, this may need to be passively (by someone else) eg your physiotherapist. As you improve you will be able to do this under your own muscle power.
Phase 3: Restore Scapular Control
Your shoulder blade (scapular) is the base of your shoulder and arm movements.
Normal shoulder blade-shoulder movement – known as scapulo-humeral rhythm – is required for a pain-free and powerful shoulder function. Alteration of this movement pattern results in impingement and subsequent injury.
Your physiotherapist is an expert in the assessment and correction of your scapulo-humeral rhythm.
Researchers have identified poor scapulo-humeral rhythm as a major cause of rotator cuff impingement. Any deficiencies will be an important component of your rehabilitation.
Plus, they have identified scapular stabilisation exercises as a key ingredient for a successful rehabilitation.
Your physiotherapist will be able to guide you in the appropriate exercises for your shoulder blade.
Phase 4: Restore Normal Neck-Scapulo-Thoracic-Shoulder Function
You may find it difficult to comprehend, but your neck and upper back (thoracic spine) are very important in the rehabilitation of shoulder pain and injury.
Neck or spine dysfunction can not only refer pain directly to your shoulder, but it can effect a nerve’s electrical energy supplying your muscles causing weakness and altered movement patterns.
Plus, painful spinal structures form poor posture or injury doesn’t provide your shoulder or scapular muscles with a solid pain-free base to act upon.
In most cases, especially chronic shoulders, some treatment directed at your neck or upper back will be required to ease your pain, improve your shoulder movement and stop pain or injury returning.
Phase 5: Restore Rotator Cuff Strength
It may seem odd that you don’t attempt to restore the strength of your rotator cuff until a later stage in the rehabilitation. However, if a structure is injured we need to provide nature with an opportunity to undertake primary healing before we load the structures with anti-gravity and resistance exercises.
Having said that, researchers have discovered the importance of strengthening the rotator cuff muscles in a successful rehabilitation program. These exercises need to be progressed in both load and position to accommodate for which specific rotator cuff tendons are injured and whether or not you have a secondary condition such as bursitis.
Your physiotherapist will happily prescribe the most appropriate program for you.
Phase 6: Restore Technique, Speed, Power & Agility
Swimming requires repetitive arm actions, which place enormous forces on your body (contractile and non-contractile).
In order to prevent a recurrence as you return to swimming, your physiotherapist will guide you with exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance.
Depending on what your training or competitive program entails, a speed, agility, technique correction and power program will be customised to prepare you for swimming-specific training.
Phase 7: Return to Swimming
Depending on the demands of your swimming season, you will require individual exercises and a progressed training regime to enable a safe and injury-free return to swimming.
Your PhysioWorks physiotherapist will discuss your goals, time frames and training schedules with you and your coach to optimise you for a complete return to swimming.
The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a through rehabilitation program has minimised your chance of future injury.
There is no specific time frame for when to progress from each stage to the next. Your injury rehabilitation status will be determined by many factors during your physiotherapist’s clinical assessment. You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves. It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and frustration.
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Article by John Miller