Surgery and the Swimmer’s Shoulder

Take Home Points on Surgery and the Swimmer’s Shoulder

  1. The best rehabilitation program is initial prevention!
  2. If having pain, early intervention is necessary to avoid worse injury and perhaps surgery.
The decision whether to go for surgery is one of the biggest decisions for any swimmer.  For young swimmers, there’s only one chance to “get it right” for a successful age group or college career.  Unfortunately though, return from surgery is often an inexact science, particularly with many surgeons and therapists unfamiliar with unique needs in swimming.   
While our backgrounds in coaching and rehabilitation may naturally bias toward conservative non-surgical treatment, the formal medical literature does offer some guidance on appropriate candidates for surgery:
  
“[S]urgery for shoulder pain is considered a last resort, and pain itself should not be the
only indication for surgical stabilization.  Some possible indications for surgery include paresthesias (eg, "dead arm" syndrome), recurrent instability, or difficulty with activities of daily living.  Furthermore, a surgical evaluation should only be sought if 3 to 6 months of conservative treatment have failed.  The decision to perform surgery is not without consequences. It is important for swimmers to understand that surgery will most likely result in decreased ROM and may reduce their level of performance.  In fact, the lengthy recovery time and inherent variability in successful outcomes may end a swimmer's competitive career." (O’Donnell 2005)

Formal study on surgical outcomes among swimmers is limited compared to other populations but we can still learn from what is out there.  In one study on competitive swimming, Brushoj (2007) found that only 56% in their sample returned to preinjury level after four months.  However, there are many variables to consider as age, activity levels, early intervention, type of surgical procedure, surgical skill, therapist skill, and patient compliance will all effect long term outcomes.  

One confounding issue is that pathology alone is an unreliable guide for surgical candidacy.   “Imaging modalities rarely help clarify the diagnosis, their main role being exclusion of other pathology. If nonoperative treatment fails, an arthroscopy with debridement, repair, or reduction of capsular hyperlaxity is indicated. The return rate and performance after surgery is low, except in cases where minor glenohumeral instability is predominant.”  (Bak 2010) (See also Radiologic Imaging and the Asymptomatic Athletic Shoulder and Abnormal MRIs in Tennis Players)

Another consideration is that not all shoulders are created equal.  Although swimming, tennis, baseball, and water polo are all overhead sports involving high repetitions, it’s possible that anatomical changes may naturally result from specific biomechanics in each sport.  Many studies exist on post-surgery return-to-play protocols for baseball players, but recent literature suggests that comparing swimmers to baseball players as surgery candidates is not always ideal.

In a study involving athletes from multiple sports, “Swimmers had fewer intraarticular abnormalities than baseball players. We found a wide spectrum of intraarticular abnormalities in the shoulder of overhead athletes with shoulder pain requiring surgery. Additional study is needed to determine whether these abnormalities or combinations relate to specific athletic movements.”  (Dewan 2012) In other words, one adaptation considered “abnormal” for one sport may be a beneficial change for another sport.  Anecdotally, such changes may relate both to soft tissue and bones, particularly with malleable skeletons in youth and college swimmers. 

What ultimately matters is function, not merely structure.  Many swimmers are told they have “impingement” as a default diagnosis, yet “It has become evident that "impingement syndrome" is not likely an isolated condition that can be easily diagnosed with clinical tests or most successfully treated surgically. Rather, it is likely a complex of conditions involving a combination of intrinsic and extrinsic factors.  We further recommend investigation of mechanical impingement and movement patterns as potential mechanisms for the development of shoulder pain, but clearly distinguished from a clinical diagnostic label of "impingement syndrome". (Braman 2013)   

Conclusion
The best way to avoid surgery is to not get hurt in the first place!  That point should be obvious, but often forgotten in the heat of battle.  Know that early intervention is critical, whether through injury prevention training or through rapid referral to a skilled rehabilitation professional. (See also, A Swimmer's Guide to the Alphabet Soup of Rehabilitation Professionals) That said, remember that even the surgical literature recommends several months of conservative care before surgical interventions should be considered.  Always consider pain, movement, and biomechanics and not merely the underlying structure when making surgery decisions.

If looking for a preventative or rehabilitative shoulder program, consider the COR Swimmer's Shoulder System!



References
  1. Braman JPZhao KDLawrence RLHarrison AKLudewig PM.  Shoulder impingement revisited: evolution of diagnostic understanding in orthopedic surgery and physical therapy.  Med Biol Eng Comput. 2013 Apr 10. [Epub ahead of print]
  2. Dewan AKGarzon-Muvdi JPetersen SAJia XMcFarland EG.  Intraarticular abnormalities in overhead athletes are variable.  Clin Orthop Relat Res. 2012 Jun;470(6):1552-7. doi: 10.1007/s11999-011-2183-5.
  3. Brushøj CBak KJohannsen HVFaunø P.  Swimmers' painful shoulder arthroscopic findings and return rate to sports.  Scand J Med Sci Sports. 2007 Aug;17(4):373-7. Epub 2006 Jun 28.
  4. Bak K.  The practical management of swimmer's painful shoulder: etiology, diagnosis, and treatment.  Clin J Sport Med. 2010 Sep;20(5):386-90. doi: 10.1097/JSM.0b013e3181f205fa.
  5. O'Donnell CJBowen JFossati J.  Identifying and managing shoulder pain in competitive swimmers: how to minimize training flaws and other risks.  Phys Sportsmed. 2005 Sep;33(9):27-35. doi: 10.3810/psm.2005.09.195.
By Allan Phillips. Allan and his wife Katherine are heavily involved in the strength and conditioning community, for more information refer to Pike Athletics.

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