Objectives

• Briefly discuss the phases of the freestyle swimming stroke.

• Discuss the prevalence and incidence of shoulder pathology in swimmers

• Identify ROM adaptation and flexibility patterns among injured and uninjured swimmer’s shoulders

• Review GIRD, total arc of motion, and external rotation deficiency

• Learn evidence based evaluation and management strategies based on the current body of literature

Shoulder Revolutions per Week

1000 1000 300

4000 rev / day

30,000 rev /

week

90%

Prevalence of Shoulder Pain

(Competitive swimmers)

40-91%3:1 female : male

Bak et al, 1997; Ciullo, 1986; McMaster 1999;

rupp et al. 1995; Sein, et al. 2010; Harrington, et

al. 2014

KNOW THE

STROKE

FreestyleFastest & most frequently performed

80%

Glide

Early pull-through

Mid pull-through

Late pull-through

Recovery

http://www.swimsmooth.

com/breathing.html

Am J Sports Med. 1991 Nov-Dec;19(6):569-76.

The normal shoulder during freestyle swimming. An electromyographic and cinematographic analysis of twelve muscles.Pink M1, Perry J, Browne A, Scovazzo ML, Kerrigan J.

Glide

• Begins as hand enters

water

• Elbow slightly higher

than hand

Normal Painful• Arm placed further

from midline

• Humerus lower and

‘dropped elbow’

• Late / decreased

recruitment of upper

trapezius

Early Pull Through

• Occurs from end

of glide to when

hand reaches

max extension

and begins

downward

motion

Normal Painful

• Decreased

serratus anterior

activity

• Increased

rhomboids

activity � net

loss of scapular

upward rotation

and protraction

Late Pull Through

• Occurs from

90◦ of flexion

to when the

hand exits the

water

• Early hand exit (to

avoid extremes of

internal rotation?).

• Increased activity in

rhomboids to

retract and elevate

the scapula

Normal Painful

Recovery

• Occurs from when the hand exits the water to just before hand entry

• No water resistance

Normal Painful

• Decreased

anterior

deltoid

activity

• More lateral

hand entry

• Scapular dyskinesias increase in frequency

throughout a training session

• Swimmers are subject to early fatigue due to

high training volume

• Serratus anterior muscle fatigues earlier in

painful swimmers

Breathing Patterns

• Unilateral breathing associated with

small tilt angle on breathing side

**High incidence of shoulder impingement

on ipsilateral side

• Case for adopting B/L breathing

Swimmers at Risk

• Small tilt angle

Mr. Smooth

https://www.youtube.com/watch?v=IyR7JYllk9U

Bak, K. 2010

Swimmers’ painful shoulder

arthroscopic findings and return rate

to sportsC. Brushøj1 , K. Bak2 , H. V. Johannsen3 , P. Faunø4

• Labral pathology (61%)

• Subacromial impingement (28%)

• Bursal sided tear of supraspinatus tendon

• Impingement of posterior rotator cuff

• Inflammation of Biceps - LH

Surgical Treatment

• Distal clavicle excision

• CA ligament resection

• Debridement

• Decompression

Outcomes

• 59% able to compete at pre-injury level after

2-9 months.

– 7 without shoulder pain (44%)

– 2 with some pain

– 7 never returned (44%)

Brushej, et al. 2007

Etiology of ‘Swimmers Shoulder’

Extrinsic Factors

• Training volume – sudden increase

• Technical errors

• Hand paddles

Intrinsic Factors

• Excessive laxity / general joint hypermobility

• Posture, core stability, increased thoracic kyphosis

• Scapular dyskinesias

• GIRD (glenohumeralinternal rotation deficit)

• Rotator cuff imbalance

• Hypomobility (posterior capsule, rotator cuff, pectoralis minor)

GIRD ‘Glenohumeral Internal Rotation

Deficiency’

• Hypermobile ER,

hypomobile IR

• Most overhead athletes

(including swimmers)

demonstrate this motion

disparity

‘The Disabled Throwing Shoulder’

series… old news?

• Burkhart, et al 2003

– GIRD: loss of IR shoulder motion on dom.

extremity

– Caused by posteroinferior capsular contracture

– Increased external rotation is an acquired

secondary cause

– GIRD is at the core of many throwing injuries

…but now we know there is more to

the story…

• Kevin Wilk, George Davies, Mike Reinold,

Kibler… change of heart?

• Lots of new data

• ‘TROM’ = TOTAL RANGE OF MOTION

GIRD: normal vs pathologic

• Manske, et al. 2013 (and Kevin Wilk, George Davies, Mike Reinold…)

– ‘Loss of GH IR is a normal phenomenon that should be expected’.

– ANATOMIC: IR loss of <18-20 degrees with symmetrical TROM B

– PATHOLOGIC: IR loss >18-20 with corresponding TROM loss >5 when compared bilaterally

Says Who?

• Pitchers whose TROM comparison was >5 were 2.5x more likely to sustain shoulder injury

• TROM should be symmetric, and not >186

• If we stretch to increase IR PROM, we may be increasing TROM and thus INCREASING risk of injury

– Increased demands on dynamic and static stabilizers of GH joint

Wilk, et al. 2012

ERD: the new GIRD

• External rotation deficiency

– Pitchers with <5 degrees extra ER on dominant

side 2.3x increased risk of shoulder injury

Summary

• GOOD / OKAY:– Symmetrical TROM

– Dominant arm has at least 5 degrees MORE ER than non-dominant (THROWERS ONLY)

– IR loss within 18-20 degrees when compared B

• BAD: – IR loss >18-20 with corresponding TROM loss >5 when

compared bilaterally

…….what about swimmers?

• Significant predictors: ER ROM and previous

history of shoulder injury

• Low (<93°) and high ER (>100°) were assoc.

with increased risk of injury

• Hypermobile in shoulder ABD, ER, and flexion

• Hypomobile in shoulder internal rotation

• Little correlation between hypermobility or

hypomobility and shoulder pain

GIRD vs PST (posterior shoulder

tightness)

• Borsa, et al. No association between joint laxity and ROM (in healthy subjects)

– Laxity measured by Telos device

– Posterior joint laxity was more commonly

associated with IR deficit

**IR loss due to osseous

adaptations and posterior

soft tissue tightness

Wilk, 2009

• Resolution of symptoms after physical therapy

treatment for internal impingement was

related to posterior shoulder tightness but

NOT correction of GIRD

Posterior shoulder tightness

Tyler Test

**BOTH are good, supine slightly better

Keep in Mind Arm Dominance!

• NORMAL for arm dominance to be associated

with:

– Forward shoulder posture

– Loss if IR ROM

– Posterior shoulder tightness

*Dominant arm involved: effects accentuated

*Non-dominant arm involved: effects absent

Other risk factors…

• Symptomatic, >12 yrs of age:

– Pectoralis minor tightness

– Decreased core endurance

• Symptomatic, <12 yrs of age:

– Reduced shoulder flexibility

– Weakness of middle trap & shouder int. rotators

– Tightness of latissimus dorsi

• Measured:

– PROM IR and ER @90

– Strength: scapular depression, adduction, IR, ER

– Core endurance (side bridge, prone- bridge)

– Pectoralis minor muscle length

A cross-sectional study examining shoulder

pain and disability in Division I female

swimmers.Harrington S1, Meisel C, Tate A.

Results

• Pectoralis minor muscle length was the only

variable which had a statistically significant

difference between groups (painful and non

painful shoulder).

Takeaways?

• GIRD: may not be pathologic

• ERD and TROM more important than GIRD

– Ideal between 93 – 100?

• Look at posterior shoulder tightness

– May be source of pathologic IR loss

• Measure pectoralis minor

• Strengthen scapular stabilizers! (serratus

anterior!)

The evidence based examination

Pec Minor Length

Pectoralis Minor

• Supine, elbows extended

• Inferomedial coracoid process � caudal edge of 4th rib at sternum

• Exhale before measurement

• Intrarater reliability: good – excellent

• Interrater: poor -moderate

Struyf, et al. 2014

Pectoralis Minor

Vertical towel roll placed

under thoracic spine

Doorway stretch wins!

Posterior Shoulder Tightness

• A Single application of

MET for GHJ horizontal

abductors provides

immediate improvements

in both GHJ horizontal

adduction and IR ROM

• Dosage:

• 5 sec contraction @

25% effort, 30 sec

stretch, x3

THAT’S ALL!

Good Resources:

• Chris Johnson, PT: YouTube Channel

– Exercise videos, tests, etc.

• ‘Mr. Smooth’ : great animations of swimming

technique

– www.swimsmooth.com

– Also, stroke animations app

LAB!!

Lab To-Do

• IR / ER measurement– positioning

– optimal scapular stabilization

• Measure posterior tightness

• Pec minor length– Novel pec minor stretch

• Treat!– MET

– Cross body stretch

– Modified cross body stretch

– Sleeper’s stretch

– Modified sleeper’s stretch

Who has tight posterior shoulder?

Modified sleepers stretch

• Method reduces

impingement

• Have patient do a

quarter turn towards

their back

• GH joint in

scapular plane

Cross body stretch

Modified cross body stretch

Standing cross body stretch

APPENDIX

The Backstroke

The Butterfly

The Breastroke