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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.

Injurious Strokes: Wide Catch, Big Problems

Other than being a swimming enthusiast, I am a Physical Therapy (PT). As a PT, I get to help swimmers of all ages return to the pool to enjoy the sport they love. This series will address stroke biomechanics and how the wrong biomechanics may increase one's risk for injury. 

The shoulder is the most commonly injured joint in swimming. Uncertainly, this injury risk correlates with swimming volume and the more volume, the higher stress at a joint. This makes it imperative to decrease the joint stress with every stroke, for a long, healthy career.

One common stroke flaw is a wide catch during freestyle. It is uncertain how this biomechanical flaw beings in a swimmer, but as you'll see a wide catch increases anterior shoulder instability (by stressing the joint capsule and dynamic tissues) and stress at the  labrum.

Capsule
The joint capsule has the role of stabilizing the joint and preventing excessive motion. The capsule is a sheet of ligamentous tissue that connects the shoulder socket of the scapula to the humerus (upper arm), with several regions identified by variations in capsule thickness. Little is known about the capsule and pathologies, but that it is responsible for the common injury adhesive capsulitis (“frozen shoulder”).

Of all the shoulder joints, the glenohumeral joint capsule is most commonly discussed due to its large size. It provides passive stability around the joint, preventing subluxations when active structures are inefficient. A subluxation occurs when the active and passive structures cannot hold the head of the humerus in the correct position. As a result, the humerus migrates out of the glenoid. The majority of subluxations occur anteriorly.
Labrum
Inside the shoulder joint there is a layer of cartilage which helps protect rubbing on the head of the humerus with the shoulder blade. This layer can be pinched or rubbed, which causes injuries. Tight muscles, specifically the biceps brachii, can directly pull on the labrum due to their direct attachment.

Bursae
Around every major joint are multiple bursae, which act as cushioning pads.

These pads help reduce friction in the shoulder to allow movement. During musculoskeletal injuries these bursae commonly become inflamed. This inflammation is known as bursitis which is caused by either excessive rubbing or irritation that can be caused by a variety of structures (for example the rotator cuff tendons).
Theoretically, the hand shoulder travel relatively straight from the shoulder-width apart entry, until the exit next to the body (debate exists on this subject, but no parties suggest the catch should occur outside of the body). This is the safest position for the shoulder and having the hand outside of the body, pushes the head of the humerus forward (increasing anterior laxity) and decreases the contact area of the humerus on the labrum, increasing the stress at the smaller contact area.


This increase in shoulder stress undoubtedly increases the risk of shoulder injury on the labrum over the duration of a swimming career.

Instead, it is more sustainable to swim with the hand underneath the body during the catch, which will decrease the stress on the labrum.


Practical Implication: Freestyle swimmers (as well as water polo players and surfers) should seek a catch underneath their body to decrease stress on the labrum of the shoulder. 

For more information about swimmer's shoulder, consider the swimmer's shoulder system.


Reference:
  1. Mullen, GJ. Swimmer's Shoulder System (First Edition). San Jose, CA: Center of Optimal Restoration, 2012. 

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.

Thoracic Spine Manipulations Improve Shoulder Tendinopathy


Rotator cuff tendinopathy (RCT) is the most common ailment in swimming. Unfortunately, effective rehabilitation methods are not fully understood. Spinal manipulation is commonly used to improve shoulder motion. This study analyzed the kinematics and muscle activity of the shoulder following spinal manipulation. 

What was done
Thirty subjects (M=16, F=14; ~30 years) with signs of rotator cuff tendinopathy (RCT) and at least 3/10 pain during clinical tests underwent numerous scapular, shoulder, and cervical spine test before and after a thoracic (TSM) and cervicothoracic manipulation (CSM).

Results
There was significantly less scapular upward rotation after the thoracic TSM. No differences were noted for scapular posterior tilt, scapular external rotation, clavicular protraction, cervical rotation, ROM, thoracic spine ROM, or humerothoracic elevation ROM. A significant increase was deterred in the middle trapezius following spinal manipulation. No differences were noted at the upper or lower trapezius, infraspinatus, or serratus anterior muscles. There was a minimal clinically important difference in pain after the spinal manipulation. There was also a significant improvement 7 – 10 days following TSM on a written questionnaire.

Discussion
The decrease in scapular upward rotation likely played a minimal role in the alteration in pain due to the small change. Also, the increase in middle trapezius activation is likely minimal, but provides more evidence that spinal manipulation minimally alters muscle activation. However, the decrease in pain (most notably 7 – 10 days after the manipulation) indicates other neurophysiological processes may be the reason for improvement.

Practical Implication
Spinal manipulation minimally alters scapular kinematics and muscle activation. However, the systemic effects of manipulation are unknown. Unfortunately, this trial did assess neural alterations after spinal manipulation (a potential route of improvement) or have a comparison group, to see if other modalities (massage, exercise, etc.) resulted in similar results. Nonetheless, TSM appears to provide a clinical improvement in those with RCT. Spinal manipulations/mobilizations have been suggested numerously for swimmer's shoulder, as well as swimmer's shoulder prevention (Mullen 2009). Moreover, specific locations for manipulations are likely unnecessary, as manipulating different spinal segments results in similar improvement in function (de Olivira 2013).

COR Swimmer's Shoulder System

Reference:
  1. 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.
  2. Mullen, GJ. Swimmer's Shoulder System (First Edition). San Jose, CA: Center of Optimal Restoration.2009.
  3. de Oliveira RF, Liebano RE, Costa LD, Rissato LL, Costa LO. Immediate Effects of Region-Specific and Non-Region-Specific Spinal Manipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Controlled Trial. Phys Ther. 2013 Feb 21. [Epub ahead of print]
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.

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.

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.

Resolution of Pain is Not the End Game!

In any sport, injuries come and they go. This is the nature of placing high levels of stress on your body. Swimming places the most stress on the shoulders and low back, both frequent sites of pain in swimmers. If you search swim decks, you'll find a plethora of swimmers with a long history of low back or shoulder injuries. Most of the time, these symptoms are in remission and all is perceived as fine. However, resolution of pain is not the end game! In fact, after any injury (no matter the severity) current research is demonstrating a residual effect of muscle coordination. Unlike popular belief, this dysfunctional muscle timing during the injury does not resolve once pain is resolved. Also, the literature suggests previous injury is universally recognized as one of the most predictive factors of future injury.

This phenomenon has been demonstrated most recently in a study by Butler (2012) in the low back, but as rehabilitation specialist, I can assure you this occurs at all joints. Just think of the last time you hurt yourself, for example if you stubbed your toe on the way to get a drink at night (read about the importance of hydration on cognitive-motor skills). When you stub your toe, you likely scream a few obscenities (this may also improve the pain), then you hobble around the house like Frankenstein until the pain resolves. This hobbling is altering your normal motor control to mitigate the pain in your toe. Now, if this pain resolves and you return to normal walking in a few minutes, then the amount of time spent altering this motor control is minimal, a little harm is done. However, most injuries don't last a few days, as they frequently last days, weeks, years, or even decades. This extended alteration in motor control is damaging and likely causing the results in Butler's study when she compared a few movements in those in remission of low back pain compared to those without low back pain. In fact, the low back pain remission group had higher muscle activation during the activity. However, the posterior fibers of the external oblique had decreased activation. This altered motor programming leads to some muscles being over active and some being under active. Moreover, this leads to stroke compensations which are repeated thousands of times every day, even if not perceptible to the naked eye; all of which leads to risk of reinjury or at least can impair performance if the swimmer is subconsciously using excess tension to maintain normal biomechanics. For a full resolution of an injury, improvement in symptoms, imbalances (muscle length and strength), and motor control (muscle timing) are key! Unless you improve all these facets, your injury is likely to return. In swimming, if you have a history of shoulder injury, you're at a higher risk of reoccurrence, unless the proper precautions and rehabilitation is received. Make sure you seek and demand full improvement of the injury, not simply resolution of pain, as this is far from the end game!

Summary
Do not be content with the resolution of pain. Seek further improvement of the injury and improve the underlying issues of muscle length, strength, and timing. For the shoulder, consider purchasing the Swimmer’s Shoulder System.


Reference:
  1. Butler HL, Hubley-Kozey CL, Kozey JW. Changes in electromyographic activity of trunk muscles within the sub-acute phase for individuals deemed recovered from a low back injury. J Electromyogr Kinesiol. 2012 Nov 28. doi:pii: S1050-6411(12)00195-2. 10.1016/j.jelekin.2012.10.012. [Epub ahead of print]
By 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.

Bursitis and Swimming

At Swim Sci, we try our best to reply to every e-mail. Recently our team has received a lot of questions regarding a shoulder condition, bursitis. A lot of this article comes directly from the Swimmer’s Shoulder System, if you want to learn about preventing or improving swimmer’s shoulder, pick up your copy today!


Before we unlock the solution for bursitis, lets discuss bursae:

Bursae

Around every major joint are multiple bursae, which act as cushioning pads. These pads help reduce friction in the shoulder to allow movement. During musculoskeletal injuries these bursae commonly become inflamed. This inflammation is known as bursitis which is caused by either excessive rubbing or irritation that can be caused by a variety of structures (for example the rotator cuff tendons).


Many adaptations occur during an injury, most notably inflammation occurs. For a review on inflammation, please see these articles: Tips to Improve Shoulder Inflammation; Inflammation and anti-inflammatory medication; Inflammation in Sports; Reader Mailbag: Cortisone Injections

Lets discuss an inflamed bursae:

Bursitis

As stated, around every major joint are multiple bursae, which act as cushioning pads. Unfortunately, when a muscle is too tight or has inadequate timing, the shoulder can get “sloppy”, cause slight subluxations, and irritate the bursae. Once the bursae are enlarged, the rotator cuff tendons have less room to move and impingement can arise. This is an unfortunate combination of muscular irritation and inflammation.

Now improving bursitis depends on the clinical presentation of the swimmer. If inflammation is driving the pain, resolving inflammation is the most likely road for success. 

If altered movement patterns are the resulting cause of pain, then it is essential to improve these areas. In most cases, inflammation and mechanical adaptations (impaired muscle length, strength, and timing) are the drivers of pain, but pain is rarely this clear cut. This makes a combined treatment with medical professionals essential, as improving one of this areas is neglecting complete resolution and prevention. Make sure if you are addressing shoulder pain, that you assess the clinical presentation and seek complete resolution of pain, as pain will alter movement patterns, result in weakness, and impair swimming performance.

For more on shoulder pain, consider these pieces:
10 Minute Solution: Shoulder Pain
10 Minute Solution: Shoulder Pain Part II
10 Minute Solution: Shoulder Pain Part III
Shoulder Pain? Protect Your Rotator Cuff Muscles

By 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.