Swimmer’s Shoulder – a whole body problem

 

This month’s blog contribution comes from chartered physiotherapist, Scott Murphy who runs InMotion Chartered Physiotherapy in Limerick and  lectures part time at the University of Limerick.

He has worked with National teams in Boxing, Rowing, Swimming and Judo. He was part of Team Ireland for the Beijing and London Olympics. He currently works with Swim Ireland’s UL Sport Performance Centre Squad.

 

 

The sport of triathlon is enjoying unprecedented popularity in Ireland at the moment – from sprint distance to Ironman, it seems everyone is dragging themselves out of the bed earlier to hit the pool. From a physiotherapy perspective this surge in popularity of swimming carries with it some clinical challenges. There are a couple of key concepts that I believe can keep the buddying triathlete in the water. Maintaining efficient technique under imposed load is the key to shoulder success.

“Swimmer’s Shoulder” – Technique

As physiotherapists we can be obsessed with anatomical pathology. Is “swimmer’s shoulder” supraspinatus or biceps tendinopathy, internal impingement, external impingement or subacromial bursitis? And does it matter? A more useful way of approaching the swimmer with shoulder pain tends to be to look for the movement dysfunctions. What technical deviations does the swimmer have away from the ideal? Clinically I’ve found either a lack of body roll or a low elbow at the catch during freestyle to be the main culprits. If swimming is not your thing, chat to a swim coach, as they’re experts in teaching movement.

 

Swimming blog_Arm position in the water

Above: Olympic medalist Rebecca Adlington from http://www.feelforthewater.com/2012/04/choosing-right-head-position-for-you.html

A high elbow enables efficient transfer of energy down the arm, while the internally rotated position enables lats and pecs to apply maximal force. If swimming is not your thing, chat to a swim coach, as they are experts in teaching movement.

Below: Front view of arm position in the water modified from http://www.alamo180.com/2013/03/swim-tip-improve-your-underwater-pull/

swimming blog_anterior view

 

“Swimmer’s Shoulder” – Load

The aim of training is to cause a physiological adaptation to an imposed load. If the body isn’t given sufficient time to adapt, excessive imposed load leads to overload. It’s possible that the load required to create pathology and pain is greatly decreased when it’s imposed on a faulty motor pattern- analogous to car tyres wearing quicker when your tracking is off.

Swimmers are Swimmers, Triathletes are Triathletes

An Olympic swimmer will swim approx 2500km per year – that’s between 1.6 and 1.7million arm strokes. Triathlon is a sport unto itself and therefore triathletes shouldn’t aim to emulate what swimmers do. Furthermore, most elite swimmers swim only 50% freestyle (front crawl) when training. The change of stroke enables swimmers to vary the way in which they load their shoulder. So if you’re a triathlete, don’t be afraid of throwing in some backstroke for balance.

What the research says…

Sein et al (2010) found the greatest predictor of supraspinatus tendinopathy was time spent swimming (greater than 15hrs or 35km per week ). It must be remembered that this study was done on elite swimmers. An elite swimmer is a unique athlete. On average these swimmers had 8 years of training under their belts; additionally these swimmers’ technical proficiency would be far superior to that of someone new to the water. Put simply they are better accommodated to this imposed load.

Swimmers as Overhead Athletes

In research about shoulder problems often swimmers are grouped in with throwers, tennis and volleyball players, but there are a few vital differences between swimmers and other “overhead athletes.” Firstly water is 784 times denser than air, therefore the speeds of movement are much slower. A pitcher’s arm when throwing a fast ball will rotate at 7000°.s-1 compared to ~380°.s-1 with a swimmer. Next the force profile of a swimmer is vastly different to that of a thrower. Once a thrower releases the ball they are working to decelerate their arm via eccentric contraction of the throwing antagonist muscles. By contrast a swimmer is continuously trying to accelerate their arm (or more correctly their body) through the water. Finally a pitcher will throw approx. 100 pitches at very high maximal voluntary contraction (MVC), conversely a swimmer will spend up to 4hrs in the pool working at relatively low MVC. These are all of huge consequence when prescribing rehabilitation exercises.

The take home message is: swimmers are unique to overhead athletes due to the environment in which they operate and the load they impose on a joint that sacrifices stability for mobility. When dealing with “Swimmer’s Shoulder” overload is key; whether it’s load through a sub optimal motor pattern or purely a load that is greater than the physiological capacity of the surrounding tissues. Unload, correct movement errors, and then progressively reload.

References

Sein, M. L., Walton, J., Linklater, J., Appleyard, R., Kirkbride, B., Kuah, D., & Murrell, G. A. C. (2010). Shoulder pain in elite swimmers: primarily due to swim-volume-induced supraspinatus tendinopathy. British Journal of Sports Medicine, 44(2), 105–113. doi:10.1136/bjsm.2008.047282

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