Swimmer’s Shoulder - An Overview

Introduction:

The shoulder boasts the most extensive range of motion among all joint systems. The collaborative efforts of ligaments and muscles surrounding the shoulder offer vital support, enabling it to withstand powerful forces while maintaining flexibility for diverse movements. Activities such as swimming, throwing, or engaging in racket sports involve overhead movements, rendering the shoulder vulnerable to injuries. In competitive swimming, the repetitive nature of strokes can give rise to shoulder issues, giving way to the swimmer's shoulder, a musculoskeletal condition manifesting in the anterolateral aspect of the shoulder.

What Is a Swimmers Shoulder?

Swimmer's shoulder serves as a catch-all term encompassing shoulder injuries prevalent among swimmers, denoting a broad spectrum of shoulder pain or swim-related injuries. Its occurrence is notably high in competitive swimmers and individuals consistently engaging in overhead arm movements, such as those integral to freestyle, butterfly, and backstroke swimming strokes. The etiology of a swimmer's shoulder is attributed to factors like repetitive use, suboptimal technique, inflammation, or direct injuries to the shoulder.

Typically, individuals afflicted by swimmer's shoulder may experience pain in the shoulder region, accompanied by weakness in the affected area. The shoulder might exhibit tenderness upon touch, posing challenges in performing various tasks. Moreover, a diminished range of motion in the shoulder joint is a common symptom. Inflammation of tendons or the bursa in the shoulder can result in noticeable swelling, and some individuals may observe clicking or popping sounds during shoulder movements. These symptoms collectively characterize the multifaceted nature of swimmer's shoulder.

What Is the Etiology of Swimmers Shoulder?

Swimmer's shoulder develops gradually due to repetitive actions, falling within the category of microtrauma, where numerous contributing factors come into play. These factors encompass:

Intrinsic Factors: This contributes significantly to the swimmer's shoulder, with subacromial impingement playing a pivotal role in compressing specific shoulder structures. This is divided into:

1. Primary impingement, although uncommon, arises from a tight posterior capsule or an unusually shaped acromion.

2. Secondary impingement is prevalent among competitive swimmers, where the anterior part of the shoulder experiences increased laxity. This condition is often associated with fatigue, as the normally stabilizing serratus anterior fails to maintain the necessary space under the acromion, altering mechanics and potentially changing shoulder rotation to avoid pain-inducing movements. Furthermore, fatigue-related symptoms impact a swimmer's mechanics and can also affect shoulder rotation, leading to adjustments to steer clear of painful actions. An additional concern involves the blood supply to the rotator cuff; during faulty mechanics or fatigue, compromised blood flow occurs when the arm is lowered, temporarily depriving the tendons of adequate circulation.

Extrinsic Factors: This includes:

1. Misuse of the shoulder occurs when improper technique, incorrect stroke mechanics, or equipment that places undue stress on the body is employed.

2. Conversely, disuse manifests when muscles are not utilized over a period, resulting in weakness and alterations in muscle control. This lack of muscle engagement can lead to muscle atrophy and changes in the control of stabilizing muscles surrounding the shoulder.

3. The repetition of activities characterizes overuse without allowing the body sufficient time to recuperate. This can result in symptoms such as muscle weakness or a lack of endurance.

4. Abuse involves the application of excessive force to normal tissues, creating stress and the potential for damage to the shoulder.

How to Assess a Swimmers Shoulder?

The assessment of the swimmer’s shoulder includes:

1. Subjective Evaluation: This phase encompasses gathering information directly from the patient regarding their presenting symptoms. If the patient reports anterior and lateral shoulder pain, particularly experiencing sharp discomfort during overhead movements, it suggests a potential issue in the subacromial region or AC joint. Conversely, if the pain is diffuse throughout the shoulder and upper arm, accompanied by burning or shooting sensations, a comprehensive assessment of the cervical spine is warranted.

2. Irritability Analysis: The irritability assessment delves into categorizing irritability levels as either low or high. Low irritability entails a moderate level of pain, typically triggered by lifting heavy weights but lasting only briefly, often just a few seconds. On the other hand, high irritability manifests as a pain rating of 7 out of 10, activated by elevating the arm beyond 90 degrees without any added load. It persists for an extended duration, often lasting several hours. Additionally, it is crucial to consider the swimmers' work routines, noting any alterations in their habitual activities.

3. Physical Observation: This phase involves a meticulous examination of the shoulder posture. Notable deviations may manifest as thoracic kyphosis, characterized by a forward curvature of the upper spine. Another common deviation is cervical lordosis, wherein the neck exhibits a forward protrusion. Also, protracted scapulae, indicating a forward positioning of the shoulder blades, can be observed. Soft tissue assessments reveal potential findings such as a tight posterior shoulder capsule, restricted anterior shoulder muscles, or weakened muscles in the front neck region.

4. Range of Motion Evaluation: Swimmers experiencing impingement may encounter discomfort within 60-120 degrees while elevating their arm. The examination should include a lateral scapular slide, measuring the distance between the inner edge of the shoulder blade and the spine during arm elevation. To rule out primary impingement, X-rays play a crucial role in identifying any abnormal acromial shapes. Furthermore, vigilant attention should be given to signs of joint instability and overall mobility.

How Is the Swimmers Shoulder Managed?

Before embarking on the treatment, a comprehensive grasp of the underlying causes and intricacies within the muscles and tissues is crucial. The procedural steps encompass:

1. Address Impairment: Targeting impairments is the initial focus, employing manual techniques to alleviate pain. Following pain management, priority is given to addressing specific concerns, including postural deviations, stiffness in chest muscles or shoulder joints, muscle weakness, restricted movement in the upper spine, and issues with range of mobility.

2. Posture: Correcting postural impairments involves employing soft tissue mobilization techniques or strengthening exercises. When the muscles in the anterior shoulder are tight, a cautious approach to manual stretching is undertaken, avoiding excessive force. Alternatively, cuff weights can be incorporated while the patient lies backward for a targeted and controlled stretching experience.

3. Joint Mobility: When confronted with tension at the rear of the shoulder coupled with laxity in the front, a therapeutic approach involves employing posterior capsule mobilization. In this technique, the patient reclines, and the therapist supports the shoulder blade while gently pushing the upper arm bone backward. Alternatively, the patient can independently perform a self-stretch targeted at the back of the shoulder for enhanced flexibility.

4. Scapular Stabilization: Ensuring scapular stabilization is paramount, given its direct influence on the positioning of the upper arm bone. The treatment strategy encompasses a diverse set of techniques, including releasing tight tissues and retraining nerves and muscles to promote proper movement patterns. Effective exercises in this regard involve face-down prone exercises, such as the rowing motion (extending the arm with a bent elbow), prone extension (straightening the arm with the thumb pointing away from the body), and prone horizontal abduction (moving the arm sideways with the elbow straight). Another beneficial exercise is Superman, where the elbows are fully extended with the shoulders externally rotated. Additionally, incorporating weight-bearing exercises contributes to scapular stabilization.

5. Address Training Errors: Addressing training errors is a crucial aspect of the rehabilitation process, necessitating modifications to training intensity and avoiding tools like hand paddles and kickboards that can induce stress on the shoulder. Emphasizing correct body positioning and incorporating shorter dry-land periods is essential for healing.

Conclusion:

In summary, the prevalence of swimmer's shoulder poses a notable challenge for athletes. However, its adverse effects can be mitigated by fostering awareness, implementing preventive measures, and intervening promptly. The pivotal role of preseason screening cannot be overstated. It serves as a critical tool in pinpointing potential issues and training errors that might manifest as symptoms.