swimmer's shoulder guide

Swimmer’s Shoulder Return to Swimming Program

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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.

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.

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.

Wide Catch 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.

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.

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 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.

Kickboards are not 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.
Day Yardage Strokes Highest Pain Level Notes
1 1000 Free 3
2 1000 Free 2
3 1000 Free 1
4 1000 Free 1
5 1000 Free 1
6 2000 Free 2
7 2000 Free, Breast 5 Performed 1,700, then kicked 300.
8 1750 Free, Breast 2
9 2000 Free 1
10 2000 Free 1
11 2000 Free, Breast 0
12 2500 Free, Breast 0
13 3000 Free 0
14 3000 Free, Breast, Back 0
15 4000 Free, Breast, Fly 7 Performed 3000, then pain during fly. Kicked last 1000.
16 4000 Free, Breast, Back 3
17 4000 Free, Breast, Back 3
18 4000 Free, Breast, Back 2
19 4000 Free, Breast, Back 1
20 4000 Free, Breast, Back 1
21 4000 Free, Breast, Back 1
22 5000 Free, Breast, Back 0
23 5000 Free, Breast, Back 0
24 5000 Free, Breast, Back 0
25 5800 All Strokes 4 Performed 4800, pain during fly. Kicked last 1000.
26 6000 All Strokes 2
27 6000 All Strokes 2
28 6000 All Strokes 2
29 6000 All Strokes 1
30 6000 All Strokes 1
31 6000 All Strokes 1
32 7000 All Strokes 1
33 7200 All Strokes 0
34 7400 All Strokes 0
35 6900 All Strokes 1
36 7100 All Strokes 0
37 7200 All Strokes 0
38 7400 All Strokes 0
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 $149!

Dr. John Mullen

DOCTOR OF PHYSICAL THERAPY
PERSONAL TRAINING WITH NATIONAL STRENGTH AND CONDITIONING ASSOCIATION

Dr. John Mullen, DPT, CSCS is a World renowned expert and speaker in sports training and rehabilitation. He received his Doctorate in Physical Therapy at USC, as well as the Josette Antonelli Division Service Scholarship, Order of the Golden Cane, and the Order of Areté. At USC, he also performed research on strength training and rehabilitation. Dr. John has worked with multiple professional and Olympic athletes, helping them earn Olympic medals.

His dedication to research and individualization spurred him to open COR in 2011. Since 2011, Dr. John has been featured in Gizmodo, Motherboard, Stack Magazine, and much more.

He has worked with the numerous colleges and teams regarding rehab and performance. Before his Doctoral program, Dr. John swam on an athletic scholarship at Purdue University.

At Purdue, Dr. John was an Academic Honorable Mention All-American and was awarded the Red Mackey Award and R. O. Papenguh Award. He also won the Purdue Undergraduate business plan and elevator pitch competition, as well as 1st prize with the Indiana Soy Bean Alliance.

Dr. John was born in Centerville, Ohio and was a 24-time high school All-American Swimmer. Dr. John is still a swimmer and holds a Masters Swimming World and Pacific Swimming Record.

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