Maintaining Shoulder Health

For coaches?

Swimmers’ Blessing

Swimmers’ Curse

Steven Kalandiak, MD, Shoulder and Elbow SurgeryUniversity of Miami, Miller School of Medicine

ASCA Conference Fort Lauderdale, FL, September 2009

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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

Elite competitive swimmers put their shoulders through millions of stroke cycles over the course of their careers. 

Michael Phelps – 80K/wk20 lap/K x 80K/wk x 50wk/yr = 80,000lap/yr

80K x 13-14cycles/lap = approx 1M cycles/yr

Ouch!

The Problem

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

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. 

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.

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

Impingement/tendonitis

Internal impingement

SLAP tear

Anteroinferior instability

Multifactorial

Impingement, laxity, instability and labral pathology can all coexist in the same shoulder

Maladaptive movement patterns (scapula) can also coexist

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.

Training (yardage/intensity)

Repetitive microtrauma“acquired capsular laxity”

?? Incorrect stretching ??

Muscle imbalance

Flaws in technique

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

“acquired capsular laxity”

when baseline laxity increases, it can become pathologic

?? Can incorrect stretching contribute??

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)

Tradition, emulate others

Injury prevention (little real proof)

Relieve muscle soreness

Loosen tight muscle groups

(correct unbalanced joints)

Doorframe stretches (Pectoralis)

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

Poor body roll

Crossing midline

Too straight elbow during pull

Persisting in the face of failing mechanics

?? Unilateral Breathing ??

?? Hand Paddles ??

Scapular plane swimming

Also fingertips not toward bottom, arm timing wrong

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

Bilateral breathe to improve stroke symmetry

? increase body roll ?

An error in and of themselves, or do they just aggravate existing flaws ?

First, second and third line treatment

“You can always operate –

you can never un-operate”

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

Moderate to severe pain

Minimal swimming

aerobic fitness (legs), and core

technique evaluation by coach

evaluation for muscle imbalance by therapist

transition to home “preventive” exercises

My office phone # is …….

Repair/reattach torn structures

Tighten stretched tissue

Debride (smooth) irreparable tears or rough surfaces (Masters)

Lengthy rehabilitation

Shoulder muscle development

but not too much

Strength, Endurance, Balance, Flexibility

Of the muscles in the shoulder

and thoughout the body

Do after practice or several hours before

Each set 2 or 3 times per week

Rotator cuff

Scapular stabilizers

Core

Stretching

One second on, one second off

Three sets of two minutes or until lose form

One second up, one second down

Three sets of two minutes or until lose form

15 sec clockwise, 15 sec counterclockwise

Three sets of two minutes or until lose form

One second on, one second off

Three sets of two minutes or until lose form

One second on, one second off

Three sets of two minutes or until lose form

One up, hold “plus” for two, one down

Three sets of two minutes or until lose form

Flat back

2 minute flutter kick or until lose form

advanced

Flat back, then bird dog

Alternate sides – 2 minutes or until lose form

Two 30 second stretched each leg

Don’t lock knee

Two 30 second stretches

Breathe!

Can do on ball

Can stretch, work abs, back or back of shoulders

The hypermobile joints that allow swimmers to compete also predispose them to injuries. 

A controlled increase in yardage and intensity, attention to proper mechanics, and preventive exercises are key to good shoulder health.

If problems arise, prompt recognition, relative rest, and an appropriate search for the underlying cause(s) are vital to returning the swimmer to competition.

Questions?