CONSERVATIVE MANAGEMENT OF SHOULDER INJURIES

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THE PAINFUL SHOULDER IN THE SWIMMING ATHLETE

Marilyn M. Pink, PhD, PT, and James E. Tibone, MD

People swim for fitness, for recreation, or for competition. Swimming is enjoyed by approximately 100 million Americans13 all ages. No of 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 ext r e m i t ~ .Most other sports (e.g., running, bi~,~ cycling, 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 throwe r ~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.
MECHANISM OF INJURY
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

From the Biomechanics Laboratory, Centinela Hospital Medical Center, Inglewood (MMP); the Department of Orthopaedics, University of Southern California WT); and the Kerlan-JobeOrthopaedic Clinic (JET),Los Angeles, California ORTHOPEDIC CLINICS OF NORTH AMERICA
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has led clinicians to make global diagnoses, such as swimmers 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.3o Also, if a swimmer tries to wait out or swim through the pain, anatomic damage is likely to occur. Conservative treatment is much more effective if intervention occurs before that point. A valuable message that can be given to coaches and swimmers is that pain is telling them something. Teaching athletes and coaches the difference between pain and soreness can help minimize the damage and hasten the return to sport after an injury. A survey of 233 competitive swimmers on 17 collegiate teams9 asked for the location of pain and the positions during the stroke of the most intense pain. The anterior-superior region of the shoulder was identified in 44% of the swimmers as the area of pain. Diffuse pain was identified in 26% of the swimmers, with lesser frequencies reported for the anterior-inferior region of the shoulder (14%of the swimmers), posterior-superior region (10% of the swimmers), and posterior-inferior region (4% of the swimmers). It is likely that swimmers who identified diffuse pain had not acknowledged the pain when it was more localized, and the inciting symptoms were masked by inflammation and more severe damage. In the freestyle stroke, the first half of pullthrough was most frequently identified as the painful phase of the stroke (approximately 70% of symptoms were noted at this time)? Another vulnerable point of the stroke appeared during the first half of recovery (18% of symptoms were elicited at these points) (Fig. 1). During the first half of pull-through, the arm is unilaterally pulling the body over the arm. The arm generates the propulsive force. In a separate surveymore than half of the swimmers reported that increasing the in-

tensity of a workout was one of the two factors (the other being an increase in distance) that appeared to provoke shoulder pain.30The increased intensity implies that the magnitude of the propulsive forces would be a factor in shoulder injuries. During the second half of pull-through, it may be that the swimmer with a shoulder injury fails to generate the propulsion from that arm and is relying on the contralateral arm to pull the body forward. Toward midrecovery, the humerus is hyperextended and swinging the forearm forward. It has been suggested that at this point the humerus moves into maximal external rotation, and this has been equated to the late cocking phase of the baseball pitch. Although it is true that at this point the humerus is as far into external rotation as it goes during the freestyle stroke, it is nowhere near the degree of maximal external rotation required during the baseball pitch. During the midrecovery phase of the freestyle stroke, the humerus is closer to neutral rotation than it is to maximal external rotation. This singular fact underscores the issue that the mechanics of injury in the swimmer are unique for that sport-they are unique for each stroke within swimming. A grouping of all overhead athletes does injustice for the specificity of understanding injury mechanics. As the freestyle swimmer approaches midrecovery it is the humeral hyperextension that likely causes the pain. In this position, the humeral head is pushed anteriorly. Any anterior impingement, labral damage, or inflammation would be aggravated in this position.
Anatomic Areas of Injury

Based on the knowledge of where the shoulder hurt during swimming and which phase of the stroke provoked the injury, an anatomic

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study was designed to determine the proximity of soft tissues with skeletal tissue. Nine cadaver shoulders were placed in the positions during the first half of pull-through, and crosssections were taken. Five of the specimens exhibited bursal and intraarticular contact with the rotator cuff, two specimens demonstrated intraarticular contact only, and two demonstrated bursal contact only.EThree of the specimens that exhibited intraarticular and bursal contact also revealed the biceps tendon in contact with the coracoacromial arch. Two of the specimens with intra-articular cuff contact demonstrated greater tuberosity contact with the acromion. The site of intra-articular contact was commonest in the anterior-superior labrum (five specimens), whereas the posteriorsuperior labrum was implicated to a lesser degree (three specimens). Cadaver specimens greatly simphfy the issue of shoulder problems in swimmers because they cannot account for the inflammation that would accompany the microtrauma of injury. The inflammation could cause more or different areas of contact. The cadavers cannot account for any pathologic instability or muscular fatigue or substitution mechanics that may occur. Although simplified, this cadaver model allows a clinician to understand the multiplicity of anatomic contact areas (bursal and intra-articular areas) during the most painful phase of the freestyle stroke.
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Stroke Analysis and Muscle Function

During the freestyle stroke, the upper trapezius, rhomboids, supraspinatus, middle deltoid, and anterior deltoid position the scapula and the humerus for hand entry and exit in the swimmer with normal shoulders (Fig. 2).26 The serratus anterior is continuously active throughout the stroke as it helps to position the scapula (along with the upper trapezius and rhomboids) for hand entry and exit and pulls the body over the arm (conceptually a reversal of origin and insertion). The subscapularis is also continuously active because the humerus is predominantly in internal rotation throughout the MonadU has demonstrated that 15%to 20% of a muscle's maximal voluntary contraction is the highest level at which sustained activity can occur without fatigue. Both the serratus anterior and the subscapularis appear susceptible to fatigue. The pectoralis major and latissimus dorsi fire sequentially during middle-pull-through because they are the major source of the propulsion force. The posterior deltoid follows these two muscles as it continues to pull the body over the arm and begins to lift the humerus out of the water at the end of pullthrough. The teres minor functions with the pectoralis major as it forms a force couple to hold the head of the humerus back and to con-

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Figure 2. Primary movers at hand entry and exit. Normal shoulders: primary movers at hand entry and exit during the freestyle swimming stroke. (From Pink M, Perry J, et al: The normal shoulder during freestyle swimming: An electromyographic and cinematographic analysis of twelve muscles. Am J Sports Med 19:574, 1991; with permission.)

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trol the internal rotation force of the pectoralis major during propulsion. The major difference in muscle action in swimmers with painful shoulders is that the serratus anterior is markedly depressed during middle-pull-through, whereas that of the rhomboids is markedly enhanced (Fig. 3A, B)J9 It is likely that the serratus anterior fatigues in swimmers with painful shoulders, producing an unstable scapula. To compensate, the rhomboids contract to stabilize the scapula. These two muscles are designed to function antagonistically. When the serratus anterior cannot perform, there is no muscle that can assist with a similar action. The only way the body can stabilize the scapula is to

recruit the rhomboids. The optimal synchrony of firing seen in normal scapular rotation is disturbed at the time of propulsion. Another asynchrony is the decrease in activity of the subscapularis during midrecovery and an overall general increase in activity of the infraspinatusmuscle (Fig. 3C, 0)J9Opposing muscles (an internal and an external rotator) change the intensity of their activity-the subscapularis decreases, and the infraspinatus increases. Similar to the serratus anterior, the subscapularis is susceptible to fatigue because of its continual activity in swimmers with normal shoulders. Swimmers with painful shoulders may have fatigued their subscapularis. The subscapularis may also diminish its func-

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Figure 3. Normal and painful shoulders muscle activity during the freestyle subscapularis (C), and infraspistroke. Serratus anterior (A), rhomboids (B), (From Scovazzo ML, Browne A, et al: The painful shoulder during natus (13). freestyle swimming: An electromyographicand cinematographic analysis of 12 muscles. Am J Sports Med 19:581, 1991; with permission.) Illustration continued on opposite page

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tion to avoid the painful extremes of internal rotation, whereas the infraspinatus increases its activity to rotate externally the humerus for the same end goal. During hand entry in swimmers with painful shoulders, there is a decrease in activity in the anterior and middle deltoids and in the u p per trapezius and rhomboids. At hand exit, there is also a diminution of activity in these two heads of the deltoid. This reduced activity is related to the dropped elbow during recovery, early hand exit, and wider hand entry, which are discussed under subtle signs of injury. There is no significant difference in the muscle firing of the primary muscles of propulsion (pectoralis major, latissimus dorsi, and posterior deltoid) when comparing swimmers with normal and painful shoulders. There is no significant difference in the muscle firing of the teres minor in swimmers with normal and

painful shoulders. The muscles of propulsion as well as the pectoralis major and teres minor force couple are intact. The supraspinatus muscle also functions normally as it compresses the head of the humerus in the glenoid. This research suggests that the key muscle on which to focus for injury prevention and rehabilitation in competitive freestyle swimmers is the serratus anterior. A stable scapula is paramount in preventing shoulder injuries, and the serratus anterior is the muscle that constantly fires to provide the necessary stability. There is no other muscle that can substitute for the serratus anterior and provide the same synchronous pattern of muscle firing. The rhomboids contract when the serratus anterior fails, but the direction of pull is directly opposed to that of the serratus anterior, causing asynchronous muscle action. The subscapularis is another muscle on

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which to focus because it may also be susceptible to fatigue. It inserts close to the humeral axis of rotation, precisely holding the head of the glenoid fossa. It also forms the first layer of muscular anterior wall for joint protection. Because this muscle exhibits diminution of muscle activity in swimmers with painful shoulders, it requires attention from the clinician.
DIAGNOSIS

Originally, swimmer's shoulder, as described by Kennedy et a1,I6was 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 than in the swimmer. Clinically, most swimmers have increased translation and increased laxity of the shoulder; however, only approximately 20% meet the criteria for generalized ligamentous laxity. Laxity is not the same as instability. Translations in the glenohumeral joint that are increased are a result of joint laxity. If the same translations cause symptoms, this is shoulder instability. The amount of laxity present in the symptomatic shoulder is usually the same as in the asymptomatic shoulder. Swimmers complain of pain not instability, and it is uncommon for them to have a true instability episode. (The exception is the backstroker, who commonly injures the anterior ligamentous structures.) The impingement that occurs is not outlet impingement but is impingement secondary to glenohumeral laxity, which places stress on the rotator cuff tendons. Also, there is a dysfunction of the scapular muscles that disturbs the scapular humeral rhythm with improper positioning of the glenoid platform during exercise. This improper positioning places increased stress on the anterior capsular structures, causing an increase of anterior translation with a secondary impingement of the rotator cuff. On examination, swimmers commonly have anterior or anterolateral shoulder tenderness. The impingement tests are positive, with the Hawkins test being positive in a greater number of patients than the Neer test.25Increased translations are usually present clinically in the anterior and inferior direction. Swimmers

should be evaluated for signs of generalized joint laxity, which includes being able to hyperextend the elbows and knees, being able to place the palms to the floor with the knees extended, being able to touch the thumb to the volar forearm, and being able to extend the metacarpophalangeal joint of the second or fifth finger greater than 90". Normal swimmers usually do not have decreased internal rotation range of motion as compared with external rotation. Even when present, it is not as dramatic as in other overhead athletes. There is usually not a marked posterior capsule tightness. When the swimmer presents in the clinic or training room, radiographs are taken to rule out any unusual anatomic variant, but the radiographs are commonly normal. There is usually no spur off the anterior acromion, and the anatomy is normal. CT scans are commonly of no value in the face of normal radiographs. MR imaging scans commonly show signal change in the rotator cuff tendon, but fullthickness rotator cuff tears or significant partial-thickness rotator cuff tears are rare. The MR imaging findings usually are confusing to the orthopedic surgeon and the athlete because many asymptomatic shoulders have similar findings on MR imaging. In general, MR imaging scans are not beneficial in evaluating swimmer's shoulder. An exception may be backstroker's shoulder, in which a gadolinium-enhanced MR imaging scan may be useful in determining if there has been any anterior labral damage.
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 dropping the elbow, the swimmer decreases the degree of humeral internal rotation. The internal rotation is painful, so by dropping the elbow, the swimmer is able to avoid the pain. Many coaches have responded to this sign by telling the swimmer to stop being lazy or to keep the elbow up. Part of an educational plan for a coach would be to note

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creased body roll allows the hand to come out the yardage when the dropped elbow occurs of the water with less shoulder hyperextenand observe whether it begins to present itself earlier in the workout. The swimmer should sion. By avoiding the shoulder hyperextension, the swimmer is actually avoiding the be pulled from the workout when a dropped elbow is consistently evident and tested for concomitant levering of the humeral head any. impingement. terior1 In that the serratus anterior is frequently a The coach can be taught the Hawkins test culprit of shoulder problems in the swimmer, for impingement. Although the Hawkins test it is worthwhile to observe the bilateral scapis not exactly the position the swimmer is subular symmetry (or asymmetry) on dry land. consciously trying to avoid by lowering the elIf a swimmer is suspected to have shoulder bow, it is similar enough that the coach can see problems, the scapula position at rest and durthat it is a test designed to elicit the pain that ing motion can be telling. It is easiest to decomes from pathology. As previously mentect problems at the end of a workout, when tioned, the Hawkins test more frequently dethe swimmer may be fatigued. Any scapular tects shoulder pain in the swimmer than does winging is a definite sign of problems. (The the Neer or relocation test.25The mechanics athlete is beyond a subtle sign of injury at this of the Hawkins test are more closely aligned point.) Premature or excessive scapular elewith the mechanics of a swimmer's shoulder vation or upward rotation during flexion or injury than other clinical diagnostic tests. abduction may be noted. Rather than being lazy with a dropped elA study by Babyar2noted that patients with bow, the swimmer is attempting to minimize painful and stiff shoulders exhibit excessive the anatomic damage. The dropped elbow, or scapular vertical motion and no changes in the decrease in humeral internal rotation, in horizontal motion. Likewise, McQuade et alZ1 swimmers with painful shoulders is suphave demonstrated excessive scapular motion ported by electromyographic observations of in normal shoulders subjected to fatigue. The more activity in the infra~pinatus.2~ lower The pathologic pattern in the swimmer is the same. elbow also allows the swimmer to enter the The pattern could be caused by a diminution water with a wider hand entry. If the observer misses the dropped elbow, the wider entry of serratus anterior function. If the serratus anmay be noted. The wider hand entry is subterior is not functioning adequately in the stantiated by altered electromyographic activswimmer, it is not able to anchor the inferior angle of the scapula, and it cannot allow for a ity in swimmers with pathologic s h o ~ l d e r s . ~ ~ These swimmers exhibit decreased activity in smooth movement. The upper trapezius apthe anterior and middle deltoids along with pears as if hyperactive, yet it is not hyperactive. It simply does not have the activity of the the upper trapezius and rhomboids. The wider antagonistic muscle (serratus anterior) to conhand entry does not require as much scapular trol the motion. The result is excessive or preupward rotation or retraction, and, by definimature scapular elevation and upward rotation, it does not require as much humeral fortion. Historically, many clinicians have called ward flexion. this scapular asynchrony a lag. It is not a lag; The swimmer's pull may be a bit more rather, it is early and excessivemotion. A naive asymmetric. The painful arm may not genereye (such as the swimmer watching himself or ate forces equal to the contralateral side. The herself in the mirror fram the front as he or she swimmer has difficulty staying in the center of elevates the arm) might detect this asynchrony the lane. Also the swimmer may compensate as almost an early shoulder shrug motion. The by decreasing the pull on the contralateral side lateral slide test as described by Kibler17can be or by changing the beat of the kick. helpful. Three positions are tested: (1)with the The swimmer may also allow the hand to arms at the side; (2) with hands on hips; and exit the water early. Swimmers continue to (3) with shoulder in abduction to 90" with propel themselves through the water in the maximal internal rotation. Measurements are later portion of the pull-through phase.I8The swimmer with a painful shoulder may, howmade from the spine to the inferior medial borever, pull the arm out early and lose that porder of the scapula. An increase of lateral slide tion of propulsion. As the swimmer pulls the reveals subtle serratus weakness. Some authors1,3,10,11,14,16,20.27,28 have sughand out early, he or she is preparing for the dropped elbow during recovery phase that gested that an imbalance of the glenohumeral was discussed earlier. internal and external rotators is also a sign of Along with the early hand exit, the swiminjury. This normal balance is a ratio with the mer may exhibit excessive body roll. The ininternal rotation component being stronger

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than the externalrotation component. Strength research would mandate an approximate normal ratio to be 3:2.3,4,5,12,33 physiologic The cross-sectional areas of the internal and external rotators would support the fact that internal rotation should be more than external rotation. A pilot study reveals the physiologic cross-sectional area of the internal rotators to be approximately 53 cm2and that of the external rotators to be approximately 16 cm3.These values would equate to a ratio 3.3:l. A true balance or a 1 :I ratio was never the intent of the human body. Also, it would be normal for the swimmer to adapt functionally to the requirements of swimming. As mentioned previously, swimming is a sport of humeral internal rotation with minimal need for external rotation. In one study comparing national competitive swimmers with controls, there was no significant difference in torque and total work for the external rotators.28 The external rotators are not weak; it is just that the internal rotators are functionally stronger. Also a separate study of 32 competitive swimmers demonstrated that shoulder pain and strength ratios were ~nrelated.~ need to balance the The humeral rotators is questionable. Perhaps one of the best educational messages the clinician can deliver to the swimmer and the coach is the differentiation between soreness and pain. Any athlete is familiar with muscle soreness and lives with soreness to a degree. Pain needs to be separated from soreness, however. Pain means pathology. Pain is telling an individual that he or she is causing damage to the anatomic structures. Once these structures are damaged, the pathology may not be reversible. When pain occurs, the athlete needs to minimize the damage and seek medical attention. Perhaps the best gift that clinicians could give to the training room of athletes is a banner with a big red circle and a line through the slogan "No pain, no gain" (Fig. 4 . ) CONSERVATIVE TREATMENT The first step in conservativetreatment 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. Non-

Figure 4. Use training room signs and banners to warn against erroneous messages.

steroidal anti-inflammatory drugs (NSAIDs) are used, usually in high doses, for 7 to 10 days. Swimmers with chronic shoulder pain are not usually kept on NSAIDs for more than a brief period of time. Each NSAID works differently in different patients, and a variety of medications may need to be tried to find the one that is most beneficial. Rarely a swimmer with a very hot shoulder may benefit from a methyl prednisolone dose pack (Medrol Dosepak) to break the inflammatory cycle so that an exercise program can be started. Cortisone injections in the subacromial space are used judiciously. If the pain becomes severe, a cortisone injection may be beneficial if the athlete stops swimming for 2 to 3 weeks. The swimmer can be in the pool with a kick board while the shoulder is recovering from the injection. The swimmer needs to be cautious, however, about the arm position on the kick board. Typically the arm position is one of full shoulder flexion with the kick board placed in front of the swimmer. This position may need to be modified to avoid the forward shoulder elevation. If this position cannot be modified without a great deal of awkwardness, the swimmer can work out temporarily on a stationary bicycle. A stationary bicycle workout allows the swimmer to continue with cardiovascular training and with the self-perception of an active athlete while allowing the inflammatory process to decrease. While in this stage, modalities such as heat, ice, ultrasound, or electrostimulationmay be applied to hasten the process. The next steps are to ensure adequate flexibility, strength, endurance, and scapulohumeral rhythm. The administration of these steps is different from swimmer to swimmer and depends on the exact nature of the injury or weakness. Guidelines are presented to this process; however, they need to be augmented

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by a sharp clinical eye to know what to work and when to progress the process.
Stretching

The two most important words about stretching for the swimmer are be careful. As other authors have eloquently stated, swimming coaches and swimmers appear obsessed with the destruction of the anterior capsule of the shoulder j ~ i n t , ~ perverse stretching and maneuvers . . . do not promote muscular flexibility, and they do not maintain adequate range of m~tion.~ Other than occasionally in the posterior capsule, swimmers do not tend to have joint tightness. The indication for stretching is limited. If a swimmer overstretches the noncontractile tissues, they may not return to normal. If the capsule is overstretched, the risk for instability and subsequent injury is permanently enhanced. A gentle warm-up is sufficient to increase the blood flow, increase body temperature, and overall prepare the muscles for a workout.22 Partner stretching is especially disconcerting because vigorousness and potential damage have been noted. Another common stretch done by the swimmer is a wall stretch, which increases anterior shoulder laxity (Fig. 5). Knowledge of the two stretches not to do is

more important than knowledge of other stretches. There are a few stretches that a clinician may find appropriate for some swimmers. Some swimmers have a posture of a forward head, rolled forward shoulders, and kyphotic thoracic region. These swimmers may have a tight pectoralis minor or major. The trainer or therapist can stretch the muscles as shown in (Fig. 6). Equally important to the specific stretch would be instruction in postural control and examination of any potential cervical problems. These swimmers can also be given a chest stretch to do on their own (Fig. 7). Swimmers with shoulder pain may occasionally present with posterior capsule tightness?* If the posterior capsule is excessively tight, it can push the humeral head anteriorly. These swimmers may exhibit early hand exit during the freestyle stroke, or excessive body roll. Both of these substitution mechanics are an attempt to minimize the humeral hyperextension that levers the head further anteriorly, causing pain. The posterior capsule stretch can be done by the clinician initially (Fig. 8A) and later can be taught to the swimmer to be done by himself or herself (Fig. 8B).
Strengthening Exercises

Research and clinical experience have pointed in the same direction for strengthen-

Figure 5. Thou shalt not do this stretch. Historically, many swimmers did this stretch; however, there is a great risk for this stretch to increase anterior shoulder instability.

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Figure 6. Pectoralis stretch.

Figure 7. Chest stretch.

Figure 8. Posterior capsule stretch with a clinician (A) and self-administered(5).(A, From Pink MM, Screnar PM, et at: Injury prevention and rehabilitation in the upper extremity. In Jobe FW (ed): Operative Techniques in Upper Extremity Sports Injuries. St. Louis, MosbyYear Book, 1996, p 5; with permission.)

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ing the shoulder muscles in the swimmer with an injury: primarily toward the serratus anterior and secondarily toward the subscapularis. The exercises that are included in this program are based on fine wire electromyographic re~earch.~*,~ exercises chosen have been The shown to be optimal for these muscles. Because no exercise recruits just one muscle, other muscles are worked simultaneously. If a careful examination reveals a deficit in muscles other than the serratus anterior and subscapularis, readers are encouraged to review the scientific literature for the optimal exercises to meet their patients needs. The exercises are initiated with no load or low load, and the loads are gradually progressed. The first exercises are done in an open chain. Once the muscle strength is in the good range, endurance exercise is initiated for short periods. As the endurance improves, the athlete can begin some sport-mimicking exercises, such as the swim bench. Once these exercises can be done without pain and with scapular rhythm, the swimmer can begin low mileage and slow-speed workouts. The individual can then progress performance within the limits of pain-free movement, no compensatory mechanics, and good scapulohumeral rhythm at the end of the workout. As the strengthening process is initiated, the clinician must insure that proper scapulohumeral rhythm is maintained. At the first sign of loss of this rhythm, the degree of elevation of the exercise must be lowered, or the load must be lightened. As the athlete begins to do the exercises alone, they should be done in front of a mirror so that the athlete can see if he or she is doing them correctly. Exercise should begin in the scapular plane. This plane allows for maximal congruency of the humeral head in the glenoid and the least stress on the capsule and ligaments.I5The exercises are first done without any weight, then at low elevations with a 2- or 3-lb weight. If the idea of low weights is met with mental resistance, swimmers can be reminded that they do not need bulk, but they need a stable shoulder on which to build speed and endurance. They can gradually increase their strengthening program to three sets of 15 repetitions throughout the range but still with a relatively low weight. To perform the first exercise, the athlete stands with the arm in the scapular plane and the thumbs down (humeral internal rotation). As the arms are raised, they begin to rotate externally (thumb begins to rotate upward).

B the time the arms are at 70 of elevation, the y thumb should be facing up (Fig.9). The elbows stay straight throughout this exercise. It is recommended that the exercise is simultaneously done with both arms so that any compensatory motions can be easily detected. Once the individual can successfully do this exercise for three sets of 15 repetitions throughout the range without any weight, he or she can attempt it in the frontal and the coronal planes. The athlete can also start to add weight to elevation in the scapular plane. After the athlete can do all three planes with a 3-Ib weight and without compensatorymechanics, he or she can proceed to the modified military press. The modified military press is performed in the seated position with the elbow close to the side (Fig. 10). The arms are raised straight overhead with the palms facing in. The elbow is kept in a straight line parallel to the body. Similar to the scapular plane exercise, this exercise is first done without weights, then gradually progressed through low weights. Another exercise is the four-count horizontal row. The four-count horizontal row is performed standing with bands or free weights. The first position is with the shoulder forward flexed 70 with maximal scapular protraction.

Figure 9. Elevation in the scapular plane.

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'

Figure 10. Military press.

The second position retracts the scapula. The third position brings the elbow in line with the plane of the body. The lust position slowing returns the arm to the first position (Fig. 11). After the athlete can perform these openchain exercises within the aforementionedparameters (pain-free motion, no compensatory mechanics, and good scapulohumeral rhythm at the end of the workout), the athlete can begin a progression of push-ups with a plus. The major benefit of these exercises is the plus maneuver, which is at the top of the push-up. At the top of the push-up, the scapulae are spread protracted as far apart as possible; this creates an arch in the thoracic area. The gluteal and low back areas are kept low. Then the swimmer lowers himself or herself to the ground, without lowering the body past the humerus. If the swimmer goes all the way to the ground, he or she causes the humeral head to be levered anteriorly. Some therapists recommend that these exercises be done against a waII (i.e., a wall push-up). Because of the numerous compensatory techniques that can be em-

figure II. Four-count horizontalrow exercise: First position (A),second position(B), third position (C), and last position (return to first position).

THE P A I N R n SHOULDER IN THE SWIMMING ATHLETE

259

B
Figure 12. Push-up with a plus, on knees and hands (plus position) (A) and toes and hands (go no further toward the floor than a 90"angle at the elbow) (B).

ployed against a wall, however, the authors prefer to teach the exercise on the floor. The progression of the push-up with a plus begins with the athlete on the knees and elbows (Fig. 12A). Once the athlete gets the feel for the plus maneuver, he or she can progress to the knees and hands. Once this movement is done safely and correctly, the athlete can progress to doing the push-upwith a plus on tKe t&s (Fig. 1 2 . B). The 'next exercise in the progression is the endurance exercise. An upper extremity ergometer works well to develop scapular muscle endurance. For this exercise, the swimmer sits so that the shoulder is flexed about 100"

from the axis of the pedals with the elbow extended when holding the pedals (Fig. 13A). The swimmer sits far away enough so that the elbows are extended fully and the scapulaeare separated. The motion begins at a rhythmic, even pace with mild resistance. The elbows are bent for about half of the cycle and are extended during the other half. The goal of the exercise is to work the muscles around the scapulae and shoulders as opposed to the elbows. The scapulae should be protracted when the arm is extended and retracted when the arm is nearer to the body (Fig. 13B). The exercise can be initiated for about 1 minute and progressed gradually.

Figure 13. Upper extremity ergonometer. A, Arms are elevated to approximately 100". B, Scapulae should be protractedwhen the elbow is extended.

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PINK & TIBONE

6. Counsilman JE: Swimming power. Swimming World and Junior Swimmer 18:30,1977 7. Douglas S: Physical evaluation of the swimmer. Presented at the First Annual vail SportsmedicineSymposium, Vail, CO, Feb 28-Mar 3,1980 8. Ekman EF, Pink MM, Jobe CM, et al: The anatomy of shoulder impingement in competitive swimming. (Submitted) 9. Ekman EF, Pink MM, Jobe Fw:Shoulder pain during competitive swimming: Arm position and anatomic location. (Submitted) 10. FalkeI JE, Murphy TC: Case principles: Swimmer's shoulder. Sports Injury Management 1:109-125,1988 11. Greipp J F Swimmer's shoulder: Influence of flexibility and weight training. Physician Sports Med 13:92105,1985 12. Ivey FM, Calhoun JH: Isokinetic testing of shoulder strength: Normal values. Arch Phys Med Rehabil 66:384-386,1985 13. Johnson D In swimming, shoulder the burden. Sportcare Fitness May-June: 24-30,1988 14. Johnson J: Musculoskeletal injuries in competitive swimmers. Mayo Clin Proc 62289-304,1987 15. Johnston TB: The movements of the shoulder-joint a plea for the use of the "plane of the scapula" as the plane of reference for movements occurring at the humero-scapular joint. Br J Surg 25:252-260,1937 16. Kennedy JC, Hawkins R, Krissoff WB: Orthopaedic manifestationsof swimming. Am J Sports Med 6:309322,1978 17. Kibler WB: The role of the scapula in athleticshoulder function. Am J Sports Med 26325-337,1998 18. Maglischo EW Front crawl stroke.In SwimmingEven Faster. Mountain View, CA, Mayfield, 1993 19. Marino M Profiling swimmers. Clin Sports Med 3~211-229,1984 20. McMaster WC: Anterior glenoid labnun damage: A painful lesion in swimmers. Am J Sports Med 14:383387,1986 21. McQuade KJ, Dawson J, Schmidt GL: Scapulothoracic muscle fatigue associated with alterations in scapulohumeral rhythm kinematics during maximum resistive shoulder elevation. J Orthop Sports Phys Ther 2874-80,1998 22. Mohr KJ, Pink MM, Elsner C, et a1 Electromyographic investigation of stretching: The effect of warm-up. Clin J Sports Med 8215-220,1998 23. Monad H Contractility of muscle during prolonged static and repetitive dynamic activity. Ergonomics 28:81-89,1985 24. Moseley JB, Jobe FW,Pink M, et a1 EMG analysis of the scapular muscles during a shoulder rehabilitation program. Am J Sports Med 20:128-134,1992 25. Pink MM, Kvitne RS,Jobe FW, a1 Joint laxity, shoulet der range of motion and clinical signs of shoulder pathology in swimmers. (Submitted) 26. Pink M, Perry J, Browne A, et a1 The normal shoulder during freestyle swimming: An electromyographic and cinematographic analysis of twelve muscles. Am J Sports Med 19:569-576,1991 27. Richardson AB, Jobe FW,Collins HR The shoulder in competitive swimming. Am J Sports Med 8:159-163, 1980 28. Rupp S, Berninger K, Hopf T Shoulder problems in : high level swimmers-impingement, anterior instability, muscular imbalance? Int J Sports Med 16557562,1995
I

At this point, endurance for the subscapularis is introduced on an isokinetic device. As mentioned previously, this muscle is vulnerable to fatigue. Internal and external rotation exercises are performed with the arm at the side. The humerus is elevated forward about 10" to 20" to protect the anterior capsule. Isokinetic speeds of 180"/s and 240"/s are used. About the same time as the endurance exercises begin, the athlete can start activities on the swim bench. Because the swimmer is painfree at this time, he or she also can return to a kick-board workout, with perhaps a few slow laps of the freestyle stroke. The swimmer continues with the elevation exercises, modified military press, and push-up with a plus. Eventually the swimmer returns to the complete workout at the prior intensity. It is hoped that the swimmer never gives up the exercise program because doing so can lead to recurrent shoulder problems. 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 and medicine, clinicians can return swimmers back to the water in the minimal time with a low recurrence of injury.
References
1. Allegmcci M, Whitney SL, Irrgang JJ: Clinical impli-

2. 3.

4. 5.

cations of secondary impingement of the shoulder in freestyle swimmers. J Orthop Sports Phys Ther 20:307-318,1994 Babyar SR Excessive scapular motion in individuals recovering from painful and stiff shoulders: Causes and treatment strategies. Phys Ther 76226-238,1996 Beach ML, Whitney SL, Dickoff-Hoffman S A Relationship of shoulder flexibility, strength, and endurance to shoulder pain in competitiveswimmers.J Orthop Sports Phys Ther 16:262-268,1992 Connelly Maddw RE, Kibler WB, Uhl T Isokinetic peak torque and work values for the shoulder. J Orthop Sports Phys Ther 10264-269, 1989 Cook EE, Gray VL, Savinar-Nope E, et al: Shoulder antagonistic strength ratios: A comparison between college-level baseball pitchers and nonpitchers. J Orthop Sports Phys Ther 8:451-461,1987

THE PAINFUL SHOULDER IN THE SWIMMING ATHLETE

29. Scovazzo ML, Browne A, Pink M, et a1 The painful shoulder during freestyle swimming: An electromyographic and cinematographic analysis of twelve muscles. Am J Sports Med 19:577-582,1991 30. Stocker D, Pink M, Jobe Fw:Comparison of shoulder injury in collegiate- and masters-level swimmers. Clin J Sport Med 54-8,1995 31. Townsend H, Jobe FW, Pink M, et al: Electromyographic analysis of the glenohumeral muscles during

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a baseball rehabilitation program. Am J Sports Med 19:264-272,1991 32. Warner JJP, Micheli LJ, Arslanian LE, et a 1 Patterns of flexibility, laxity, and strength in normal shoulders and shoulder with instability and impingement. Am J Sports Med 18:366-375, 1990 33. Weldon G, Snouse SL, Shultz S Normative strength values for knee, shoulder, elbow and ankle for females ages 9-73 as determined by isokinetic testing. Athletic Train 23325-331,1988
Address reprint requests to James E. Tibone, MD Department of Orthopaedics University of Southern California 1510 San Pablo #322 Los Angeles, CA 90033