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

Coded for Swimming Science by Cameron Yick

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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.

    Weekly Round-up

    1. Genetic Trainability: Your Genes Influence Your Workout Results - Nick Tumminello.
    2. Hypotheses about the Specificity of Physical Conditioning in Swimming: It Is a Lot -More Specific than Commonly Believed - Brent S. Rushall. 
    3. Ultra-short Race-pace Training and Traditional Training Compared - Brent S. Rushall. 
    4. Current Swimming Techniques: The Physics of Movements and Observations of Champions - Brent S. Rushall. 
    5. A Training Possibility - By Brent S. Rushall. 
    6. Adapting to the USRPT Format - Brent S. Rushall. 
    7. Aerobic Training is Not Enough - Brent S. Rushall.  
    8. USRPT and the Non-taper - Brent S. Rushall. 
    9. Understanding a USRPT Set - Brent S. Rushall. 
    10. Coaching Knowledge and USRPT - Brent S. Rushall. 
    11. Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy: A Randomized Controlled Trial With 1-Year Follow-up -S Kesikburun.
    12. Chronic Effect of Static Stretching on Strength Performance and Basal Serum IGF-1 Levels- CL Borges Bastos.
    13. The effect of fatigue on the underwater arm stroke motion in the 100-m front crawl - by H Suito.
    14. Six weeks of aerobic training improves VO2max and MLSS but does not improve the time to fatigue at the MLSS- by TT Mendes.
    15. DRD2 C313T and DRD4 48-bp VNTR polymorphisms and physical activity of healthy men in Lower Silesia, Poland (HALS study)- by P Jozkow.
    16. Sex differences in central and peripheral mechanisms of fatigue in cyclists-by BW Glace.
    17. Long-term creatine supplementation improves muscular performance during resistance training in older women-by AF Aquiar.

    Brief Swimming Review Volume 1 Edition 9

    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

    Cross-education for Rehabilitation
    Cross-education is the phenomenon when strengthening one arm, strengthens the untrained arm. This is a valuable and effective tool when rehabilitating the other arm isn't an option: "For the fractured hand, the training group (17.3±7.4kg) was significantly stronger than the control group (11.8±5.8kg) at 12 weeks postfracture (P<.017) (Magnus 2013)."

    This phenomenon may not only cross arms, but could potentially cross to the legs. For this, it is advised to still kick and train (at least the other arm) during an injury. 

    Further Reading
    Peak Force Correlated with Starting Success
    The Omega OSB11 starts are known to improve performance, but what characteristics lead to a better start? This study looked to determine which variables were correlated with an improved start:

    "[r]esults from these data suggest that swimmers generating higher than average peak forces were more likely to produce a better overall start performance than those who produced forces lower than the average, for this population of athletes (Slawson 2013)".

    Now, some may speculate that improving peak force (via jumping or resistance training) will improve starting performance, but this study does not imply this. All this study suggests is those who have generate higher than average peak forces are correlated with greater starts on the OSB11.



    Further Reading
    Painful Arc and External Rotation Predict Rotator Cuff Disease
    Many swim coaches want nothing to do with shoulder injuries, but this simply isn't an option when shoulder pain is estimated at 60% in the sport. A recent systematic review looked at predictors of rotator cuff disease and found: 
    "[a] positive painful arc test result and a positive external rotation resistance test result were the most accurate findings for detecting RCD [rotator cuff disease], whereas the presence of a positive lag test (external or internal rotation) result was most accurate for diagnosis of a full-thickness rotator cuff tear (Hermas 2013)."

    These simple tests can be performed before a coach in the beginning of a season. If you want to help your swimmers and learn other troubleshooting methods, pre-order Swim Sci Troubleshooting!

    Muscular Fatigue is Individual
    The principal of individuality is essential for maximal improvement. This principal is gaining popularity for energy system training, but also must be applied for biomechanics and fatigue.

    In this study:
    "[s]urface electromyography signals were collected from the flexor carpi radialis, biceps brachii, triceps brachii, pectoralis major, upper trapezius, tibialis anterior, biceps femoris, and rectus femoris muscles of 10 international-level swimmers; 4 underwater cameras were used for kinematic analysis. In addition, blood lactate was measured before and after the test using capillary blood samples (Figueiredo 2013)." 

    The author concludes:
    "The changes in stroke parameters were associated with an increase in integrated electromyography (20%-25%) and a decrease in spectral parameters (40%-60%) for all of the upper-limb muscles, indicating the reaching of submaximal fatigue. The fatigue process did not occur regularly during the 8 laps of the 200 m but was specific for each muscle and each subject. Lower-limb muscles did not present signals of fatigue, confirming their lower contribution to swimming propulsion. The test was conducted to individualize the training process to each muscle and each subject (Figueiredo 2013)".

    This study adds evidence to a few features:
    1. The principle of individuality
    2. The low contribution of the lower-limbs to propulsion (perhaps not at all (Rushall 2013)
    3. The importance of staying "relaxed" during fatigue, since lactate is correlated with increased electromyographic activity
    Further Reading
    References:
    1. Magnus CR, Arnold CM, Johnston G, Dal-Bello Haas V, Basran J, Krentz JR, Farthing JP.Cross-education for improving strength and mobility after distal radius fractures: a randomized controlled trial. Arch Phys Med Rehabil. 2013 Jul;94(7):1247-55. doi: 10.1016/j.apmr.2013.03.005. Epub 2013 Mar 22.
    2. Slawson SEConway PPCossor JChakravorti NWest AA. The categorisation of swimming start performance with reference to force generation on the main block and footrest components of the Omega OSB11 start blocks. J Sports Sci. 2013;31(5):468-78. doi: 10.1080/02640414.2012.736631. Epub 2012 Nov 7.
    3. Hermans J, Luime JJ, Meuffels DE, Reijman M, Simel DL, Bierma-Zeinstra SM.Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review .JAMA. 2013 Aug 28;310(8):837-47. doi: 10.1001/jama.2013.276187.
    4. Figueiredo P, Rouard A, Vilas-Boas JP, Fernandes RJUpper- and lower-limb muscular fatigue during the 200-m front crawl. Appl Physiol Nutr Metab. 2013 Jul;38(7):716-24. doi: 10.1139/apnm-2012-0263. Epub 2013 Feb 4.
    5. Rushall BS. CURRENT SWIMMING TECHNIQUES: THE PHYSICS OF MOVEMENTS AND OBSERVATIONS OF CHAMPIONS Swimming Science Bulletin, 44, 3 pp. 2012. [http://coachsci.sdsu.edu/swim/bullets/Current44.pdf]
    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 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.

    Brief Swimming Review Volume 1 Edition 6

    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

    Altitude Training Improves Body Composition in Swimmers 
    We've discussed Chia's work on Swimming Science previously (Altitude training for weight loss?; Friday Interview: Dr. Chia-Hua Kuo and Dr. Futoshi Ogita; Friday Interview: Dr. Chia-Hua Kuo), but he once again released a paper in the Chinese Journal of Physiology interpreting the results of his research on hypoxia reducing body fat in swimmers.

    "The purpose of the study was to examine changes in body composition after altitude hypoxia exposure and the role of blood distribution to the skeletal muscle in swimmers. With a constant training volume of 12.3 km/day, young male swimmers (N = 10, 14.8 ± 0.5 years) moved from sea-level to a higher altitude of 2,300 meters (Chia 2013)".

    Chia et al. (2013) found the altitude training group had a reduction of body fat mass by 1.7 kg and an increase in lean body mass of 0.8 kg. Arterial oxygen saturation significantly decreased with an increase in plasma lactate during hypoxic training. Increases in total hemoglobin concentration and sympathetic activity also occurred with hypoxic training.

    This team concludes"the present study provides evidence that increased blood distribution to the skeletal muscle under postprandial condition may contribute to the reciprocally increased muscle mass and decreased body mass after a 3-week altitude exposure in swimmers (Chia 2013)". However, one could argue an increase in sympathetic nervous system activity increases fat use and total hemoglobin concentration. Unfortunately, this theory would not explain the increase in lean body mass (unless the sympathetic increase simply caused an increase in training capacity).

    Practical Implication: High altitude training appears to improve body composition in swimmers, unfortunately the use for performance benefits still lacks support.

    Effects of Fatigue During Women 100-m Fly 

    It is well established differences in swimming velocity alter stroke biomechanics. However, the specific alterations during each stroke is not well known. This study analyzed the effects of kinematic changes in women performing maximal and submaximal 100-m butterfly bouts.

    de Jesus (2012) note: "[v]elocity, stroke length, stroke frequency were lower for 4th than 1st lap, at both intensities. Dropped elbow and foot vertical amplitude of 1st and 2nd downbeats were higher for 4th than 1st lap, at both intensities. At submaximal and maximal intensity, swimmers spent more time during push and recovery phases. At submaximal intensity, swimmers experienced fewer difficulties to cope with fatigue between 1st and 4th lap, which allowed the maintenance of intracyclic velocity variation. However, at maximal intensity, swimmers were probably more fatigued and, as a consequence, less mechanically efficient, showing an increase in intracyclic velocity variation."

    Practical Implication: Unfortunately, this reviewer does not have the full paper for a complete review, since the abstract is rather vague and somewhat obvious. Let me know if anyone has the full work!

    Lat Stiffness Alters Scapular Kinematics

    Launder (2013) measured nineteen NCAA Division III swimmers' (M=7, F=12; ~18.8 years) latissimus dorsi stiffness. The results showed latissimus dorsi stiffness had "moderate-to-good relationships with increased scapular upward rotation (r > -0.63, P < 0.002) and posterior tilt (r > -0.62, P < 0.004) at all four angles of humeral elevation. Increased latissimus dorsi stiffness also showed moderate-to-good relationships with decreased scapular internal rotation at humeral elevation angles of 60° (r = 0.47, P = 0.03) and 90° (r = 0.54, P = 0.01). (Launder 2013)".

    Practical Implication: Many rehabilitation specialist find those with shoulder pain had decreased scapular upward rotation and posterior tilt. These results contradict those views, requiring confirming studies. Nonetheless, coaches should assess latissimus stiffness and scapular kinematics.

    References:

    1. Chia M, Liao CA, Huang CY, Lee WC, Hou CW, Yu SH, Harris MB, Hsu TS, Lee SD, Kuo H.Reducing body fat with altitude hypoxia training in swimmers: role of blood perfusion to skeletal muscles. Chin J Physiol. 2013 Feb 28;56(1):18-25. doi: 10.4077/CJP.2013.BAA071.
    2. de Jesus Kde Jesus KFigueiredo PAGonçalves PVilas-Boas JPFernandes RJ. Effects of fatigue on kinematical parameters during submaximal and maximal 100-m butterfly bouts. J Appl Biomech. 2012 Nov;28(5):599-607. Epub 2012 May 8.
    3. Laudner KG, Williams JG.The relationship between latissimus dorsi stiffness and altered scapular kinematics among asymptomatic collegiate swimmers. Phys Ther Sport. 2013 Feb;14(1):50-3. doi: 10.1016/j.ptsp.2012.02.007. Epub 2012 Jul 28.
    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

    Abnormal MRIs in Tennis Players


    The association between diagnostic imaging abnormalities and pain has been discussed before. However, more research on this subject continues to surmount. Remember, structural abnormalties do not equal pain! Now, this doesn't suggest an acute rotator cuff tear will not cause pain, instead it means overuse of any joint (from sport or life) will result in structural defects, but not necessarily pain.

    A recent study by Alyas (2013) analyzed magnetic resonance imaging (MRI) in the lumbar spines of elite adolescent tennis players who did not have pain. This study took MRIs of 33 players (mean age 17.3) and found only five of the players showed no structural abnormalities! This small sample implies a mere 15% adolescent tennis players without pain had no structural abnormalities. The most common structural change were facet joint arthopathy in 23 of the 33 players. Synovial cyst formation was seen in 10 of the subjects. Thirteen of the subjects showed disc degeneration. Pars injuries occurred in nine of the subjects.

    This high rate of abnormalities suggest the high stresses of the low back with tennis result in structural changes. Alyas (2013) implies in their study that these structural changes may be predictors of pain later in an athletes career, but as we've discussed if you have proper surrounding muscular support and muscle length, strength, and timing the body can adapt and handle the stress and work with the structural changes. 

    Summary
    It is clear every sport has excess stress at one joint or another. These stresses often damage structures in even youth athletes. However, if an athlete has proper length, strength, and timing they are likely able to handle the demands of the sport and have a healthy career. Make sure you are taking care of your body and understanding the importance of muscle length, strength, and timing, even in your young swimmers!


    Reference

    1. Alyas F, Turner M, Connell D. MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. Br J Sports Med. 2007 Nov;41(11):836-41; discussion 841. Epub 2007 Jul 19.
    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.

    Injury Prediction in Swimmers

    One way to improve injury prevention is to understand injury risk factors.  Every athlete carries some general risk inherent in their sport, but optimal injury prevention requires individualization.  A key step toward individualization is recognizing risk factors and identifying in whom those risk factors reside.

    Certain risk factors appear repeatedly in the athletic literature: previous injury, asymmetry, poor neuromuscular control, and body mass index are common themes.  But is there anything specific to swimming? As we know, swimming is a much different game than football, basketball, and other commonly studied sports.  The ability to withstand a collision or prevent an ACL tear is far different than the demands of manipulating water in repeated stroke cycles.

    Recently, Chase (2013) studied both men and women in a D-I swim program.  This was a prospective study, meaning the participants were assessed before and after the season.  During the season, twenty of the thirty four swimmers sustained thirty one total injuries.   Consistent with other swim studies, the most common injury sites were shoulder, back and knee.   The most predictive variables for injury were previous injury to same anatomical location and previous injury elsewhere in the body (Interestingly, practice injury rates were higher for female swimmers than other NCAA athletes).

    As a side note, in injury studies with athletes; always consider reporting rates, as it’s possible that athletes may hide injuries to avoid missing time.  Further, this study only looks at one team.  As we all know, training programs can vary significantly, with some teams running slaughterhouses while others have very few injuries.





    Another prospective study out of Australia studied 74 swimmers (37 males and females) ranging from 11 to 27 years old (Walker 2012).  During the one year study, 38% reported minor injuries (defined as less than two weeks) while 23% reported serious injuries (more than two week interruptions).  Authors also found that swimmers with the lowest and the highest range of shoulder external rotation (ER) were at greatest risk of injury.  Swimmers with both high and low ER range were at 8.1 and 12.5 times greater risk of sustaining a subsequent minor injury respectively and 35.4 and 32.5 times greater risk of sustaining a longer injury than those with mid-range ER.  As with the Chase study, a history of shoulder pain was also highly predictive of recurring pain.

    Several weeks ago, Dr. Angela Tate reviewed her recent study looking at injury patterns through all ages in swimming (See Interview with Dr. Tate). Although a cross sectional, not a prospective study, this study did identify key injury trends (Tate 2012):
    • Swimmers who engaged in another sport such as walking or running for masters swimmers and soccer for youth swimmers were less likely to have shoulder pain.
    • Those who swam a greater number of hours and high school swimmers who participated in competitive swimming for a greater number of years or who played water polo were more likely to have pain.
    • Those who had better core endurance, middle trapezius (mid back) strength and longer pectoral (chest muscles) were also less likely to have shoulder pain.
    • 31% of our youth swimmers (aged 8-11) had pain during swimming, 56% of our 12-14 year olds,  81% of our high school swimmers and 64% of masters swimmers had shoulder pain.
    Finally, Wymore (2012) surveyed eleven NCAA men’s squads with a total of 187 respondents (note, this was a relatively low response rate as surveys were sent to all the top 25 teams).  Authors found 

    “no significant difference in the rates of shoulder pain among the four strokes and individual medley specialists.” The other risk factors surveyed (distance trained, type of equipment, weight training, and stretching) did not show a significant correlation with shoulder pain (Wymore 2012)".

    Practical Application
    Swimming is no different than many other sports in that previous injury is a very common risk factor.  However, the fact that previous injury remains closely tied to future injury is disconcerting.  Perhaps one reason past injury is associated with future injury is that athletes focus narrowly on removing symptoms and inadequately deal with function to prevent future injury.  The correlation between past injury and future injury is indisputable.  Coaches and therapists should look closely at whether their rehab programs are improving function in their swimmers or whether they are simply measuring recovery by the resolution of painful symptoms.

    Moreover, though further studies looking at predictors of injury are necessary for more effective injury prevention, the importance of muscle length, strength, and timing is clear in the findings above.  As Walker noted, excess and inadequate shoulder range of motion are predictors of shoulder pain.  As Dr. Tate found, core endurance and mid-back strength are associated with injury in all swimming populations.  The relationship between past injury and future injury speaks to the effect that injury can have to impair muscle timing despite the resolution of pain.  

    Finally, for rehabbing athletes, remember that recovery is at least a two stage process: first resolve pain, but always ensure that optimal function (length, strength, and timing) have been restored so the athlete can minimize the risk of future injury.  Past injury is not only a predictor of future injury to the same location, but also to other sites in the body.    

    References

    1. TATE, A., TURNER, G. N., KNAB, S. E., JORGENSEN, C., STRITTMATTER, A. & MICHENER, L. A. 2012. Risk Factors Associated With Shoulder Pain and Disability Across the Lifespan of Competitive Swimmers. Journal of Athletic Training, 47, 149-158.
    2. 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.
    3. Chase KI, Caine DJ, Goodwin BJ, Whitehead JR, Romanick MA.  A prospective study of injury affecting competitive collegiate swimmers. Res Sports Med. 2013 Apr-Jun;21(2):111-23. doi: 10.1080/15438627.2012.757224.
    4. Wymore L, Reeve RE, Chaput CD.  No correlation between stroke specialty and rate of shoulder pain in NCAA men swimmers.  Int J Shoulder Surg.  2012 Jul;6(3):71-5. doi: 10.4103/0973-6042.102555.
    By Allan Phillips. Allan and his wife Katherine are heavily involved in the strength and conditioning community, for more information refer to Pike Athletics.