Swimming Energy Calculator

OttrLoggr: Energy Use Calculator

Swim Energy Usage

Distance
Time
:
RER
Stroke

RER Value Guide

Slow (0.7)
A1 band - warm-up, recovery, cool-down sets
Moderate (0.85)
A2 band - aerobic capacity sets
Intense (1.00)
A3 band - aerobic power, VO2max sets

Data Source: Zamparo P, Bonifazi M (2013). Bioenergetics of cycling sports activities in water.

Coded for Swimming Science by Cameron Yick

Freestyle data

Velocity
/s
Cost
kj/
Total Cost
kj
Calories
kcal
Carbs
g
Fat
g

Quick Food Reference

Bagel
48g Carbs
Apple
25g Carbs
Peanut Butter
16g (2 tablespoons) *

Are Push-Ups Safe for Swimmers?

Take Home Points on Are Push-Ups Safe for Swimmers?
  1. Push-ups are a safe and effective exercise for swimmers with proper biomechanics and programming.
Questioning the safety of push-ups seems like it would make for a rather straightforward article, and 
if it was as straightforward as it seems, I would say that they are undoubtedly safe, and an extremely effective exercise for swimmers, at that; however, we need to create some more questions in order to form an educated answer. Is the coach qualified to supervise a push-up? Do they know what to look for in the exercise? Do they understand what variations may be best for different populations? Is the athlete doing enough mid and upper back work to balance the effect push-ups may have on the muscles of the shoulder girdle? 

Is the Coach Qualified to Supervise a Push-Up and Do They Know What to Look For?

When I say ‘qualified’ I don’t mean certified in Strength and Conditioning, or having a background in exercise science, all I mean by this, is that the coach or athlete has a basic understanding of what is really happening during a push-up, and what contraindications to look for in their respective populations.

Some of the most common flaws in an athlete’s push-up pattern are: poor arm position (either too close or too far from the body), extended or flexed head position (looking up, or down too far), and the most common—sunken hips with an arched back.

When judging arm position the rule of thumb is to put 45 degrees of space between the torso and the upper arm. This 45 degree position prevents the athlete from flaring the arms out too far and therefore placing too much stress on the shoulder girdle, it also prevents the arms from being in too close, causing too much flexion at the elbow, and therefore acute elbow pain or tendinitis.

A flexed head position is caused simply by the athlete either looking to make sure the arms are in the correct spot or just general poor body awareness (very common in swimmers). The best neck position is going to be neutral, where the head is looking straight down; not down at the feet, but simply down at the ground directly below their face.

An extended neck position is the result of some poor mechanics lower in the body. When the head is hyperextended, it is generally following the rest of the spine. When the spine is hyperextended, it is generally a result of passive restraints dominating throughout the core and hips. To mitigate this, the athlete must be cued to squeeze the glutes, as well as the abs. This whole complex of muscles firing is one reason why I trust athletes who tell me they can do 5 push-ups more than those who tell me they can do 50—at this number, it is very likely that the athlete is relying on passive restraints (ligaments, tendons, and bones) rather than actively engaging the appropriate muscles, and likely shortening range of motion, as well. 

If push-ups are done correctly, it is very possible for the abs and glutes to give out before the triceps or chest. This weakness usually subsides as the athlete becomes more experienced.

Does the Coach Understand What Variations May Be Best for Different Populations?

This question is crucial. Athletes have many different backgrounds, levels of experience, shoulder pathologies, leverages, and strength—all of which can drastically change exercise prescription. Most swimmers should stick with the simplest variations of push-ups, focusing on a tight core, as well as going through as large of a range of motion as possible (without pain). Even with a basic push-up many swimmers are not strong enough to demonstrate an entire set with decent form, and in many cases can’t even perform one single repetition. Many coaches here would have the athlete do push-ups from the knees, this variation however, tends to really hamper core activation, among other things, which drastically changes the movement. I prefer to have the athlete be assisted with bands. You can do this by setting up a large band around low pegs in a squat rack, then having the athlete lay over the band so that they are assisted as they get closer to the ground, and less as they get closer to the lockout, this is known as accommodated resistance. The further up the legs/torso that the band is placed, the athlete receives more assistance, the further down, less assistance is given. If a band is not available, a secondary option is to have the athlete perform a push-up to a bench or wall. Again, the more upright the athlete is, the most assistance they are receiving, so try to work the athlete to get close to the ground, and in the banded set up, have the athlete work at lowering the band placement each session. 

Some of my favorite progressions for the exercise are: hand-release, clapping, foot-elevated, single foot, gymnastic ring push-ups. These are all rather advanced and should only be attempted after a mastery of the standard push-up is present. On the other hand, some of the best regressions are the aforementioned band-supported, and incline push-ups (to a wall or bench).

It is very possible that having the hand on the ground during the push-up can irritate the athlete’s wrist. In this case, I suggest using dumbbells, placing them slightly outside of shoulder-width, and having them turned so that the hands can be slightly supinated—this will further reduce pain/ joint problems. Dumbbells with hexagonal bells are ideal here because they won’t roll away from the athlete during the movement. 

Is the Athlete Doing Sufficient Upper and Mid-Back Work to Balance the Effects of the Push-Ups?

Push-ups are partially so awesome because they can be done anywhere that there is the space to perform them, but what is not so awesome is that push-ups can make up far too much of a swimmers dryland program because there may be very restricted access to further equipment. Too many pressing exercises can pull the shoulder girdle forward over time causing pain, as well as poor performance. To counter problems associated with this, we must make sure that enough work is in place for the mid and upper back to keep the shoulder girdle in a neutral resting position. Many strength coaches go as far as saying that the ratio of pulling to pushing exercises should be 3:1, I however, think 1.5:1 is more reasonable, as long as the athlete already has a decent resting posture. 

This back work should hit the lats, traps (upper, mid, and lower), rhomboids, and rear delts. Great exercises for this are dumbbell rows, pull-ups, chest-supported rows, rear delt raises, among others. There are thousands of variations to the exercises already listed, focusing on these, and variations thereof, will give you enough dryland programs to last for years. 

Many argue that the demands on the back are high enough in swimming that there should be a reduction in back work during dryland to compensate. The work done by the back in swimming is usually too low in intensity/load to make significant hypertrophic differences, plus the fact that outside of the pool time, many athletes are in a state of flexion, be it at a desk at work or school, at home watching tv, or driving, which all needs to be accounted for (the 22 hours outside of practice are frequently overlooked during program design). 

The push-up is a fantastic exercise for swimmers and should be a mainstay of a swimmers’ training programs. Proper coaching of the exercise is more likely to determine its safety and effectiveness more so than any other factor. Keeping exercises balance is another huge key to long-term athletic development and safety, so be sure to implement a full dryland regimen to improve body awareness, speed, and conditioning.

Written by John Matulevich a powerlifting world record holder in multiple lifts and weight classes, as well as a Head D-2 Strength Coach, and previously a nationally ranked college athlete. His concentrations are in sports performance, powerlifting, and weight training for swimming. To learn more about how John trains his athletes, check his Twitter page: @John_Matulevich. He can also be reached at MuscleEmporium@gmail.com with inquiries.

Are Ice and NSAIDs Beneficial for Recovery?

Take Home Points on Are Ice and NSAIDs Beneficial for Recovery?
  • Ice helps decrease pain, but does increase muscle damage.
  • NSAIDs restore function, but improve bone, but not soft tissue healing.
The use of non-steroid anti-inflammatory drugs (NSAIDs) and ice are common staples in
sports medicine. Yet, the use of these modalities has recently received resistance from some online experts (Kelly Starrett, Dr. Gabe Mirkin). Despite this criticism, these modalities are still frequently used, sometimes ad libium. Now, before I make a notion on these modalities, it is important to understand the injury process, below is an exert from the COR Swimmer's Shoulder System.

Everyone is familiar with inflammation. The inflammatory process occurs within seconds of every injury, but can linger for weeks or months with bad injuries or poor management.

Inflammation is stemmed by the infiltration of cells, entitled neutrophils, during the first 6-24 hours; they are replaced by other cells (monocytes) in 24-48 hours. These cells will try to attack the inflammation and remove injurious agents. Phagocytosis is involved in the process of engulfing foreign particles and releasing the enzymes of neutrophils and macrophages which are responsible for eliminating the injurious agents. These are two major benefits derived by the accumulation of leukocytes at the inflammatory site.

Chronic inflammation is a different warrior. The key player is another type of cell, the macrophage. Macrophages are large cells that can remain for weeks to months, perpetuating injuries.

The classic signs and symptoms of inflammation are swelling, redness, throbbing, radiating heat, and constant pain. These pains especially occur when you wake up in the morning and last between thirty and sixty minutes. Also, just because you had the initial injury four months ago doesn’t mean inflammation has resolved or hasn’t returned, so pay closer attention to the signs and symptoms as opposed to the duration.

Once again, the inflammtory process initiates every injury. This process is beneficial in restoring the body, but does decrease strength. This decrease in strength is why many seek improvement [well and the pain]. This has resulted in the use of the two most common modalities NSAIDs and ice. Unfortunately, these two modalities may prevent the normal physiological reaction of an injury. This impairment is thought to alter long-term improvement. However, many people take NSAIDs and ice for short-term gains. If someone needs improvement, for a quick return to the pool, then NSAIDs and ice are beneficial. However, the use of these modalities likely decreases long-term recovery, perhaps increasing the risk of re-injury. Unfortunately, most of this research is based on rodents, not humans and as I've mentioned before, rodents have different inflammatory processes! This makes the research nontransferable to humans ... oh well! Nonetheless, lets look at the research we have!

NSAIDs on Healing

The authors reviewed the effectiveness of NSAIDS and selective (COX-2 inhibitors) NSAIDS on soft tissue and bone healing. A total of 44 articles reviewed (9 on soft tissue and 35 on bone healing). Thirty-nine of these articles were on animals and 5 on humans.

No humans studies have been done on humans assessing the interaction between NSAIDS and soft tissue healing. Of the studies reviewed, there is a controversy between the administration of selective and non-selective NSAIDS after surgery, as many studies suggest detrimental effects on bone and soft tissue healing. However, the literature on this subject in humans is minimal.

It appears inflammation mediated by prostaglandins is necessary to improve bone healing. However, in soft tissue injury, growth factors are more important and prostaglandins less involved. This suggest NAIDS are likely beneficial in soft tissue, but potentially not bone healing.

Improving inflammation is necessary to decrease symptoms, however the use of NAIDS during bone repair may impair recovery, therefore only use NSAIDs in soft tissue injuries. However, more human clinical trials are necessary before a definitive answer is possible.

NSAIDs on Gut Bacteria

One potential hazardous result of NSAID consumption is the potential loss of integrity of bacteria, making the gut permeable to harmful substance.

Nine male trained cyclists underwent small intestine lining permeability in four different conditions (Van Wijck 2012):

1) during and after cycling after intake of ibuprofen

2) during and after cycling without ibuprofen

3) rest with prior intake of ibuprofen

4) rest with prior ibuprofen intake

The small intestinal lining was evaluated by providing the subjects a sugary drink, then assessing the amount of human intestinal fatty acid binding protein (I-FABP).

The ibuprofen conditions took 400 mg of ibuprofen the night before and 1-hour prior to cycling on a fasted stomach. The cyclist performed roughly 90 minutes of cycling at moderate/hard cycling.

In both exercise conditions, the I-FABP levels gradually increased with cycling. However, cycling with ibuprofen ingestion resulted in even high levels of I-FABP.

These results show cycling alone increases both gastroduodenal and small intestinal permeability. This difference increased with ibuprofen intake. This is thought to be from splanchic hypoperfusion, reducing the blood to the gut and including injury to the enterocytes. One of the major pathways suspected for GI damage is:

“to be involved is the inhibition of COX isotypes 1 and 2, resulting in local inflammation and vascular dysregulation, ultimately reducing perfusion and promoting mucosal integrity loss within the splanchnic area (Van Wijck 2012)”.

Unless ergogenic benefits from NSAIDs exists, swimmers should not use these medications prior to exercise. Moreover, inflammation may yield greater results in endurance sports. One flaw with the study is the fact the athletes were fasted while taking NSAIDs. However, one note is the athletes were fasted during this test, this may have increased the intestinal lining to susceptibility.

For rehabilitation, NSAIDs may still be beneficial, but at this time it is not certain if the benefits outweigh the risks.

Ice and Muscle Damage Healing

Eleven male college baseball players underwent two trials: sham application and topical cooling. Each trial was used five sessions of 15-min cold pack application to the exercised muscles 0 hours, 3 hours, 24 hours, 48 hours, and 72 hours after eccentric exercise training.

The eccentric training protocol consisted of 6 sets of 5 eccentric contractions with 2 min rest between sets at 85% of their maximal strength. Muscle hemodynamics (hemoglobin most notably), inflammatory cytokines (multiple interleukins), muscle damage markers (Creatine kinase), visual analog scale (VAS), and muscle isometric strength.

After topical cooling, rapid and sustained elevations in total hemoglobin and tissue oxygen saturation were noted. Also, creatine kinase was noted in both trials, but was elevated after topical cooling. Inflammatory markers were not changed following cooling. VAS was not different between groups, however topical cooling significantly increased rating of fatigue post-exercise. No significant differences were noted in strength between groups.

Increased muscle damage, most notably the creatine kinase increase, was apparent in the topical cooling group. This is thought to occur from the rapid deviation in blood supply to the muscle.

Using ice after practice improves muscular soreness, but appears to increase muscle damage due to rapid changes in ischemia. Therefore, unless injured topical cooling should be avoided.

Ice and Blood Flow

Nineteen subjects participated in this single-blinded, where the clinician was blinded. There was no history of lower extremity injuries for the past 6 injuries. Each participant visited the laboratory four separate times where baselines were measured at the first two visits, then the next two visits a trial of ice (750-g of crushed ice placed on the medial gastrocnemius) and a control trial.

“There was a significant correlation (r = 0.49) between subcutaneous tissue thickness and change in intramuscular temperature immediately after treatment (P = 0.05) for the cryotherapy condition. Significant correlations were also found for change in temperature during the rewarming period and change in blood volume at rewarming (r = 0.53, P = 0.033) and change in blood flow at rewarming (r = 0.56, P = 0.025) for cryotherapy (Selkow 2012)”.

Microvascular perfusion of the gastrocnemius did not decrease from baseline with cyrotherapy was applied, despite the decrease in subcutaneous temperature. The result was different than past studies, as many think cryotherapy decreases blood flow. This may be from no alterations noted in the microvascular.

In the healthy population, cryotherapy appears not to alter blood-flow. Therefore, benefits and risks associated with cryotherapy application for inflammation may be negligible. However, next research must look at inflammation specifically. Until then, the effects of ice for injuries seem purely for slowing nerve conduction to gate pain.

NSAIDs or Corticosteroids for Recovery


Zheng (2014) performed a systematic review of all the high-quality studies comparing NSAIDs and corticosteroid injections, a total of ten full articles. Overall, 267 patients were analyzed and of the six studies two focuses on rotator cuff tendonitis patients, two on shoulder impingement syndrome, one studied frozen shoulder of diabetes and the other investigated shoulder pain.

Of these studies, NSAIDs and corticosteroids did not have a significant difference in pain improvement. Corticosteroids were significantly better for remission of symptoms. Five of the studies reported range of active shoulder abduction and note NSAIDs did not significantly improve the active shoulder abduction compared to corticosteroids. The studies assessed were 4 – 6 weeks in length.

Compared to NSAIDs, corticosteroid injections provide faster relief. However, comparisons of other therapies and conjunctions of therapy are needed, as well as longer study periods and follow-ups.

My Recommendations


If you are injured, stop exercising. If the pain is non-stop, see a rehabilitation specialist like a physical therapist. At this time, apply ice, as it does reduce pain and doesn't seem to alter blood flow. However, apply the ice for a short period, as it may increase muscular damage. I suggest applying the ice for up to 10 minutes and remove it for 20 minutes. Only ice immediately after the injury, ~6 hours after the injury. If you are competing at a meet and must perform, NSAIDs can help decrease pain and restore function. However, if you are not in a rush for return, try not to ice and consider compression instead. Compression helps naturally clear the fluid from the joint, facilitating recovery. When you are able to move comfortably without pain, do so. Movement also helps move fluid out of the joint and restore function. However, do not move into pain, as this can alter movement patterns and impair function. 

Try and prevent using NSAIDs, unless unrelenting pain exists and the injury appears muscular. If recovering from an injury, a corticosteroid injection is likely better than just NSAIDs, but remember other rehabilitation is needed. 

We have much more research needed on the subject, but it isn't clear that ice and NSAIDs are a “no brainer”. Until more research is performed, I'll continue the suggestions I've made for years, if you're in no rush, let the inflammation naturally make it's way throughout the body, giving yourself rest and compression for improvement. Once you're able to move naturally do so! However, if you are in a rush, like at a big competition and need to get in the pool, NSAIDs and ice can help!

References

By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

Subacromial Bursa Thickness and Swimming Shoulders

Take Home Points on Subacromial Bursa Thickness and Swimming Shoulders
  1. Changes to subacromial bursa thickness correlate poorly with painful symptoms
  2. Always consider imaging changes in their full context of structure, symptoms, and training load
  3. Certain changes may be a natural adaptation to repetitive movements in swimming
Shoulder injuries are an unfortunate reality in swimming.  We’ve written about this general topic before (Radiologic Imaging and the Asymptomatic Athletic Shoulder), but have additional information to add based on recent studies and with a focus on a particular shoulder area, the subacromial bursa. 

One “en vogue” diagnosis in rehabilitation has been bursitis.  For non-radiating pain with generalized pain symptoms, many providers will simply diagnose the condition as bursitis when they can’t figure out the underlying cause.  It might be harsh to call this a throwaway diagnosis, but in some cases that’s the unfortunate reality.   While this may in fact be correct in some cases, in others it may overlook the underlying problems entirely. 

The diagnosis is only part of the story without addressing overall function (that a whole topic unto itself).  But the focus in this post will be the significance of whether changes to the subacromial bursa are meaningful indicators for painful shoulders. 

Most recently, Couainis (2014) studied 22 open water marathon swimmers competing in a 19.7km event.  Ultrasounds were taken four months and two weeks prior to the race and one week after.  Authors noted the following findings:
  • SAB (subacromial bursa) thickness is significantly correlated with kilometres swum in the pool in the preceding week.
  • SAB thickness was not significantly correlated with pain when measured prior to the race.
  • At 1 week post-race, SAB thickness of shoulders with pain were significantly greater than those without pain
Now does this mean SAB thickness is a meaningful pain indicator?  Maybe but maybe not.  Authors conclude that painless SAB thickening may be a natural adaptation to repetitive swim mechanics when viewed chronically and thus not a cause of painful symptoms.  But when viewed acutely after a triggering event, increases in SAB thickness may in fact be meaningful.  Ultimately, “these two entities can only be differentiated by clinical history and examination.”  Also consider training factors.  Although most pool swimmers won’t swim 19.7km continuous, a series of hard training bouts may cause changes to structure and trigger painful symptoms.  (See, Hell Weeks and Swimming; Hell Weeks and Swimming Revisited)   

Appreciating the connection (or lack thereof) between SAB thickness and symptoms is especially important in determining whether to have surgery and in evaluating post-op outcomes.  Remember that many clinicians, though highly competent and well meaning, may not always appreciate the specialized demands of swimming and may not be aware of structural changes that accompany swimming biomechanics.

Hodgson (2012) studied patients with full thickness rotator cuff tears detected by ultrasound, with 18 having pain and 15 having no pain.  After finding no relationship between SAB thickness, rotator cuff tears, and pain, authors concluded, “Although enhancement of the subdeltoid/subacromial bursa was common, no evidence was found to support the hypothesis that bursal enhancement is associated with pain in rotator cuff tears. It is therefore unlikely to determine reliably which patients would benefit from rotator cuff repair. Advances in knowledge Bursal enhancement and thickening does not reliably correlate with symptoms or presence of rotator cuff tear.”

Studying post-op shoulder patients after rotator cuff surgery, Tham (2013) found short term increases in SAB thickness up to six months (along with increases in tendon vascularity and posterior glenohumeral capsule thickness), but noted these changes normalized after six months.  Ultimately, there was no significant connection between structural changes and pain. 

Conclusion

Nothing here is a new message, but recent literature reinforces what had already been suggested in prior findings.  Changes to structure observed through advanced imaging are only one piece of the puzzle in evaluating painful swimming shoulders.  Key take home point is to not only to correlate imaging with clinical findings but also to appreciate how modulations to training load may affect the swimmer’s condition, as both recent and long term training may determine what is normal and what is abnormal for each individual swimmer’s shoulder.  

References

  1. Tham ER1, Briggs L, Murrell GA.  Ultrasound changes after rotator cuff repair: is supraspinatus tendon thickness related to pain?  J Shoulder Elbow Surg. 2013 Aug;22(8):e8-15. doi: 10.1016/j.jse.2012.10.047. Epub 2013 Jan 23.
  2. Couanis G, Breidahl W, Burnham S.  The relationship between subacromial bursa thickness on ultrasound and shoulder pain in open water endurance swimmers over time.  J Sci Med Sport. 2014 May 20. pii: S1440-2440(14)00087-5. doi: 10.1016/j.jsams.2014.05.004. [Epub ahead of print]
  3. Hodgson RJ1, O'Connor PJ, Hensor EM, Barron D, Robinson P.  Contrast-enhanced MRI of the subdeltoid, subacromial bursa in painful and painless rotator cuff tears. Br J Radiol. 2012 Nov;85(1019):1482-7. doi: 10.1259/bjr/45423226.
Written by Allan Phillips is a certified strength and conditioning specialist (CSCS) and owner of Pike Athletics. He is also an ASCA Level II coach and USA Triathlon coach. Allan is a co-author of the Troubleshooting System and was selected by Dr. Mullen as an assistant editor of the Swimming Science Research Review. He is currently pursuing a Doctorate in Physical Therapy at US Army-Baylor University.

Forgotten Aspect of Swimmer's Shoulder Prevention/Rehabilitation: Motor Control Training!

Take Home Points on the Forgotten Aspect of Swimmer's Shoulder Prevention/Rehabilitation: Motor Control Training!

  1. Overhead sports increase shoulder laxity and decrease motor control.
  2. Shoulder impingement decreases motor control of the shoulder.
  3. A complete shoulder injury prevention program must include motor control training.
Recently, I've been writing extensively for About.com about the shoulder injury rate in
swimming and the future injury rate. Overall, the exact prevalence of shoulder pain in swimmers was 3% in a study published in 1974 and has increased in recent publications: 42% in 1980 (Richardson 1980; Neer 1983), 68% in 1986 (McMaster 1987), 73% in 1993 (McMaster 1993), 40 – 60% in 1994 (Allegrucci 1994), 5 – 65% in 1996 (Bak 1996), 38% (Walker 2012). These rates in frequent surgeries for the swimmer's shoulder.

Even more disturbing is the prevalence of shoulder pain. Eighty-five percent of high school-aged swimmers reported mild shoulder pain in the past year, 61% reported moderate shoulder pain, and 21% reported severe shoulder pain. Of these, only 14% had been to a physician (Hibberd 2013). Also, 47% of these swimmers report using pain medication one or more times per week (Hibberd 2013). These unsafe and improper practices increase burnout, prevent swimming improvement, ending many swimmer's careers.

This results in many swimming programs performing elongated shoulder injury prevention
programs. Despite their best intentions, traditional shoulder prevention programs do not improve shoulder blade strength and control, termed motor control (Hibberd 2012). Even worse, many programs incorporate dangerous shoulder stretching programs which further increase instability at the shoulder, leading to worse shoulder motor control [consider mobility for swimmers, a more practical use of mobility training and static shoulder stretches].

I commonly refer to motor control as timing, a simpler way of understanding the importance of timing between various muscles at the joint. 

Shoulder impingement is thought to be the most common cause of shoulder pain in swimmers. There are several causes of shoulder impingement, one is poor motor control of the peri-scapular muscles. Overhead athletes undergo high levels of stress at their shoulder during maturation.  This high force is thought to cause microtrauma that over time causes adaptive changes which increase one's injury risk. One adaptive change is adapting the soft tissue around the shoulder, causing an increased range of motion which is thought to affect the shoulder motor control. However, as the motor control decreases, so does an athlete's ability to maintain correct biomechanics. Does high volume of overhead motions decrease motor control?

Motor Control in Healthy Overhead Athletes

Launder (2012) analyzed thirty collegiate baseball players (13 pitchers and 17 position players) without a history of shoulder injury for the past two year.

Shoulder motor control was tested on the throwing arm with the participant in the seated position with the shoulder and elbow flexed 90 degrees. Then, the shoulder was moved into 75 degrees external rotation, 30 degrees external rotation, or 30 degrees internal rotation. With the participant blindfolded, the shoulder was moved into one of these three positions, then the arm was held there for 10 seconds. After this, the arm was moved into a different position and then asked to return to the last position. The mean error for each position was measured.

The mean anterior shoulder deviation was 14.1 mm. There was no relationship between anterior glenohumeral laxity with 30 degrees internal an external rotation. However, there was a moderate association between anterior glenohumeral laxity with 75 degrees external rotation.

This study suggests as the amount of shoulder range of motion increases, the greater decrease in shoulder motor control. 

“This is most likely due to the increased tension placed on the static restraints and potentially increased activity of the mechanoreceptors at the higher range of shoulder external rotation (Launder 2012)”.

These findings suggest prevention programs should focus on improving motor control at the end-range of motion. However, it can not be concluded increased joint laxity causes altered joint proprioception.

In swimming, high amounts of shoulder range of motion are used for swimming success. Unlike baseball, swimming uses high amounts of shoulder internal rotation during the catch. This study showed 30 degree internal and external rotation did not find association with altered position sense, but did not assess full internal range of motion. However, this reviewer hypotheses large internal rotation results in similar motor control deficits. This suggests proprioception training at full range internal range of motion is required for prevention of injury of swimmers.

Motor Control and Shoulder Impingement

Worsley (2012) matched sixteen young adults with shoulder pain with 16 healthy controls. All those with shoulder pain were assessed for shoulder impingement manually and with ultrasound. Then, the group received motor control training where alignment, coordination, proper scapular orientation at rest, specific muscle (trapezius and serratus anterior), and manual therapy. The intervention was performed at home twice a day for 10 weeks, with 5 follow-up appointments.

Before and after the intervention scapular kinematics and surface electromyography of the shoulder muscles were assessed. Subjective questions of function were also provided before and after the intervention.

Before the intervention, the impingement group demonstrated  significant muscle delays in both the serratus anterior and lower trapezius. However, these muscles also had early termination during arm lowering in all planes. Imagine a swimmer having a delay of their muscles rotating the their shoulder for 1,500 strokes during a practice!

After the intervention, the subjective exam (shoulder pain and disability index, SPADI) improved significantly, on an average of 3.4 points [not a huge drop, but not bad for the intervention applied]. Also, post-intervention the delayed onset of muscle activation reduced significantly for these muscles.

This study further suggests improving motor control or muscle timing of the periscapular muscles for shoulder rehabilitation. 

Further studies the blinding of athletes is necessary, as well as a comparison intervention group, and more subjects. Moreover, the use of surface EMG increases the amount of cross-talk between muscles, further confirmation studies should utilize fine wire EMG. Unfortunately, until this research is performed all those seeking ideal shoulder injury prevention and rehabilitation should include shoulder motor control or timing exercises. I've been advocating these forms of exercises for swimmers for the past three years with limited acceptance in the shoulder prevention community. Let's change the course of shoulder injury in swimmers and start adding shoulder motor control training today! 

Check out this motor control exercise:

If looking for a complete shoulder injury prevention and rehabilitation program for swimmers including muscle length, strength, timing and improved biomechanics, check out the COR Swimmer's Shoulder System!

References:

  1. Worsley P, Warner M, Mottram S, Gadola S, Veeger HE, Hermens H, Morrissey D, Little P, Cooper C, Carr A, Stokes M. Motor control retraining exercises for shoulder impingement: effects on function, muscle activation, and biomechanics in young adults. J Shoulder Elbow Surg. 2012 Sep 1.
  2. Laudner KG, Meister K, Kajiyama S, Noel B. The Relationship Between Anterior Glenohumeral Laxity and Proprioception in Collegiate Baseball Players. Clin J Sport Med. 2012 Aug 14. [Epub ahead of print]
  3. Hibberd EE, Oyama S, Spang JT, Prentice W, Myers JB. Effect of a 6-week strengthening program on shoulder and scapular-stabilizer strength and scapular kinematics in division I collegiate swimmers. J Sport Rehabil. 2012 Aug;21(3):253-65. Epub 2012 Mar 2.
  4. Hibberd EE, Myers JB. Practice Habits and Attitudes and Behaviors Concerning Shoulder Pain in High School Competitive Club Swimmers. Clin J Sport Med. 2013 Sep 13. [Epub ahead of print]
  5. McMaster WC, Troup J. A survey of interfering shoulder pain in United States competitive swimmers. Am J Sports Med. 1993; 21:67-70.
  6. McFarland EG, Wasik M. Injuries in female collegiate swimmers due to swimming and cross training. Clin J Sport Med. 1996 Jul; 6(3):178-82.
  7. Muth S, Barbe MF, Lauer R, McClure PW. The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy. J Orthop Sports Phys Ther. 2012 Dec;42(12):1005-16. doi: 10.2519/jospt.2012.4142. Epub 2012 Aug 17.
  8. Travell, J. Simons, D. Myofascial Pain and Dysfunction The Trigger Point Manual. Williams and Wilkins 1983.
  9. Tucker, Ross. "Training, Talent, 10000 Hours and the Genes."The Science of Sport. 11 Aug. 2011. Web. 08 Jan. 2012. .
  10. Weir PL, Leavitt, JL. Effects of model's skill level and model's knowledge of results on the performance of a dart throwing task. Human Movement Science. 1990 Sept; 9(3): 369-383.
  11. Wilk, KE, Reinold, MM, Andrews JR. The Athlete's Shoulder. Elsevier Health Sciences, 2008
  12. Kenal KA, Knapp LD. Rehabilitation of injuries in competitive swimmers. Sports Med. 1996 Nov;22(5):337-47. Review.
  13. McMaster WC, Roberts A, Stoddard T. A correlation between shoulder laxity and interfering pain in competitive swimmers. Am J Sports Med. 1998 Jan-Feb;26(1):83-6.
  14. Stocker D, Pink M, Jobe FW. Comparison of shoulder injury in collegiate- and master's-level swimmers.Clin J Sport Med. 1995;5(1):4-8.
  15. Ruwe PA, Pink M, Jobe FW, Perry J, Scovazzo ML. The normal and the painful shoulders during the breaststroke. Electromyographic and cinematographic analysis of twelve muscles.Am J Sports Med. 1994 Nov-Dec;22(6):789-96.
  16. Bak K. Nontraumatic glenohumeral instability and coracoacromial impingement in swimmers. Scand J Med Sci Sports 1996;6(3):132-144.
  17. Richardson AB, Jobe FW, Collins HR. The shoulder in competitive swimming. Am J Sports Med 1980;8(3):159-163.
  18. Neer CS, 2nd. Impingement lesions. Clin Orthop 1983(173):70-77.Allegrucci, Whitney SL, Irrgang JJ. Clinical implications of secondary impingement of the shoulder in freestyle swimmers. J Orthop Sports Phys Ther 1994:20(6):307-18.

By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University where he swam collegiately. He is the owner of COR, Strength Coach Consultant, Creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

Loaded Eccentric Training for Swimmer's Shoulder

Take Home Points on Loaded Eccentric Training for Swimmer's Shoulder

  1. Loaded eccentric shoulder training may improve shoulder strength.
  2. Loaded eccentric shoulder training does not improve function more than traditional shoulder impingement rehabilitation programs. 
Shoulderinjuries are the most common site of injury in swimming. Specifically, shoulder
impingement is the most common injury, commonly called swimmer's shoulder. However, two types of impingement exist, requiring further classification:

Shoulder external impingement (Subacromial Impingement)

This is the most common injury associated with a swimmer. In fact, the term “swimmer’s shoulder” is synonymous with shoulder impingement. However, in recent years the volume of external impingements in has decreased swimming is decreasing secondary to an increase in types of impingement (see below). External impingement is usually caused by an inflamed rotator cuff tendon (supraspinatus) that gets pinched while raising your arm overhead. The symptoms are noticeable during a “painful arc” of overhead motion of 60-130 degrees (for example, the recovery of freestyle). There are many causes for the rotator cuff to be pinched, most commonly irritation to a tendon is the cause. Often times, the area is irritated because the muscles around the shoulder are too tight, decreasing the area in the front of the shoulder and rotator cuff, thereby causing compression.

Shoulder internal impingement

Internal impingement involves the infraspinatus, a rotator cuff muscle located in the back of the shoulder. Repeated internal rotation (for example, the freestyle catch) can pull the labrum. The infraspinatus pulls on the labrum either due to tightness of the infraspinatus, weakness of the shoulder upward rotator muscles, or poor timing of the infraspinatus during stressful tasks causing irritation to the infraspinatus, labrum, or both.

Eccentric Exercise for Subacromial Impingement

Eccentric exercises have recently been found beneficial in tendon injuries, especially in the hip and ankle. Tendon degeneration occurs in subacromial impingement and heavy eccentric loading is believed to increase collagen production. Research of the shoulder with heavy eccentric exercises is lacking, but associations suggest that heavy eccentric exercise should improve shoulder impingement.

Maenhout et al. looked at sixty-one patients with subacromial impingement were randomly assigned to the traditional rotator cuff training (TT) or traditional rotator cuff training with heavy load eccentric training (ET). Isometric strength of abduction at 0, 45 and 90 of scapular abduction and internal/external rotation was measured. A questionnaire was used to measure shoulder pain and function. Outcomes were assessed at baseline, at 6 and 12 weeks after starting the intervention. The traditional rotator cuff training performed rotator cuff strengthening exercises 1x/day and the rotator cuff training and eccentric training group performed normal rotator cuff training 1x/day and heavy load eccentric exercise training 2x/day for 12 weeks with 9 physiotherapy treatments.

Results of Loaded Eccentric Training for Swimmer's Shoulder

Improvements in strength was greater in all directions in both groups, with the TT + ET group showed 15% higher gain in abduction strength at 90 degrees. Self-rated perception of improvement was similar in both groups.

Practical Implication of Loaded Eccentric Training for Swimmer's Shoulder

The improvement in strength is promising, but the mechanism of strength improvement was not physiologically analyzed. Also, the lack of self-reported function improvement is discouraging, as function is the the biggest factor in sports. Another problem with this study is the difference in training volume between groups. The extra volume in the TT + ET group could (and is likely) the reason for improvement.

For those with subacromial swimmer's shoulder, adding heavy eccentric exercises in
combination of traditional physical therapy rehabilitation may improve strength. Unfortunately, swimmer's commonly have secondary impingement our internal impingement of the infraspinatus, not the supraspinatus. Therefore, it is important to realize not all impingements are the same and subacromial impingement is unlikely for young swimmers. Also, remember biomechanics and other aspects of rehabilitation are as essential as improving strength. At COR, we provide a balanced approach of rehabilitation and return to swimming, ensure your rehabilitation program fits the bill. 

Reference

  1. Maenhout AG, Mahieu NN, De Muynck M, De Wilde LF, Cools AM. Does adding heavy load eccentric training to rehabilitation of patients with unilateral subacromial impingement result in better outcome? A randomized, clinical trial. Knee Surg Sports Traumatol Arthrosc. 2012 May 12.
Written by G. John Mullen received his Doctorate in Physical at University of Southern California (USC) and is a certified strength and conditioning specialist (CSCS). At USC, he was a clinical research assistant performing research on adolescent  diabetes, lung adaptations to swimming, and swimming biomechanics. G. John has been featured in Swimming World Magazine, Swimmer Magazine, and the International Society of Swim Coaches Journal. He is currently the owner of COR, providing Physical Therapy, Personal Training, and Swim Lessons to swimmers and athletes of all skills and ages. He is also the creator of the Swimmer's Shoulder SystemSwimming ScienceSwimming Science Research Review, and the Swimming Troubleshooting System.

Friday Interview: Dr. Kristof De Mey Discusses TRX and Redcord Training

For more background on Dr. Kristof De Mey, please read: Friday Interview: Kristof De Mey | Swim Sci

1. You recently published an article on muscle activation and Redcord slings, could
you explain what your study looked at?
We questioned whether the use of the slings had an effect on the shoulder muscle activation levels. We did that by using surface electromyography during 4 closed kinetic chain exercises commonly performed in practice: half push-up, knee push-up, knee prone bridging plus, and pull-up.

2. What were the main results of this study?
When using the slings, serratus anterior muscle activation decreased during the knee push-up and knee prone bridging plus exercise. In addition, a drastic increase in pectoralis major muscle activation was found during the half push-up and knee prone bridging plus exercise. This means that the use of Redcord slings does not necessarily imply that higher levels of scapular stabilizer muscle activation will be attained. Consequently, these findings suggest Redcord slings might be an appropriate training tool when used within a general strengthening program, but should not be preferred over a stable base of support when training for specific scapular stabilization purposes.

3. With TRX band extremely common in swimming, I thought this study was extremely pertinent. Do you think a coach should include TRX or Redcord slings with the hopes of injury prevention?
Yes. I think they can both be of added value, despite the scientific evidence to state that they will lower the risk for e.g. shoulder impingement symptoms in swimmers is not yet there. On the other hand, the effectiveness might be influenced by the underlying reason that is causing the symptoms. In case lack of muscle control and strength could not be identified as one of the major causes of the symptoms (but instead e.g. structural issues as rotator cuff tendinopathy or SLAP lesions can be diagnosed by clinical examination and/or medical imaging), one should question the relevance of using the slings. Also, based on the results of our study, slings should not be used when the goal is to re-train the local muscle system responsible for low-level stabilization. The slings seem to have a more general impact on both the local and the global musculature, what is not wanted in this initial phase of training. Nevertheless, for general training purposes, it may be a very interesting tool to work with. Overall, more research is needed on this topic, since making clinical conclusions based on just one study is never a very good thing to do.

4. Now you only looked at four exercises, do you think any other exercises would show different results?
Yes. If you take a closer look at the results, you will see the influence varies between exercises. This means that we have to conclude that making general statements as “slings are good or bad” should be avoided. Probably, the truth will be in between. As with so many stuff in this area, a multitude of factors determine the effect of an application or intervention. Consequently, what research can tell is remains limited when compared to an individual approach (despite research is needed to have a better insight at those factors we should individually look for in practice).

5. What research or projects are you currently working on or should we look from you

in the future?
I finished my PhD this year titled: ‘Scapular Muscle Recruitment during Shoulder Impingement Rehabilitation and Injury Prevention Exercises for Overhead Athletes’. Since September, I´m working as a Sports Technology / Business developer for ‘Victoris’, the valorization centre at our University. You will see more info soon on www.victoris.ugent.be. So instead of doing the research, my job is now to bring more research into practice. However, for those still interested in the topic of shoulder training, please follow my promotor´s work, Prof Ann Cools. (or follow me on Twitter, @krdemey).

COR Swimmer's Shoulder System 2nd Edition


It has been approximately four years since writing the original Swimmer's Shoulder System. In this 2nd edition, much of the information remains, but numerous citations have been included. In the 1st edition, I purposefully made the piece low on references, with the hopes of improving the read and making it more simplistic. After talking with various customers and mentors, I have decided to add the references with the hopes of improving research based and evidence-based coaching.

Another difference in this edition is the removal of some fluff and concentration of some material. Overall, the exercises prescribed have not changed, but remember it is simply an example outline and many combinations of the exercises listed are feasible. 

As included in the 1st edition, I'd like to thank some additional people, some of which I've never met, but simply for their tireless effort and research:

Dr. Brent Rushall
Dr. Rod Havrulik
Dr. Tiago Barbosa

Now, the literature is still a bit sparse on self myofascial releases (SMR), but the novel research seems promising for safe implementation. Hopefully, further research is performed on this subject, confirming or declining the suggestions made in this book. When adequate research surmounts, a third edition will happily be completed.

Keep Swimming,
Dr. John, DPT, PT, CSCS
Houston, TX 2013

This great resource for coaches and swimmers is valued at $370, but is yours for only $59.99