Friday Interview: Dr. Wymore on Healthy Swimmers More Dysfunctional Than Injured Baseball Players: Swim Shoulder Pain

This is an interview with Dr. Lucas Wymore. Dr. Wymore recently published: Shoulder Functional Performance Status of National Collegiate Athletic Association Swimmers: Baseline Kerlan-Jobe Orthopedic Clinic Scores. This interview discusses this research article, but don’t forget to look at Dr. Wymore’s other study: No correlation between stroke specialty and rate of shoulder pain in NCAA men swimmers. For more on Swimmer’s Shoulder checkout Swimmer’s Shoulder Return to Swimming Program  or consider purchasing the COR Swimmer’s Shoulder System.

1. Please introduce yourself to the readers (how you started in the profession, education, credentials, experience, etc.).

My name is Lucas Wymore, and I am an orthopedic surgeon specializing in sports medicine. I attended Notre Dame for college where I swam for the 

Irish. I went to medical school at Texas A&M University, completed my orthopedic residency at the University of North Carolina at Chapel Hill and a sports medicine fellowship with the San Diego Sports Medicine and Arthroscopy fellowship. I became interested in sports medicine while in high school. I loved sports, and because of swimming, I had a desire to remain involved in the sport and work with athletes as a career.

2. You recently published an article on subject active swimmer responses based on their shoulder. What do we know about the accuracy of subjective responses ?

We know with any survey study, there are some inherent limitations. Recall bias can change people’s responses due to memory of past events. Some athletes may wish to underreport their symptoms if they fear that they may lose playing time. In order to decrease this bias, our study was to be completed based on shoulder symptoms at the present time, in an effort to minimize recall bias. Privacy was assured so that athletes would be more comfortable answering as truthfully as possible.

3. What did you choose the KJOC and did you consider any other subjective questionnaires ?

The KJOC score was selected because it is validated for overhead athletes. It is specific for function and performance in the athlete, which will pick up differences that may be missed in other scores. Many studies have used this questionnaire for a variety of shoulder and elbow research in athletes. There are other shoulder scores in the orthopedic literature, but these focus on activities of daily living. For example, the Disabilities of Arm, Shoulder, and Hand (DASH) ask questions including difficulty with preparing meals or washing one’s hair because of shoulder pain. In many athletes, they may have a debilitating shoulder problem and are completely disabled for sport, but can still have a nearly perfect DASH score. The KJOC score evaluates function and performance specifically for athletes to find these differences.

4 . What exactly did your study look at and why is this a point of interest ?

Our study was designed to define a baseline KJOC score for active swimmers. We wanted to take a group of swimmers that were actively competing in the sport at a high level, and determine a numerical value for their shoulder function. This had been done previously with baseball pitchers. Our goal was to provide similar data to the swimming community that can be useful for comparison both with future research and clinical evaluation.

5. What were the results of your study ?

The study showed that swimmers had a surprisingly low baseline KJOC score. The mean score for all participating athletes was 79.0 out of a possible 100. For swimmers competing without shoulder trouble, the mean score was 84.4, those with shoulder trouble was 53.9. We found swimmers competing for 11 years or longer had a significantly lower score than those swimming for 10 years or less, 72.0 vs 86.4, respectively. We have no other swimming data like this for comparison. However, other studies looking at baseball pitchers show a baseline score of 94.8 (Kraeutler et al, Journal of Shoulder Elbow Surgery, 2013.) That study concluded that scores for healthy pitchers should be greater than 90. Our study showed a baseline score less than 80.

6. What were the practical implications for coaches and swimmers from your study ?

This data can be useful when evaluating swimmers with complaints of swim shoulder pain. The survey is very simple to use and can be completed in under 5 minutes. Physicians and athletic trainers can now compare their athlete’s score to our baseline scores to help guide treatment.

7. Do you think the results would be different if you had older, elite or untrained swimmers?

Yes, I think the results would have been different. We focused only on NCAA swimmers, which gives a consistent age and skill level. Older studies show that youth or age group swimmers have less incidence of swim shoulder pain than older swimmers. Most research shows that the more elite swimmers have a higher incidence of shoulder trouble. I think that generalizing our results to all swimmers- competitive or recreational, youth or masters, is difficult and should be done with caution.

8. There has recently been research on perceptions of swim shoulder pain in swimmers (mainly by Hibberd), what are your views on the perception of swim shoulder pain in the sport of swimming?

Dr. Hibberd has published some excellent research in swimming. Her recent article on perception of swim shoulder pain gives a scientific insight to the culture of the sport. I think that in swimming, shoulder pain is considered part of the sport in ways not seen in other overhead athletes. Pitchers are shut down if they develop shoulder pain. Swimmers tend to accept it as normal. I think our data shows this. Athletes who define themselves as competing without shoulder trouble have an average score of 84.4- still lower than what is considered the cutoff for a healthy pitcher.

9. I’m often asked, especially in maturing young swimmers, how can you tell the difference between pain and soreness, how do you respond to that question?

It can definitely be difficult to define. In general, I think of soreness as the body’s physiological response to intense athletic activity. It is generally milder discomfort, resolves on its own, and should not interfere with sport. Pain from injury tends to be more severe and consistent in location and nature. Pain that forces alteration in technique, or causes a noticeable decline in performance in both training and competition is more concerning.

10. There has been more of a shift towards high intensity swimming training with a lower volume, do you feel this training approach reduces shoulder stress ?

I think that the “swimmers shoulder” is a cumulative effect of the miles on the shoulders. Swimming is still an inexact science- both with training and medicine. I think that less miles reduces shoulder stress. The true test will be if it improves performance as well as decreases shoulder problems.

11. If a swimmer has pain in their shoulder, what course of action do you suggest?

I would first recommend a short period of rest (3 days rest to minimize deconditioning,) ice, and anti inflammatory medications. Then a gradual return into the pool, with a focus on warm up. Pain that was persistent and more debilitating warrants work up with a careful exam of the shoulder, X-rays, and possibly an MRI if there was concern for a soft tissue structural problem, such as a tear of the labrum or rotator cuff. 

12. What research or projects are you currently working on or should we look from you in the future?

I would like to design a study that determines prevention strategies to decrease shoulder problems in swimmers. In our study, the question “How difficult is it to get loose or warm up before practice?” had the lowest score, a mean of 6.4 out of 10. I think that investigating warm up is an area that may help the athletes decrease shoulder problems.