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Swimmer's Shoulder Return to Swimming Program

Take Home Points:
  1. When returning from any injury (in this case a shoulder injury), many training alterations are required.
  2. These are general outlines, please see a healthcare professional if you have shoulder pain and set an individual return to swimming outline.
  3. Don't rush your return to full swimming practice. Work on biomechanics, reduce pain, and elongate your swimming career!
The commonly used plans for returning a swimmer to the pool after a shoulder injury have many flaws. Swim coaches and health care professionals have vastly different views, both contributing to the problem. Swim coaches do not want their swimmers to miss any time from the pool as they feel any missed time will prevent progress. Health care professionals want swimmers to take weeks off from swimming to allow full recovery. The appropriate approach lies somewhere between these two options.

Yes!! He recovered from swimmer's shoulder!
A typical health care approach to recovery from a shoulder injury includes numerous “blank periods”. This is when a swimmer is not receiving care or swimming as they wait to be seen by the next professional. After these sessions, the health care professional expects the swimmer to return to the pool after their symptoms have alleviated, but often times don't necessarily stress their shoulder for the demands required in swimming. In their eyes, this is considered a successful treatment; unfortunately time away from the pool causes an athlete to lose “feel” which can only be acquired and maintained by spending time in the water.

This is the best-case scenario, but sometimes the symptoms never improve. Sometimes the swimmer will continue to swim with the pain. Other times, the symptoms may disappear and the swimmer will return to practice, hop in the pool, go full throttle, only to have the symptoms return. This reckless approach will likely cause a re-injury and add more “blank periods”. This is a sad, all too common case, for many age-group swimmers.

Many health care professionals don’t know how to safely return a swimmer to the pool with guidelines to benefit recovery. Applying continual, gradual swimming stress is essential to see if the swimmer’s shoulder pain is improving. Therefore, it is important to know their current pain level and have them progressively return to the pool. Tiers of limitations can be used to gauge improvement, yet maintain neural feel. Knowing an athlete's current level of pain will help in monitoring whether or not their symptoms are improving, as it is unlikely for the athlete to go from 8/10 to 0/10 pain after a few sessions with the rehabilitation specialist, especially if these symptoms are long-standing. Helping them progress with milder and fewer symptoms allows the swimmer to see progress, keep their sanity, and stay positive as they return to the pool.

After working with thousands of swimmers, I began piecing together simple tricks to speed recovery while maintaining “feel”, thereby preparing the athlete for a full return to practice.

Follow these guidelines closely to ensure shoulder recovery, while maintaining “feel” and strength in the water.

Return to Swimming Freestyle Biomechanics

Proper technique for injury prevention is essential. I’m sure not all of the readers will agree with these biomechanical corrections for swimming propulsive reasons. However, I recommend them because they will put less stress on the shoulder joint and muscles, the primary correction for those with shoulder pain. During freestyle, ~75% of the “most pain” occurs during the first half of the pull and ~18% of pain occurs during the first half of the recovery (Pink 2000).

The most common biomechanical causes of shoulder pain in swimmers are:

Crossing Over

Crossing over occurs when the swimmer initiates their catch and brings their arm across their body. When the arm crosses the body, it closes the space on the anterior shoulder. The anterior shoulder contains the supraspinatus, the most commonly injured rotator cuff muscles.

Solution: The most common reason for this error is a lack of emphasis on biomechanics. Most swimmers can prevent a crossover catch with concentration and appropriate cuing from their coach.

If the swimmer lacks shoulder blade stability, this may be causing them to cross their arm across their body on the catch. Stabilize the shoulder during the initial catch by performing the compact position. In the compact position, it is nearly impossible to cross over and impinge the anterior rotator cuff muscles.

Thumb-First Entry

If an athlete enters with his or her thumb, the whole hand can enter through a smaller hole, decreasing drag. However, many athletes achieve a thumbs-first entry through shoulder internal rotation. This orientation can stress the anterior structures of the shoulder and increase the risk for shoulder impingement.

Luckily, the thumb first entry can be achieved with no movement at the shoulder. Instead, instruct your athletes to use forearm pronation (rotating the forearm inwards) instead of shoulder internal rotation to get their thumbs to enter first, decreasing the amount of drag on the entry.

Solution: Either instruct your swimmers to enter finger tipss first or thumb first with only forearm pronation, a difficult but beneficial difference. Consider performing finger tip drag drills or hesitation drills just prior to entry to perfect the entry.

Head-Up Swimming

If an athlete swims with a head-up position, this will lead to the athlete curling their neck upwards, putting many shoulder and neck muscles in improper positions. Many masters swimmers and some age-group swimmers still use this head position, impairing their strength and putting their shoulder muscles at risk for injury.

Solution: Focus on swimming with your head down, try looking at the bottom of the pool or only slightly in forward. Invest in a snorkel and practice having the swimmer have the water line just above their hair line.

Armpit Breathing

Every coach knows the armpit breather. This indentured swimmer has difficulties controlling and timing their neck rotation. These swimmers will often look back when they breathe or breathe late. This can irritate the shoulder by stretching and putting the shoulder muscles at the wrong muscle length.

Solution: Instruct the swimmer to initiate their breath just prior to their arm on the same side exiting the water. For example, if you are breathing to your right, initiate your breath just prior to your right arm exiting the water. Also, focus on a rapid inhale and exhale, allowing the head to return to the water rapidly. Performing six kick rotational drills with the swimmer’s arms at their side can help the swimmer learn how far and in what direction to turn their head.

Overtaking or Catch-Up

Although the catch-up stroke is commonly performed, this position of elongated shoulder flexion
aides to approximately 70% of shoulder impingements [likely primary impingements] (Yanai 1966). Extended time in this stretched out position minimizes the subacromial space and increases rubbing of the rotator cuff muscles, a major injury risk.

An example of a "catch-up" stroke.
Solution: Have the swimmer enter their hand at a ~45 degree angle, with their hand traveling down, instead of parallel to the floor of the pool.

Wide Catch

A wide catch typically embodies vigorous and excessive shoulder abduction while internally rotating the humerus increases shoulder stress (Yani 1966).

Solution: Instruct adduction of the humerus during the initial catch, ensuring the hand is not moving outside the body line.


Other Strokes Biomechanics

This is mainly a piece regarding freestyle, but here are some quick tips for other strokes. If you are interested in more detailed biomechanical adjustments for other strokes, please comment below.

Backstroke

Swim with a wider stroke, like you have your arm around your friend's back, not underneath your body.

Breaststroke

Outsweep with your hands flat or parallel to the bottom of the pool. Do not rotate your arms inward during the catch, having your thumbs face the bottom of the pool.

Butterfly

Initiate the catch earlier, do not press the chest down with the arms remaining elevated, see this piece by Dr. Rod Havrulik

Swimmer's Shoulder Return to Swimming Program

Once swimming biomechanics are improved (via coaching, drills, underwater video, and/or concentration), it is necessary to have guidelines for return. Here are the nuts and bolts for returning to swimming in no time.

No more than 3

Knowing the pain level of a swimmer is important for determining when the swimmer should return to the pool. A pain scale of 0 to 10 is commonly used, with 0 representing no pain and 10 representing unrelenting pain. For discussion of shoulder pain, we will assume that the swimmer has at least a level of 1/10 pain. The typical presentation of shoulder pain is a swimmer with pain only during swimming. Their pain level is typically 0/10 at rest. However, once they start swimming, it is likely their pain level will steadily increase. The 'No more than 3' rule allows a swimmer to maintain their “feel” for the water, until the pain level reaches a 3/10.

It is unrealistic to expect any swimmer with a history of shoulder pain to jump in the pool and have
0/10 pain. The 'no more than 3' rule allows the swimmer to swim until they reach a 3/10 pain level. This rule is based on the belief that 0/10, 1/10, or 2/10 pain is not causing more injury or inflammation. However, if a 3/10 pain level is reached, it assumes more irritation, damage, and inflammation will ensue. When the pain reaches 3/10, the first pain plateau, changes to the swimming routine need to be made. Once a 3/10 pain level occurs, it is best to rest and allow the shoulder irritation to dissipate. This is accomplished by having the athlete kick on their back with fins, eliminating arm movements and stress to the shoulder (with streamline unless this prevents resolution of the 3/10 pain level. If pain persists in streamline, move to the arms next to the body). Hopefully a swimmer’s pain will not reach between a 4/10 and 7/10 while in the pool, because they will have stopped at the 3/10 level and proceeded with directions on how to adjust their practice routine.

If you have a shoulder injury, be excited for fin kicking!
If the swimmer has a 3/10 or greater pain at rest, it is best to have them stay out of the water, it is likely the cause is inflammation or sympathetic pain. If this is the case, it is recommended to see a health care professional for treatment and further evaluation.

This approach is effective when the athlete is seeing a health care professional on a regular basis and their symptoms are continually improving. If the symptoms are not improving with a rehabilitative specialist, either find a new one or consider taking a break from doing the activity which causes the symptoms (likely stroking). As much as I realize maintaining “feel” is important, keeping a swimmer’s shoulder away from the knife of surgery is even more important.

Solution: Have the swimmer swim the typical workout until their symptoms reach 3/10. Once a 3/10 occurs, have them kick on their back with their arms at their side or in streamline (if their symptoms don't increase with streamline) with fins when their symptoms reach 3/10. This allows them to stay in the water and keep “feel” while minimizing shoulder stress. Moreover, most swimmers can do main sets and intervals with fins, keeping them involved in practice and their face in the water. If they have 3/10 symptoms prior to practice, discontinue for the day and have them seek treatment for inflammation or sympathetic pain.

No Kickboards

Kickboards are recommended if someone has shoulder pain. Most cases of shoulder pain occur due to repeated overhead motions, leading to musculoskeletal pain. Holding a kickboard for a stagnant period is locking the arm in an overhead position and irritating the shoulder repeatedly (Pollard 2001). Moreover, athletes commonly push their shoulders down on the board, leading to overpressure on the joint, a hazardous move.

Kickboards will perpetuate the pain and is easily replaced with the swimmer kicking on their back. In fact, to prevent this dangerous position and prevent re-injury, I will have swimmers kick without a board for an extended period after the symptoms resolve (approximately one month).

Solution: Kick on your back in streamline if symptoms are less than 3/10; if symptoms are greater than 3/10, have them kick on their side or with their arms next to their side.

No Paddles

This is a tough one for some programs, but paddles place higher stress on the shoulder by allowing the swimmer to grab more water (Pollard 2001). This obvious statement supports the fact that moving more water requires more arm strength and use of shoulder muscles. Even with perfect technique, paddles will increase shoulder stress, which is bad for shoulder pain. Removing paddles will give the shoulder time to recover, getting them back to paddles sooner.

Solution: Discontinue pulling until symptoms have fully resolved for at least one month. 

Bottom Hand

When coming off a flip turn, the swimmer should initiate their pull with their bottom hand. This is biomechically advantageous to rapidly rotate and spiral the athlete to the surface. Unfortunately, this powerful stroke is always performed by the same arm as swimmers are robotic. For athletes with shoulder pain, it is necessary to give the overworked shoulder a break. In almost all overuse injuries the bottom hand off the turn is the injured shoulder.

Solution: Reverse your rotations off the wall and start your stroke with your opposite arm. This will feel like writing with your opposite hand, but will distribute shoulder stress and allow adequate shoulder healing. Another option is starting your stroke with your top hand.

Proper Pacing

During times of stress, the body adapts. At the end of a race, the body adapts to finish. Unfortunately, these adaptations are often inefficient and hazardous. At the end of a 100-m race (when the swimmers slowed ~7.7%), their biomechanics shifted from using more adduction to more shoulder internal rotation. This adaptation will increase shoulder stress and risk of injury.

Solution: Attempt to even split your races and sets during practice. This minimizes the amount of time undergoing poor, injurious biomechanics.

Snorkel

Recent research suggests that swimmers with shoulder pain have higher neck muscle activation during overhead movement outside of the pool. It is hypothesized, that if the neck muscles are overactive on land, then in the water they must be even more active. Neck rotation and breathing uses the neck muscles and can feed into the increased neck muscle activation. Using a snorkel will minimize head rotation and neck muscle activation.

Solution: Consider using a snorkel during workouts if your symptoms persists.


Return to Swimming Yardage

Knowing how much yardage to begin with is difficult. I often suggest starting with 1,000 yards of breast and freestyle. Once again, if pain increases past a 3/10, I suggest kicking on your back with fins until it returns to a 0-1/10. After this, I suggest adding 500 - 1,000 yards every 3 days with a maximum of 1/10 pain. Once you're able to swim 3,000 yards, I suggest adding butterfly and backstroke (ideally on separate days, to know which is the irritant). 

Example 6 Week Return to Swimming Program

Below is an example 6 week return to swimming program, she swam once a day, six times per week, for the entire six weeks. The swimmer also did not perform any meets during this six weeks. 

The swimmer had infraspinatus tendinits initially and she received 2x/week of physical therapy for the entire 6 weeks. 

DayYardageStrokesHighest Pain LevelNotes
11000Free3
21000Free2
31000Free1
41000Free1
51000Free1
62000Free2
72000Free, Breast5Performed 1,700, then kicked 300.
81750Free, Breast2
92000Free1
102000Free1
112000Free, Breast0
122500Free, Breast0
133000Free0
143000Free, Breast, Back0
154000Free, Breast, Fly7Performed 3000, then pain during fly. Kicked last 1000.
164000Free, Breast, Back3
174000Free, Breast, Back3
184000Free, Breast, Back2
194000Free, Breast, Back1
204000Free, Breast, Back1
214000Free, Breast, Back1
225000Free, Breast, Back0
235000Free, Breast, Back0
245000Free, Breast, Back0
255800All Strokes4Perforemd 4800, pain during fly. Kicked last 1000.
266000All Strokes2
276000All Strokes2
286000All Strokes2
296000All Strokes1
306000All Strokes1
316000All Strokes1
327000All Strokes1
337200All Strokes0
347400All Strokes0
356900All Strokes1
367100All Strokes0
377200All Strokes0
387400All Strokes0

As you see, there were days when the pain exceeded 3/10. This is expected as recovery from an injury isn't linear. Nonetheless, sticking with a plan, which emphasizes rehabilitation (ideally with skilled physical therapy), progressive addition of swimming volume and strokes, and biomechanical adjustments can enhance the recovery a swimmer's shoulder. Ensure all these for a quick and long-lasting swimmer's shoulder recovery and be a life-long swimmer (#fist pump)!

References:

  1. Yanai, T., & Hay, J. G. (1966). The mechanics of shoulder impingement in front-crawl swimming. Medicine and Science in Exercise and Sports, 28(5), Supplement abstract 1092.
  2. Suito H, Ikegami Y, Nunome H, Sano S, Shinkai H, Tsujimoto N. The effect of fatigue on the underwater arm stroke motion in the 100-m front crawl. J Appl Biomech. 2008 Nov;24(4):316-24.
  3. Pollard B. The prevalence of shoulder pain in elite level British swimmers and the effects of training technique. British Swimming Coaches and Teachers Association; 2001.
  4. Spigelman T, Sciascia A, Uhl T. Return to swimming protocol for competitive swimmers: a post-operative case study and fundamentals. Int J Sports Phys Ther. 2014 Oct;9(5):712-25.

The COR Swimmer's Shoulder System E-book and video database starts with a comprehensive e-book that guides you through Mullen's four-phase system. This book details everything about the shoulder, why swimmers are at risk for shoulder pain, to which training frequency option you should choose to exactly how you can make effective program modifications if you don't have specific equipment at your disposal.


A video database gives you video access to more than 40 exercise videos, so you'll never have to worry about how to execute a correct movement again! It'll be like G. John Mullen is there with you, teaching you how to perform the entire program in person! This great resource for coaches and swimmers is valued at $370, but is yours for only $59.99!

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.

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.