THE PAINFUL SHOULDER IN THE SWIMMING ATHLETE

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People swim for fitness, for recreation, or for competition. Swimming is enjoyed by approximately 100 million Americans13 of all ages. No specially designed implements are required to swim, and no team or rules are required to enjoy the sport. Nobody invented swimming. The only thing needed to become a swimmer is water.

The shoulder is a vulnerable joint in the swimmer. Ninety percent of the propulsive force in swimming comes from the upper extremity.6, 7 Most other sports (e.g., running, bicycling, golfing, pitching, or batting) require the feet to push into the ground (or bicycle pedal), which initiates the propulsive or ground reaction force. In swimming, there is no such force. In swimming, the athlete must pull the body over the arm.

Another unique aspect of swimming is the factor of upper extremity endurance. Competitive athletes may swim 10,000 to 14,000 m(6 to 8 miles) a day, 6 or 7 days a week. Distance swimmers may double that distance. This distance equates to 16,000 shoulder revolutions per week, or approximately 2500 revolutions per day. Many of these revolutions are done in sequence, without any rest for the muscles to recover. Although a golfer swings, then walks, then swings again, a swimmer undergoes continuous revolutions. This continuous movement puts stress on the shoulders, leading to injury from repetitive microtrauma.

To add to the complexity of these mechanical characteristics of swimming is the fact that the shoulder is relatively unstable. When putting together the training distances, unique propulsive demands, and inherent shoulder laxity, the risk of injury is understandably high. Shoulder problems are reported in 66% of swimmers, whereas only 57% of professional pitchers, 44% of collegiate volleyball players, and 29% of collegiate javelin throwers13 report shoulder injuries.

Given the popularity of swimming and the high risk of injury, many clinicians come into contact with the swimmer's shoulder. This article focuses on conservative treatment for swimmer's shoulder. To design the optimal treatment, one needs to understand the mechanism of injury, diagnostic tools, and subtle signs of injury. Because the freestyle stroke is the commonest stroke in swimming, the focus here is on the freestyle.

Section snippets

Painful Areas

The earlier that a swimmer reports shoulder pain, the more specific the diagnosis can be. If the swimmer waits to report pain, inflammation has set in, and the pain is more global, masking the inciting symptoms. Global pain has led clinicians to make global diagnoses, such as swimmer's shoulder. Likewise, the treatment is then nonspecific with limited success. This limited success is demonstrated by the fact that more than half of shoulder injuries in swimmers recur.30 Also, if a swimmer tries

DIAGNOSIS

Originally, swimmer's shoulder, as described by Kennedy et al,16 was regarded as an outlet impingement syndrome, with impingement of the rotator cuff tendons under the coracoacromial arch. It has been suggested, however, that swimmers do not have a true outlet impingement but a tendinitis secondary to swimming as part of the increased laxity translation that is present in this population. Nowhere is the relationship between impingement, laxity, and instability more prevalent or more confusing

SUBTLE SIGNS OF INJURY

The earlier a potential injury is noted, the better the chance of recovery without significant anatomic damage. The subtle compensatory mechanics are most likely to be identified by the swimming coach. To be able to identify subtle signs of injury, the coach must first understand the basics of normal mechanics of the normal and pathologic muscle firing patterns, which have been discussed.

One of the signs of potential injury is a dropped elbow in the recovery phase of the freestyle stroke. By

CONSERVATIVE TREATMENT

The first step in conservative treatment is to eliminate acute inflammation. The earlier the injury is noted, the less inflammation, and the less time it takes to move past this step. Paddles, if they have been used, should be discouraged because they put undue stress on the shoulder and can lead to injury. A brief period of rest is beneficial to the swimmer; however, it is difficult to keep the competitive swimmer out of the pool for more than a few days. Nonsteroidal anti-inflammatory drugs

SUMMARY

The ability to return a swimmer back to normal is a blend of art and science. It entails a knowledge of normal mechanics, injury mechanics, subtle signs of injury, diagnostic tools, and exercises specific to the injury. All of this knowledge is for naught, however, unless the clinician also possesses a sharp eye and a feel for the appropriate rehabilitation progression. The science gives a platform from which to select the progression artfully. By applying the art and the science of swimming

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