Shoulder Problems in Competitive Swimming

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Shoulder Problems in Competitive Swimming

Scott A. Rodeo, M.D.

Chief, Sports Medicine and Shoulder Service, The Hospital for Special Surgery

Chairman, USA Swimming Sports Medicine Committee

Team Physician, New York Giants Football


Incidence 40-70%

• Estimate: 500,000 stroke revolutions/arm/season

• 6-8 miles/day, 5-6 days/week

• High training volumes overuse injuries

Swimmer’s Shoulder

“To convert a merely good swimmer into a champion, you must expose him to what he thinks is the ultimate agonizing limits of physical performance and then teach him to go beyond that limit day after day”

James “Doc” Counsilman


Swimmer’s Shoulder


• Shoulder kinematics



• Rehabilitation and prevention


Factors Associated with Swimmer’s Shoulder

1) Muscle fatigue / overload

2) Rotator cuff tendonosis

3) Impingement positions during swimming stroke

4) Shoulder laxity


Shoulder Kinematics

Glenohumeral stability dependent on:

- Static stabilizers (capsule) - Dynamic system (muscles)

Controlled by synchronous pattern of muscle firing

Balanced force couples to center humeral head

- Subscapularis + infraspinatus

Rotator cuff functions as humeral head depressor


Glenohumeral Kinematics

Scapular stabilizing muscles play critical role

Scapula is stable base from which all else follows

Mistake to emphasize only rotator cuff


Swimmer’s Shoulder

Rotator cuff fatigue / overload:

Over-training muscle fatigue

In particular, serratus anterior & subscapularis (Pink et al, Amer.

J. Sports Med 1991)

Muscle imbalance Abnormal force couples

Experimental studies demonstrate superior migration of humeral head with rotator

cuff fatigue (Chen et al., 1994)

Altered shoulder mechanics impingement pain


Muscular fatigue

Rotator cuff dysfunction Loss of synchronous firing

patterns, abnormal proprioception Abnormal kinematics Secondary impingement


Rotator Cuff Tendonosis

Shoulder pain in elite swimmers is related to supraspinatus tendinosis

Correlation between supraspinatus

tendinopathy and training volume (Murrell et al)

- hours swum per week - weekly training mileage


Kilometres swum per week

0 20 40 60 80 100

Suprapsinatus tendinosis

0.0 0.2 0.4 0.6 0.8 1.0 1.2

r = 0.34, p = 0.01




Sein, Murrell, et al.


Specific Abnormalities in Swimmers

EMG studies document muscle fatigue and

alteration in muscle force couples in swimmers

Subscapularis and serratus anterior

vulnerable to fatigue, since firing at >20%

MMT Pink et al, Clin Ortho 1993


Loss of serratus function exacerbates impingement

Serratus Anterior Functions to Decrease

Impingement by Scapular Protraction


Specific Abnormalities in Swimmers

• Asynchronous muscle forces

Serratus  and rhomboids 

• The rhomboids try to compensate, but this is

antagonist to serratus anterior

• No muscle can substitute for

serratus anterior


Specific Abnormalities in Swimmers

• Asynchronous muscle forces

- Subscapularis  - Infraspinatus 

• Compensatory increased infraspinatus firing to

decrease internal rotation


Force Couple Between Internal and External Rotators to Stabilize Humeral Head

• Internal rotators stronger than external rotators in normal shoulder

• Imbalance between internal and external rotators in swimmers

• Goal: ER/IR ratio 65%

Internal rotator External rotator

Pink et al, Clin Ortho 1993


Postural Abnormalities

Posture of rounded shoulders and forward

head leads to weakness of scapular retractors due to elongation of these muscles

Weakness of scapular retractors Anterior tilt / protraction of scapula



Fatigue of the “core” muscles including abdominal and pelvic muscles can also

contribute by affecting scapular kinematics and body position in the water


Shoulder Stability / Laxity

Stability dependent on:

- Static stabilizers (capsular ligaments)

- Dynamic system (muscles forces)

Swimmers often have some generalized laxity

Fine balance between stability and laxity


The Role of Laxity

• With shoulder laxity more dependence on dynamic stabilizers

• If these dynamic stabilizers fatigue abnormal kinematics

• Role of laxity in shoulder pain debated but it often correlates with shoulder injury

• Instability secondary impingement


The Role of Laxity

• Anterior laxity is typically symptomatic in abduction + external rotation

• This is the arm entry position in



Specific Abnormalities in Swimmers

Capsular constraint mechanism:

Head translates away from tight capsule

Anterior capsular laxity

Combination results in anterosuperior translation of humeral head  impingement

Tightness of posterior rotator cuff



Impingement During Swimming

Certain stroke positions can cause impingement

Classic impingement

position = forward elevation + internal rotation

Position of hand entry in freestyle, butterfly

Rotator cuff tendons/bursa impinge on acromion


Impingement During Swimming

Early pull-through : Forward flexion, IR

Late pull-through: hyperextension

Recovery: Elevation


Anterior Internal Impingement?

(articular side)

Articular surface of rotator cuff against glenoid and

anterosuperior labrum

Responsible for

“biceps” pain??

Impingement between cuff & anterosuperior labrum with arm in flexion + IR


Diagnosis and Management



Accurate diagnosis begins with a careful history and examination

Recent change in training regimen? Training volume?

Dryland exercises?

Specific attention to

– glenohumeral laxity

– strength of rotator cuff and periscapular muscles – impingement signs

– localizing tenderness – labral signs

– acromioclavicular joint pathology

Careful analysis of the swimming stroke


Stroke Alterations with Painful Shoulder

Dropped elbow: avoids internal rotation

Wider hand entry: less forward flexion

Early hand exit with pull: avoids hyperextension

Excessive body roll: allows less hyperextension

Are stroke alterations cause or effect???



Radiographs usually normal

Obtain an imaging study if symptoms persist


- Capsular thickening (previous instability episodes)

- Rotator cuff tendinosis

(suggestive of tendon overload)

Diagnostic injection may be helpful to confirm the source of pain


Swimmer’s Shoulder Treatment

Rest: change stroke, eliminate paddles, more kicking sets

Avoidance of strokes and training exercises that exacerbate the pain


Modalities such as electrical stimulation and ultrasound are useful to control pain and

inflammation in the initial treatment phase

Proper warm-up


Swimmer’s Shoulder Treatment

Stroke corrections:

Butterfly: wider hand entry, shorten follow- through

Freestyle: less internal rotation at hand entry, breathe bilaterally,

shorten follow-through


Swimmer’s Shoulder Treatment

The most important part of the

rehabilitation program is identification

of any deficits in muscle strength,

endurance, balance, and flexibilty


Swimmer’s Shoulder Treatment

• Gentle stretching: posterior rotator cuff, scapular stabilizers, posterior capsule, pectoralis major

• Generally do not need to stretch anterior



Swimmer’s Shoulder Treatment

Posterior capsule Pectoralis stretch

Anterior capsule stretch


Treatment Considerations

Focus on serratus anterior, scapular retractors (lower trapezius, rhomboids), subscapularis

Rotator cuff (external rotation) strengthening: goal is ER:IR ratio at least 65%

Proprioceptive neuromuscular facilitation (PNF) patterns to facilitate agonist/antagonist muscle co-contractions

Development of core strength: lumbar stabilization, abdominals, pelvic girdle

Avoid / correct excessive anterior pelvic tilt / lumbar lordosis



Comprehensive program to develop muscle strength, endurance, balance, and flexibility

Address three important areas:

1. rotator cuff

2. muscles that stabilize the scapula

3. muscles of the low back, abdomen, and pelvis that make up the “core” of the body

Emphasis placed on endurance training and strengthening for the serratus anterior,

rhomboids, lower trapezius, and subscapularis


External rotators

Full Can Scaption Ball on the Wall

Rotator Cuff Exercises


Scapular Muscle Exercises

Theraband Rows



Scapular Muscle Exercises

Push-ups with a plus


Core Strength Development

“Dead bug”



Flexibility Exercises

Hamstring stretch

Upper back stretch


Trapezius stretch

Flexibility Exercises


Swimmer’s Shoulder Treatment

• Further evaluation if unresponsive to initial treatment

• Radiographs

• Rule out underlying instability

• Pathologic lesions

• Injection used sparingly



• Operative management is generally indicated only after a comprehensive course of conservative treatment

• Surgical intervention is most commonly required to address instability and

secondary impingement



Proliferative, inflamed subacromial bursa

Subacromial bursectomy

Acromioplasty not performed

Capsular plication as indicated


Arthroscopic Capsular Repair


Capsular Repair


Post-Surgical Rehabilitation

• Post-operative protection 4-6 weeks

• Gradual restoration of motion

• Comprehensive strengthening

• Swimming ~ 12-16 weeks

• Training semi-normally by 6 months

• 1 year total for return to full training



Shoulder pain in swimmers related to muscle fatigue/overuse and altered shoulder mechanics

Shoulder pain in swimmers can usually be improved with a comprehensive rehabilitation program

Prevention is most important

Team approach critical (athlete + coach + parent + therapist + physician)


Sports Medicine and Shoulder Service The Hospital for Special Surgery

New York, NY

Thank You


Swimmer’s Shoulder

• Incidence 40-70%

• Estimate: 500,000 stroke revolutions/arm per season

• 6-8 miles/day, 5-6 days/week

• High training volumes overuse



“To convert a merely good swimmer into a champion, you must expose him to what he

thinks is the ultimate agonizing limits of physical performance and then teach him

to go beyond that limit day after day”

James “Doc” Counsilman Indiana University


Specific Abnormalities in Swimmers

• Imbalance between internal and external rotators

• Goal: ER/IR ratio 65%

• Weakness of posterior cuff, serratus anterior, lower trapezius, rhomboids

• Tight pectoralis minor


Hours swum per week

5 10 15 20 25 30 35

Supraspinatus tendinosis

0.0 0.2 0.4 0.6 0.8 1.0 1.2

r = 0.35, p = 0.01



Sein, Murrell, et al.


Other Entities Causing

“Swimmer’s Shoulder”

Cervical spine

Labral tears/degeneration

IR + adduction loads superior labrum

Biceps tendinitis

AC joint arthrosis

Coracoid impingement

Coracoid apophysitis





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