Post-Operative Prognosis for Swimmers

Take Home Points on Post-Operative Prognosis for Swimmers

    1. Many factors determine shoulder surgery outcomes
    2. Prognosis for return to prior levels of performance is bleak for overhead throwing athletes
    3. Limited research exists on post-op outcomes on swimmers
    Shoulder injuries are unfortunate realities of competitive swimming.  Most commonly, injuries can be treated with some combination of rest, treatment, and exercise.  Evidence favors conservative care before trying surgery and also encourages rehabilitation post-op for optimal function.  Unfortunately though, many injuries progress to needing invasive care (ie surgery). 

    Many factors go into surgery: surgical skill, injury mechanism, severity, patient status (Age, health, etc), patient motivation, among others variables.   But what are realistic expectations for surgical outcomes among swimmers?  At the extremes, some believe you can never return to prior performance, while others believe surgery cures all.  The truth likely exists somewhere in the middle. 

    Asking the right questions is imperative: what are the chances of returning to prior level of performance (or even higher)?  Surgeons may sometimes evaluate success based on a) the quality of their craftsmanship (it didn’t break!!!!) and b) whether the patient can resume normal activities of daily living.  The problem for swimmers is that the swimming shoulder has far greater demands than 99 pct of the general population. 

    To my knowledge, there has been no formal study on post-op outcomes on return to level of performance in swimming.  Designing these studies can be difficult too, with the temptation of surgeons to cherry pick cases with a likelihood of a favorable outcome.  Though swimming has unique demands, research from other sports can offer some clues. 

    One recent study (Fedoriw 2014) examined professional baseball players who suffered superior labrum anterior posterior (SLAP) tears.  Of the pitchers, 22% who attempted conservative (non-surgical care) returned to a prior level of performance or higher, with level marked by the level of league in which they competed (A, AA, AAA, Majors).  Only 7% who underwent surgery returned to prior performance levels though 48% returned to play at all.  However, among non-pitchers, 54% returned to prior performance levels.

    A similar study by Van Kluenen (2012) focusing only on pitchers revealed another low rate of return to prior performance.   All players studied underwent surgery (no conservative care in this study) but only 6 of the 17 players in the sample returned to their same or higher level of play following their procedure.  Notably, all the patients in this study presented with Glenohumeral Internal Rotation Deficit (GIRD). 

    Another review (Sayde 2012) expanded the inquiry beyond baseball players and found
    better results among non-overhead athletes.  Overall, 83% had "good-to-excellent" patient satisfaction and 73% returned to their previous level of play whereas only 63% of overhead athletes returned to their previous level of play.”  Though the results seem more favorable when expanded beyond pitchers, it’s still unclear where swimming falls on the continuum between non-overhead athletes to pitchers.

    Conclusion

    Shoulder surgery is a very personal choice.  While favorable outcomes are very possible in high level athletes, the prognosis gets bleaker with greater overhead demands on the shoulder.  If we equate swimming shoulder demands to baseball pitchers, at best we can say that return to prior performance levels is unlikely.  That said, there can be many confounding variables at work.  Better surgical skill and deeper athlete motivation can make or break and outcome.  Ultimately, know that swimmers who return to higher levels of performance after shoulder surgery have done so against long odds. 

    References

    1. Fedoriw WW1, Ramkumar PMcCulloch PCLintner DM.  Return to play after treatment of superior labral tears in professional baseball players.Am J Sports Med. 2014 May;42(5):1155-60. doi: 10.1177/0363546514528096. Epub 2014 Mar 27.
    2. Van Kleunen JP1, Tucker SAField LDSavoie FH 3rd.  Return to high-level throwing after combination infraspinatus repair, SLAP repair, and release of glenohumeral internal rotation deficit.  Am J Sports Med. 2012 Nov;40(11):2536-41. doi: 10.1177/0363546512459481. Epub 2012 Oct 10.
    3. Sayde WM1, Cohen SBCiccotti MGDodson CC.  Return to play after Type II superior labral anterior-posterior lesion repairs in athletes: a systematic review.  Clin Orthop Relat Res. 2012 Jun;470(6):1595-600. doi: 10.1007/s11999-012-2295-6.
    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.

    Does Spinal Manipulation Help with Shoulder Pain?

    Before we get to the article today, some big news! The popular COR Swimmer's Shoulder System now has a digital version! Purchase today for only $39.99! This incredible product has helped many improve shoulder pain and many teams have integrated these techniques into their prevention programs.

    Order your copy today!


    Take Home Points on Does Spinal Manipulation Help with Shoulder Pain?
    1. Spinal manipulation appears to reduce pain in patients with shoulder impingement through the placebo effect.
    2. However, spinal manipulation does seem to improve scapular upward rotation. 
    This question was received from one of our readers. If you have a question for the
    Swimming Science team, e-mail us today or tweet @swimmingscience #swimsciq! What are you waiting for? Send us a question today!

    Question: 
    I'm a high school senior and have been relatively healthy until this summer when I started having shoulder pain. I went to our local chiropractor and he has been giving me spinal manipulation therapy. Is this helpful for shoulder pain and if so, how?

    Answer: 
    Great question! Well, like a lot of aspects of science, we don't have a precise answer for your individual case, as more information is required. However, a recent study in the Journal of Sports Physical Therapy (JOSPT) looked at the effects of thoracic spine manipulation for those with and without shoulder pain. 

    A little bit of background on the shoulder first, and if you want more, check out some of my previous work on this website, Swimming World Magazine, About.com, USA Swimming, Swimming World Magazine, and in my product the COR Swimmer's Shoulder System.
    The shoulder is the second most commonly injured joint, only behind low back pain. Shoulder pain is extremely common in overhead athletes, especially swimmers.  In swimmers and the general population, shoulder impingement is the most common cause of shoulder pain.  

    Previous reports suggest excessive internal rotation combined with less scapular upward rotation and posterior tilt are associated with shoulder pain.

    Thoracic spine manipulations are most commonly associated with chiropractic treatment. However, physical therapists and other health care professionals can also provide high-velocity, low-amplitude movements in the same manner. This cracking and popping of the mid-back has been consider a beneficial treatment by many patients in the past. However, how manipulation therapy effects shoulder pain and those without pain is not well known.

    Now, this recent study was out of Brazil and Haik (2014) split ninety-seven subjects, 47 asymptomatic and 50 with shoulder impingement into 1 of 4 groups:
    1)    Thoracic spine manipulation impingement group
    2)    Sham impingement group
    3)    Thoracic spine manipulation asymptomatic group
    4)    Sham asymptomatic group

    More or less, some with shoulder impingement and some without shoulder impingement received either a thoracic manipulation or a sham manipulation.

    Measurements of 3-D scapular motion were assessment before and after the treatment sessions.

    For the manipulation, a therapist provided a seated thoracic thrust up to four times until cavitation (audible crack) was heard.

    The sham intervention involved the same protocol and same force, without applying a thrust.

    Did Spinal Manipulation Improve Shoulder Pain and Function
    Shoulder pain while elevating or lowering the arm after thoracic spine or a sham manipulation resulted in similar improvements for patients with shoulder impingement. No clinically relevant changes in scapular motion were observed in the shoulder impingement group. A significant increase in scapular motion was observed after spinal manipulation in the impingement group, but this did not reach clinical significance.

    In the asymptomatic group, scapular upward rotation was also improved.

    For your second question, it appears the positive effects of spinal manipulation are mainly through a placebo mechanism. Now, the use of thoracic manipulation is not well understood, but believed that a sudden stretch could impact neurons in the paraspinal tissues resulting in pain reduction.

    The improvements in upward rotation are potentially from increased muscular activation of the lower trapezius following spinal manipulation.

    More or less, we aren't sure how spinal manipulation helps (if it does) for shoulder impingement. 

    Practical Implication
    If seeking improvements in scapular upward rotation, spinal manipulation is helpful. However, it seems the placebo effect is the main cause of pain reduction after spinal manipulation in those with shoulder impingement. Remember, this was not a study in athletes and only looked at range of motion, not high level exercise. Also, it didn't include other treatments like exercise therapy or massage, common adjuncts with spinal manipulation.

    Reference
    1. Haik MN, Alburquerque-Sendín F, Silva CZ, Siqueira-Junior AL, Ribeiro IL, Camargo PR. Scapular kinematics pre- and post-thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study. J Orthop Sports Phys Ther. 2014 Jul;44(7):475-87. doi: 10.2519/jospt.2014.4760. Epub 2014 May 22.
    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.

    Weekly Round-up

    1. How sleep helps brain learn motor task.
    2. Fatigue shifts and scatters heart rate variability in elite endurance athletes. - by Dr. Schmitt
    3. The development of peripheral fatigue and short-term recovery during self-paced high-intensity exercise. - by Dr. Froyd
    4. Postural control and low back pain in elite athletes comparison of static balance in elite athletes with and without low back pain. - by Dr. Oyarzo
    5. Virtual swimming--breaststroke body movements facilitate vection. - by Dr. Seno
    6. Symmetry of support scull and vertical position stability in synchronized swimming. - by Dr. Winiarski
    7. Is bone tissue really affected by swimming? A systematic review.- by Gómez-Bruton
    8. Effect of gene polymorphisms on the mechanical properties of human tendon structures. - by Dr. Kubo
    9. Relation between efficiency and energy cost with coordination in aquatic locomotion. - by Dr. Figueiredo
    10. Is There a Minimum Intensity Threshold for Resistance Training-Induced Hypertrophic Adaptations? - by Brad Schoenfeld
    11. The Temporal Profile of Postactivation Potentiation is related to Strength Level. - by Dr. Seitz
    12. Athletes and novices are differently capable to recognize feint and non-feint actions. - by Dr. Güldenpenning 
    13. Effects of betaine on body composition, performance, and homocysteine thiolactone. - by Dr. Cholewa
    14. Fructose-Maltodextrin Ratio Governs Exogenous and Other CHO Oxidation and Performance. - by Dr. O'Brien
    15. Sports drink consumption and diet of children involved in organized sport. - by Dr. Tomlin
    16. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. - by Dr. Selkowitz
    17. Scapular Kinematics and Shoulder Elevation in a Traditional Push-Up. - by Dr. Suprak

    Brief Swimming Review Volume 1 Edition 5

    In an attempt to improve swimming transparency, a brief swimming related literature review will be posted on Saturday. If you enjoy this brief swimming review, consider supporting and purchasing the Swimming Science Research Review

    Risk Factors for Shoulder Pain

    Walker (2012) took 74 competitive swimmers and took self-reported data over 12 months as well as anthropometric features and swimming characteristics before the competitive season. Shoulder pain was classified as "significant interfering shoulder pain (SIP) defined as pain interfering (causing cessation or modification) with training or competition, or progression in training. A significant shoulder injury (SSI) was any SIP episode lasting for at least 2 weeks (Walker 2012)".

    These results found 38% reported SIP and 23% reported SSI. Swimmers with high and low external rotation range of motion were at 8.1 and 12.5 times greater risk for for SIP and 35.4 and 32.5 times greater risk for SSI. Also, those with a history of shoulder pain were 4.1 and 11.3 times greater to sustain a SIP and SSI.


    One again, it seems extreme ranges of motion and a history of shoulder pain are predictors of shoulder pain. Unfortunately, I do not have this whole study and am curious about their criteria or specificity for normal range of motion. Nonetheless, screening and acknowledging these features is essential for a proper shoulder injury prevention program. 

    Shoulders and Swimming

    5 Swimming Shoulder Stresses
    Swimmers Shoulder
    COR Swimmer's Shoulder System


    Asthma and Swimming Training in Children and Adolescents
    Beggs (2013) performed a Cochrane review of all the quality research on asthma and swimming in children and adolescents. Overall they analyzed eight studies involving 262 participants with stable, mild to severe asthma. In all the studies, the participants were 5 - 18 in age and swam 30 - 60 minutes 2 -3 times/week.

    Swimming training increased exercise capacity compared with usual care or a control group. VO2max increased ~9.67 mL/kg/min.

    Source

    "Swimming training was associated with small increases in resting lung function parameters of varying statistical significance; mean difference (MD) for FEV1 % predicted 8.07; 95% CI 3.59 to 12.54. In sensitivity analyses, by risk of attrition bias or use of imputed standard deviations, there were no important changes on effect sizes. Unknown chlorination status of pools limited subgroup analyses.Based on limited data, there were no adverse effects on asthma control or occurrence of exacerbations (Beggs 2013)."

    Swimming is not associated with any adverse reactions and is well-tolerated in children and adolescents. However, the positive influences on lung function and cardio-vascular fitness may also occur in other forms of training. 
    Asthma and Swimming
    Asthma and Swimming
    Asthma and Swimmers
    Asthma and Swimming: Know the Rules
    Friday Interview: Giacomo Crivelli on Asthma and β2-Agonists

    Warm-up is Better than no Warm-up!
    Neiva (2013) had twenty competitive swimmers performed two maximal 100-m freestyle trials with and without a 1000-m warm-up (intermediate swimmers, ~67 100-m time trial). 

    The warm-up condition resulted in significantly faster 100-m performance. However, three swimmers swam faster without warm-up. Swimmers who warmed-up had a significantly greater distance per stroke and swimming efficiency (measured by stroke index). Stroke kinematics, blood lactate concentrations, and perceived exertion were similar between trials.

    Unfortunately (once again), I don't have this whole article for review, but it brings some interesting notes. For one, could those with a short distance per stroke benefit more from a warm-up than those with a long distance per stroke? Also, what characteristics result in those having greater performance without a warm-up? For this difference warm-ups are necessary for different swimmers.

    Other studies have analyzed swimming performance and was discussed in Perfect' Swimming Warm-up (2012). 

    This article discussed a study out of Alabama had swimmers perform 50-yard time trials with three different warm-up variations: no warm-up, short warm-up (two 50-yard paces), and regular warm-up. The researcher's concluded "individual data indicated that 19% of participants performed their best 50-yd time after short-, 37% after no-, and 44% after regular warm-up" (Balilionis, 2012).

    Once again, individual warm-up is essential for elite performance in sprint swimming. However, more research is necessary on different strokes and longer distance. Until this is achieved, different warm-ups lengths should be considered for each individual.


    References
    1. Walker H, Gabbe B, Wajswelner H, Blanch P, Bennell K.Shoulder pain in swimmers: a 12-month prospective cohort study of incidence and risk factors. Phys Ther Sport. 2012 Nov;13(4):243-9. doi: 10.1016/j.ptsp.2012.01.001. Epub 2012 Feb 29.
    2. Beggs S, Foong YC, Le HC, Noor D, Wood-Baker R, Walters JA.Swimming training for asthma in children and adolescents aged 18 years and under.Cochrane Database Syst Rev. 2013 Apr 30;4:CD009607. doi: 10.1002/14651858.CD009607.pub2.
    3. Neiva HP, Marques MC, Fernandes RJ, Viana JL, Barbosa TM, Marinho DA. Does Warm-Up Have a Beneficial Effect on 100m Freestyle?Int J Sports Physiol Perform. 2013 Apr 9. [Epub ahead of print] 
    4. Balilionis G, Nepocatych S, Ellis CM, Richardson MT, Neggers YH, Bishop PA. Effects of Different Types of Warm-Up on Swimming Performance, Reaction Time, and Dive Distance.J Strength Cond Res. 2012 Jan 10.
    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. He is the founder of Mullen Physical Therapy, the Center of Optimal Restoration, head strength coach at Santa Clara Swim Club, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

    Latent Non-Painful Trigger Points Inhibit Strength


    Myofascial trigger points are palpable taut bands. These bands may be active (producing pain) or latent (non symptom producing). This study looked at the relationship between latent trigger points and muscle strength in the shoulder. A recent study analyzed fifty healthy adults (20 women and 30 men) were assessed for trigger points on both their dominant and nondominant shoulder. The author’s note this criteria for assessing trigger points:

    “[f]our criteria: 1. tender spot in a taut band of skeletal muscle; 2. patient pain recognition on tender spot palpation; 3. referred pain pattern (the pain distribution expected from a trigger point in that muscle); 4. local twitch response” (a transient local contraction of skeletal musclefibers in response to palpation) were the most frequently used in establishing a diagnosis of MTrPs [15]. For LTrP assessment in all muscles, the subject was asked “When I pressed this muscle, did you feel any pain or discomfort locally, and in other areas (referred pain)”. If the elicited local or referred pain did not produce the pain sensation as the patient suffered from before, the TrP was considered latent (Celik 2011).”

    Next, strength was assessed with a dynamometer for flexion and scaption.

    Results
    No significant difference was noted between arms, yet arms with latent trigger points demonstrated significantly decreased strength.

    Discussion
    Latent trigger points are correlated with decreased shoulder strength. However, the criteria for classifying trigger points are still evolving. Further research is also necessary on the physiology of trigger points and effective treatment methods.

    Practical Implication
    Latent trigger points are likely in all swimmers secondary to the amount of swimming stress on the shoulder. Currently, self myofascial releases are likely the best means for resolving these points, but research must validate these methods.

    Often dry-land coaches focus on adding strength, yet removing inhibitors of strength may be more effective. 

    References:

    1. Celik D, Yeldan I. The relationship between latent trigger point and muscle strength in healthy subjects: a double-blind study.J Back Musculoskelet Rehabil. 2011;24(4):251-6. doi: 10.3233/BMR-2011-0302.
    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. He is the founder of the Center of Optimal Restoration, head strength coach at Santa Clara Swim Club, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review

    Shoulder Stretching Doesn't Help Shoulder Motion!

    Proper shoulder-blade function is closely related to overall shoulder health, as many shoulder pathologies are associated with faulty shoulder-blade control. The pectoralis minor is one muscle commonly used in stroking and is influential in shoulder-blade movement. 


    Most swim coaches and some rehabilitative specialists feel that stretching is the best means to improve muscle length. From my experience, swimmers need little to no shoulder stretching. Swimmers have hypermobile shoulder blades, and the common shoulder stretches cause instability of the shoulder blade.

    Prior to USA Swimming 2011 Summer National Championships at Stanford University, a Russian swimmer practiced at the Santa Clara International Swim Stadium. His warm-up consisted of an acrobatic shoulder mobility stretch which appeared to involve subluxing and popping in and out his shoulder. Once I saw this, I had to talk to the athlete about his warm-up routine and see if he had a history of shoulder pain. During a ten minute conversation he revealed that he did experience shoulder pain. His warm-up routine was recommended by his rehabilitation specialist at the time. I talked to him about his routine and how it was likely contributing to his symptoms. After I offered a brief informational session and exercise demonstration, he discontinued his shoulder stretching routine and replaced it with the aforementioned muscle length exercises. He informed me at the competition that his shoulders were asymptomatic (Mullen 2012).
    Despite common recomendations, little is known about the effects of stretching and swimming. A recent study compared two different stretching protocols of the pectoralis minor and subsequent shoulder-blade kinematics in college swimmers. Twelve healthy in-season Division I and seventeen healthy Division III (4 male, 25 female; mean age 19.5). Before testing, manual tape measurements of the pectoralis minor were obtained from origin to insertion. Then, with 3-dimensional kinematic analysis, each athlete performed 10 shoulder movements in the sagittal, frontal, and axial plane of motion. The stretching was then performed for 2 repetitions of 30 seconds with 30 seconds in between repetitions. The participants were split into the focused or gross stretching group. 

    “For the focused stretch shoulders, the authors placed each subject in a supine position with the test arm at their side while the primary investigator palpated medially into the proximal axilla, followed by proceeding superiorly towards the coracoid process. This maneuver allowed the investigator’s fingers to be fixed posterior to the proximal end of the pectoralis minor muscle. The investigator then applied pressure in the anterior direction, similar to attempting to lift the muscle, thereby applying tensile force directly to the pectoralis minor. The opposite hand of the investigator was used to stabilize the scapula and humeral head (Williams 2013).” 

    “For the gross-stretch, subjects were positioned in the supine position with the test arm abducted and externally rotated to 90° and the elbow flexed to 90°. The investigator stabilized each subject’s body by placing a hand on the contralateral coracoid. The investigator then passively, horizontally abducted the subject’s shoulder (Williams 2013)”.


    The participants other shoulder was used as a control. 

    The results noted the gross pectoralis minor stretch produced significantly more lengthening to the pectoralis minor than the control. No significant differences were noted between groups. No significant differences were noted in the shoulder-blade kinematics. 

    Despite improvements in muscle length, there were no changes in acute shoulder-blade kinematics.This suggest these improvements in range of motion were not beneficial in improving faulty shoulder-blade motion.

    In asymptomatic swimmers, pectoralis minor stretching does not alter (notably improve) shoulder-blade kinematics. For asymptomatic swimmers, this stretch is not beneficial, but potentially hazardous as the increased pectoralis minor length may be from an increase in passive tissue length (ligaments, capsule, etc.), not muscle length. Future studies should analyze symptomatic swimmers or those with shoulder-blade dyskinesia.

    If you are looking for healthy method for improving shoulder mobility, read these posts:
    Shoulder Blade Contribution to Axial Rotation
    Swimmers Shoulder ISOSC

    If you are looking for much more information, consider the Swimmer's Shoulder System:
    COR Swimmer's Shoulder System

    Reference:
    1. Williams J, Laudner K, McLoda T. The acute effects of two passive stretch maneuvers on pectoralis minor length and scapular kinematics among collegiate swimmers.Int J Sports Phys Ther. 2013 Feb;8(1): 25-33.
    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. He is the founder of the Center of Optimal Restoration, head strength coach at Santa Clara Swim Club, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

    Shoulder Blade Contribution to Axial Rotation

    The role of the shoulder blade during overhead movements is still being discovered. Despite the assumed role of the shoulder blade, research studies confirming the necessity of shoulder blade stability are still necessary (discussed in shoulder injury prevention). In swimming, the shoulder performs frequent overhead axial rotations, making understanding the role of the shoulder during axial rotation mandatory as it likely plays an essential role for injury prevention and force production. Luckily, Ribeiro (2012) et al. looked at the contribution of the shoulder blade at end-range shoulder rotation in overhead athletes. In this study, handball players without a history of pain and controls both performed a seated full-range internal and external rotation in the scapular plane with the humerus supported. The athletes utilized greater shoulder blade retraction and posterior tilting during external rotation.

    These results suggest alterations in scapular kinematics occur during shoulder axial rotation in athletes compared to a control group. It is unclear if these adaptations occur to aid sporting success, decrease repetitive stress, or is simply an adaptation to repetitive injury, but one could speculate all three of these reasons play a role in this adaptation (Mullen 2013). The amount of scapular retraction is also greater in athletes, as Ribeiro states:

    “the inability to retract the scapula, appears to impart several negative biomechanical effects on the shoulder structures, including a narrower subacromial space, reduced impingement-free, reduced strength of the glenohumeral muscles (Ribeiro 2012)”.

    He further suggest healthy athletes:

    “keep their scapula stable while the arm is fastly moved from a full external position to a full internal position. Scapular stabilization could be challenged when the arm motion is very (too) fast. Therefore, an inadequate scapular position at the end-range of glenohumeral motion will lead to shoulder dysfunction and pathology (Ribeiro 2012)”



    Practical Implication
    It seems shoulder adaptations are present at the shoulder-blade in overhead athletes during axial plane movement. It is imperative to provide strengthening exercises of the shoulder-blade in retraction and posterior tilting movements for shoulder-blade stability. Future studies must look at planes other than the scapular plane and without the arm supported (Mullen 2013). 

    Ensure you are keeping you and your team healthy, as any injury deceases the likelihood of success, purchase the Swimmer's Shoulder System today.

    References:

    1. Ribeiro, A, Pascoal, AG. Scapular contribution for the end-range of shoulder axial rotation in overhead athletes. Journal of Sports Science and Medicine (2012) 11, 676-681.
    2. Mullen, GJ. Swimming Science Research Review. (2013) 1: 9, 30.
    By Dr. G. John Mullen founder of the Center of Optimal Restoration, head strength coach at Santa Clara Swim Club, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

    Are Tight Muscles Fatiguing you?

    All swimming programs use high-intensity training. No matter if this high-intensity comes from short race pace sprints or high volume training, every team does some form of high-intensity. High-intensity will undoubtedly result in sore muscles. Sore muscles, typically cause tight muscles, commonly referred to as myofascial trigger points (MTPs). These trigger points are commonly associated with injuries and pain, but latent myofascial trigger points commonly exist in tight or over-worked muscles. 

    Now, I know it seems obvious, but recent research has shown these latent myofascial trigger points can increase fatigability in muscles during isometric exercises of the shoulder (Ge 2012). Moreover Ge et al. found the muscle fibers surrounding the MTPs also exhibited early fatigue!

     Luckily, there are simple methods which likely improve latent and active myofascial trigger points. Unfortunately, not many swim clubs are incorporating these simple fatigue preventing exercises prior to workout! Instead, swimmers will take a hand full of sodium bicarbonate (baking soda) or supplements with the goal of striving off fatigue. These supplemental tools may help, but more evidence is supporting the notion of performing soft-tissue techniques for improvement of MTPs. It seems clear to take advantage of the simple tools and tricks to prevent fatigue and injury.

    Last week on Swimming World, I went over a new soft tissue technique to the subscapularis. This is just one of many potential techniques to take your career and health to a new level. 



    Summary
    Improving latent (and likely active) MTP is essential for reducing early fatigue.It swimming, it is imperative to perform techniques to prevent fatigue. It is believed myofascial releases (self or with a rehabilitation specialist) may improve these MTP, but future studies must confirm this notion and confirm these improvements improve fatigability. If you are not performing self soft tissue techniques for injury and fatigue prevention, you may be putting yourself at a disadvantage before you hit the water! Make sure you're doing all you can to stay healthy and prevent fatigue for every workout. 

    For more information and methods for improving MTPs, consider purchasing the Swimmer's Shoulder System.




    References:


    1. Ge HY, Arendt-Nielsen L, Madeleine P. Accelerated muscle fatigability of latent myofascial trigger points in humans. Pain Med. 2012 Jul;13(7):957-64. doi: 10.1111/j.1526-4637.2012.01416.x. Epub 2012 Jun 13.
    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. He is the founder of the Center of Optimal Restoration, head strength coach at Santa Clara Swim Club, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

    Friday Interview: Kristof De Mey

    1. Please introduce yourself to the readers (how you started in the profession, education, credentials, experience, etc.).
    Kristof De Mey, I´m a physical and manual therapist in Ghent, Belgium, working in the Department of Rehabilitation Sciences and Physiotherapy of the Ghent University. I have a background in sports rehab and athletic training. My research contain the rehabilitation and prevention of shoulder injuries in overhead athletes in general, and the muscle recruitment during exercise training for athletes with impingement symptoms in particular.

    2. You recently published an article on the role of conscious control of the scapular in overhead athletes, could you please explain the significance of your results?
    We investigated the effect of conscious scapular orientation during four exercises which showed low upper trapezius activation compared to the amplitude levels of the middle and lower parts of that muscle. We found that actively setting the scapula into a more neutral position before starting the exercise significantly increased the activation levels during the prone extension and side-lying external rotation exercise, while during the side-lying forward flexion and prone horizontal abduction with external rotation this was not the case. We also demonstrated that in none of the exercises, the muscle ratio´s, which were previously found to be low, were not altered.

    3. Do you think these results would transfer to painful subjects?
    From a scientific point of view, we cannot state this. However, we suppose they would, however depending on the levels of pain by the subjects. In patients with high pain levels, we might find different results. Future research on this topic is needed before making any conclusions on this topic.

    4. In those with pain, it is theorized motor control is impaired, do you think this conscious control improves motor control?
    Well, this is an interesting point. The question is how conscious control of muscle activation can influence the movement of the scapula during functional activities. In fact, I intuitively suggest that corrective movement exercises are more relevant compared to a muscle-oriented approach, which can only serve as a basis within a functional progression of exercises.

    5. What are the most important muscles in preventing shoulder injuries in overhead athletes?
    The rotator cuff and the scapular stabilizers (middle and lower trapezius and serratus anterior).

    6. Is this the same for rehabilitation?
    Yes.

    7. Do you feel the high volume of shoulder rotations in swimmers requires a different approach to rehabilitation or injury prevention?
    I think it would. Correction of swimming technique (thoracic rotation and scapular plane arm elevation) are more important than conscious muscle control during muscle strength training exercises, although both can be of complementary value.

    8. What makes your research different from others?
    I focused on the muscle recruitment during exercises and on the effect of exercises on this parameter. Previous research showed exercise training can help to treat patients with impingement, but few investigated whether these benefits are caused by alterations in the scapular muscle recruitment.

    9. Who is doing the most interesting research on shoulder injury prevention/rehabilation in the field? What are they doing?
    My promoter Prof Ann Cools, she is constantly looking for new links between scientific evidence and clinical implications to the field. Of course the work of Dr. Ben Kibler and his team is well known because they made clear that the scapula plays a major role in shoulder treatment and prevention. Finally, there are people who do not focus on the shoulder but rather on how to implement the existing knowledge into practice (referring to the work of Prof. Meeuwisse and Dr. Finch).

    10. Which teachers have most influenced your research?
    Again the same people as mentioned above.

    11. What are your favorite books on the role of shoulder rehabilitation/prevention?
    Diagnosis and treatment of movement impairment syndromes by Sahrmann.

    Complete shoulder and upper extremity conditioning by Evan Osar.

    A book in Dutch called “Exercise therapy in those with shoulder injury” by Ann Cools

    12. If I were looking for the most comprehensive shoulder injury prevention program, what program would you give me over 6 weeks?
    One which is individualized. There are so many exercises and different approaches in this field, that a standardized program is difficult to describe. In a recent study in the American Journal of Sports Medicine, we investigated a 6-week exercise program consisting only four exercises in a group of overhead athletes with impingement symptoms who did not yet stopped training. We found that it could be helpful for those, however, a program tailored to individual needs, would probably increase the effectiveness and long term benefit.

    13. What are the most common mistakes you see in those training shoulder musculature?
    Training too much in a position of abduction with external rotation, without any additional value. Many exercises can be done in a more safer position, not increasing the risk for impingement of the rotator cuff tendons beneath the acromion.

    14. What mistakes still exist in professional athletes and rehabilitation clinics?
    They fix too much on a certain approach. I think the future belongs to those working with people from different disciplines, integrating the existing knowledge on this topic.

    15. What research or projects are you currently working on or should we look from you in the future?
    We are working on the effect of a fascial therapy approach compared to a more conventional approach (as is outlined in our recently published study) for correction of scapular dyskinesis.


    Thanks Kristof!

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