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Swimmer's Shoulder
by James N. Johnson, M.D.

"Swimmer's shoulder" is the term most commonly used to refer to the triad of over-use injuries which affect the anterior capsule (front) of the shoulder. The three conditions which all cause similar pain are biceps tendonitis, subacromial bursitis, and rotator cuff (usually supraspinatus) tendonitis. These entities all overlap and are related. The problem develops one of three ways or a combination of the three - improper technique related to a strength/laxity imbalance, too rapidly increasing volume, or too rapidly increasing intensity.

Improper technique, most often in freestyle swimming which makes up the largest percentage of training volume, develops because the athlete that chooses swimming usually has lax (loose) joints. A loose shoulder joint causes what is commonly called "dropping the elbow" but is actually the front part of the shoulder joint moving anterior (forward) to the plane connecting the body to the arm, more technically called anterior subluxation.

The simplest way to correct this is teaching the swimmer to roll his or her body as a unit - hips, core, and shoulders at the same time. The idea is to keep the head and spine in line and for the body to rotate on the long axis of the spine like a barbecue skewer. Bilateral breathing may help some swimmers who have asymmetric body roll. Pulling with a buoy may help in the learning process by floating the legs thus decreasing the load on the shoulders and emphasizing the importance of generating the roll from the hips and core.

Too rapidly increasing the volume or intensity of training especially in the context of improper technique exacerbates the problem. Volume in itself is not bad. Some swimmers respond physiologically to high volume training based on their cardiovascular characteristics and muscle fiber type. Also, there is a place for high intensity training for a different type of athlete. And combinations of volume and intensity in different percentages benefit different athletes. But generally a progressive training program in terms of volume and intensity will protect the athlete with improper technique from "swimmer's shoulder." So, it is important to know each athlete's training and racing history before beginning a season. Important aspects to consider are: maximum training volume per week in career, average training volume per week over the last season, number of years training and number of practices per week over that career, and, of course, history of race times and when they occurred during each season.

If an injury does occur despite proper technique and progression, prompt and considerate treatment is required. First, athletes must be allowed to communicate that they are injured. Once an injury is identified, the first thing a coach should recommend is to get a physician with an interest in sports involved. The athlete needs to have a proper evaluation and appropriate diagnostic work-up to diagnose "swimmer's shoulder" because there are less common more serious problems, which must be ruled out.

After a diagnosis of "swimmer's shoulder" is made, the initial treatment includes relative rest, ice, and anti-inflammatory medication. Relative rest is generally returning to the level of training at which the shoulder did not hurt. If the pain persists at this level, further reduction in training load should be considered. Ice should be applied for 20 minutes at a time at least three times daily or more often if possible (as much as 20 minutes per hour in the evening after practice and prior to sleep). And, under a physician's supervision, a 10-14 day course is prescribed of anti-inflammatory medication (being aware that stomach pain could indicate a side effect, which would require discontinuation of medication). If initial treatment is unsuccessful after a two-week trial, reevaluation by a physician and subsequent physical therapy may be indicated. Cortisone injections are recommended by some physicians, and there is a place for them; but make sure the physician knows if the athlete has had any previous injections and where the athlete is in the progression of their swimming career (someone approaching their last ever meet may be a better candidate for an injection than someone early in their career). Surgery is a late stage treatment in rare cases.

In addition to monitoring technique and progression of training, prevention should also focus on strength development of the primary scapular stabilizers in addition to the rotator cuff. The rotator cuff muscles should function only as the secondary stabilizers of the shoulder joint. The rotator cuff is designed to move the shoulder through its full range and should not bear a heavy load. Strength training should focus on the trapezius, rhomboids, serratus anterior, and latissimus dorsi muscles of the back in addition to band exercises for the rotator cuff DONE PROPERLY, (emphasizing the inner range of motion which is well described in the literature) .

"Swimmer's shoulder" is a common entity which all coaches should be familiar with. There are accepted modes of prevention, diagnosis, and treatment that should be followed, which can help the athlete return to competition. If the physician, coach and athlete communicate and work closely together, fast and fun and injury-free swimming will be the end result.

References:
  1. Swimmer's Shoulder Lecture by Craig Ferrell, M.D. ACSM Annual Meeting. 3 June 2000
  2. Swimmer's Shoulder: Targeting Treatment Scott Koehler M.D. and David Thorson M.D. The Physician and Sports Medicine. Vol. 24, No 11, 39-50, Nov 96.
  3. Swimming Injuries William C. McMaster M.D. Sports Medicine. Vol. 22, No 5, 332-36, Nov 96.
  4. Rehabilitation of Injuries in Competitive Swimmers Katherine Kenal and Laura Knapp. Sports Medicine. Vol. 22, No 5, 337-47, Nov 96.
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Dr. Johnson works at the Mayo Clinic Department of Family Medicine in Jacksonville, FL. He is a member of USA Swimming Sports Medicine Society, an Assistant Coach of Gustavo Borges, and Beaches Aquatics Club Olympic/Olympic Trials Group l.

Taken from ASCA Online