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A Cross-Sectional Study Examining Shoulder

Pain and Disability in Division I Female
Swimmers

Article in Journal of Sport Rehabilitation August 2013

DOI: 10.1123/JSR.2012-0123 Source: PubMed

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Journal of Sport Rehabilitation, 2014, 23, 65-75
http://dx.doi.org/10.1123/JSR.2012-0123 www.JSR-Journal.com
2014 Human Kinetics, Inc.
ORIGINAL RESEARCH REPORT

A Cross-Sectional Study Examining Shoulder Pain

and Disability in Division I Female Swimmers
Shana Harrington, Corinne Meisel, and Angela Tate

Context: The prevalence of shoulder pain in the competitive swimming population has been reported to be
as high as 91%. Female collegiate swimmers have a reported shoulder-injury rate 3 times greater than their
male counterparts. There has been little information on how to best prevent shoulder pain in this population.
The purpose of this study was to examine if differences exist in shoulder range of motion, upper-extremity
strength, core endurance, and pectoralis minor length in NCAA Division I female swimmers with and without
shoulder pain and disability. Methods: NCAA Division I females (N = 37) currently swimming completed
a brief survey that included the pain subscale of the Penn Shoulder Score (PSS) and the sports/performing
arts module of the Disabilities of the Arm, Shoulder, and Hand (DASH) Outcome Measure. Passive range of
motion for shoulder internal rotation (IR) and external rotation (ER) at 90 abduction was measured using a
digital inclinometer. Strength was measured using a handheld dynamometer for scapular depression and adduc-
tion, scapular adduction, IR, and ER. Core endurance was assessed using the side-bridge and prone-bridge
tests. Pectoralis minor muscle length was assessed in both a resting and a stretched position using the PALM
palpation meter. All measures were taken on the dominant and nondominant arms. Results: Participants were
classified as positive for pain and disability if the following 2 criteria were met: The DASH sports module
score was >6/20 points and the PSS strenuous pain score was 4/10. If these criteria were not met, participants
were classified as negative for pain and disability. Significant differences were found between the 2 groups
on the dominant side for pectoralis muscle length at rest (P = .003) and stretch (P = .029). Conclusions: The
results provide preliminary evidence regarding an association between a decrease in pectoralis minor length
and shoulder pain and disability in Division I female swimmers.
Keywords: swimming, upper-extremity function, pectoralis muscle length, outcome measures

The prevalence of shoulder pain in the competitive
swimming population has been reported to be as high as
91%.1 One study found that 69% of National Collegiate
Athletic Association (NCAA) Division I swimmers
experienced shoulder pain.2 This shoulder pain can be so
severe that it may lead to functional impairments and even
cessation of swimming participation.3 The reported injury
rate in collegiate swimmers ranges from 2.12 to 3.78 per
1000 athlete exposures, and 35% to 44% of those injuries
were to the shoulder or upper arm.4,5 This indicates that
swimming has an overall lower risk of injury compared
with other sports but a high risk for shoulder injury. In
addition, 1 study6 found that competitive swimmers with
a history of shoulder pain were 4.1 times more likely to
have a future shoulder injury.
Females are of particular interest when it comes
to examining shoulder pain and disability in overhead
Harrington is with the Dept of Clinical & Applied Movement
Sciences, University of North Florida, Jacksonville, FL. Meisel
is with the DiSepio Inst for Rural Health and Wellness, Saint
Francis University, Loretto, PA. Tate is with Willow Grove
Physical Therapy, Willow Grove, PA.
competitive sports for 3 main reasons. First, in a study
conducted by Sallis et al,7 collegiate female swimmers
were found to have a significant increase in reported
shoulder injuries when compared with males (21.05 per
100 swimmers compared with 6.55). Second, research
has found that females demonstrate more generalized
glenohumeral-joint hypermobility than men.4,8 Hyper-
mobility has been described as a potential risk factor for
injuries during sporting activities.9,10 Finally, participation
in female collegiate swimming has doubled over the last
20 years, indicating a steady rise in its popularity.11 Cur-
rently, there are over 500 collegiate female swim teams
in the United States, and swimming ranks seventh overall
in female sport participation.11
Unfortunately, even with the high shoulder-injury
rate in competitive swimming, a clear understanding
of how to prevent and treat shoulder pain in collegiate
female swimmers is lacking. Several studies have investi-
gated risk factors for shoulder pain in swimmers,2,3,6,1215
2 of which limited their investigation to the college popu-
lation.2,14 Since subacromial impingement is the most
common underlying condition responsible for swim-
mers should pain and injury, various physical character-
istics that are associated with subacromial impingement

65
66Harrington, Meisel, and Tate
have been compared between swimmers with and
without shoulder pain and injury. These factors include
scapular kinematics, internal- and external-rotation
strength, the ratio of external-rotation to internal-rotation
strength, joint laxity, yardage, flexibility, shoulder range
of motion, and types of training.2,3,6,1216 However, the
results from the previous studies have been inconsistent.
Beach et al2 found no significant correlations between
shoulder flexibility, strength ratios, and shoulder pain in
28 NCAA Division I swimmers and 4 club swimmers.
Based on data collected in a survey, Stocker et al14
concluded that collegiate and masters swimmers did
not subjectively report an association between shoulder
pain and shoulder flexibility. They went on to postulate
that pain was perceived to increase with swim-training
intensity, with a possible relationship between muscle
fatigue and shoulder pain.14 It is important to note that
these studies were conducted over 18 years ago, and
both on-land and in-water collegiate swim training have
changed drastically during this time. In addition, the
results of those studies should be interpreted cautiously
due to methodological variability.
Due to these limitations and gaps in the research,
we sought to explore relationships between different
physical measures and shoulder pain. Bak16 recently
discussed the etiology of swimmers shoulder related to
intrinsic and extrinsic factors. Intrinsic factors included
joint hypermobility; scapular dyskinesis; glenohumeral
internal-rotation deficit; rotator-cuff imbalance; lack
of flexibility, or stiffness; posture; core stability; and
increased thoracic kyphosis.16 A recent study conducted
by Tate et al3 examined several of these risk factors associ-
ated with shoulder pain and disability across the lifespan
of female competitive swimmers and found potentially
modifiable variables that could be used as a basis to
test the effectiveness of a shoulder-injury-prevention
program in the age groups studied. However, collegiate
swimmers were not included in the study, and despite
the high incidence of shoulder pain in female collegiate
swimmers, there is a lack of recent research on factors
associated with shoulder pain and disability in female
Division I swimmers.
Due to the high rate of shoulder pain and disabil-
ity in this cohort, it is important to discern the clinical
impairments that exist in collegiate swimmers with pain
and disability to assist with creating injury-prevention
and -rehabilitation programs. Therefore, the purpose of
this study was to determine if differences exist in shoul-
der range of motion (ROM), upper-extremity strength,
core endurance, and pectoralis minor length in NCAA
Division I female swimmers with and without shoulder
pain and disability. Based on the findings of Tate et al
and Bak, we hypothesized that female collegiate swim-
mers who report significant shoulder pain and disability
would demonstrate increased shoulder ROM, decreased
upper-extremity strength, decreased core endurance, and
decreased pectoralis minor length when compared with
swimmers who do not report significant shoulder pain
and disability.
Methods
Design
A cross-sectional design was used.
Participants
The participants consisted of women from 2 NCAA
Division I swim programs (N = 37, age = 19.5 1.19 y,
height = 170 7 cm, weight = 64.7 6.8 kg, body-mass
index = 22.5 2.3 kg/m2) who were at least 18 years old,
currently participating in full team practices, and had no
history of shoulder surgery in the past 12 months. Recruit-
ment occurred through e-mails sent to NCAA Division I
swim coaches who would be conducting winter training
in the state of Florida.
Procedures
Participants reported for a single testing session lasting
40 minutes located at a designated area near the swim-
ming pool. All participants read and signed an informed-
consent form approved by the University of North Florida
institutional review board. Participants completed a brief
survey titled the Sports and Symptom Survey Form used
by Tate et al3 to capture basic demographic information
about the swimmers and their sport participation and pain
or shoulder symptoms (see the Appendix). This survey
included a subscale of the Penn Shoulder Score.17 Pain
was rated at rest, with normal activities (eating, dressing,
bathing), and with strenuous activities (sports, reaching,
lifting) on a numeric rating scale of 0 (no pain) to 10
(worst possible pain). Shoulder function during swim-
ming was assessed using the sports/performing arts
module of the Disabilities of the Arm, Shoulder, and
Hand Outcome Measure (DASH).18 The DASH sports
module asks participants to rate 4 items (physical abil-
ity with sports technique, participation, satisfaction, and
frequency) using a 5-point scale, with 1 signifying no
difficulty and 5 signifying unable over the past week.
Next, passive shoulder ROM, shoulder strength, core
endurance, and pectoralis minor muscle length were
measured by the same licensed physical therapist.
Bilateral shoulder passive ROM was measured
in degrees using a digital inclinometer (The Saunders
Group, Inc, Chaska, MN) in the following order: supine
external rotation (ER) at 90 of abduction and supine
internal rotation (IR) at 90 of abduction per Norkin.19
Two trials of passive ROM were performed, and the
average was used for data analysis. Intratester reliability
was previously established for passive ROM (ICC3,1 =
.921.0, SEM = 0.671.54).
Bilateral shoulder peak muscle force in kilograms
was measured by means of a maximal voluntary iso-
metric contraction (MVIC) using a handheld dyna-
mometer (Lafayette Instrument, Lafayette, IN) and was
normalized to each participants body mass. Strength
was assessed using methods described by Daniels and
Worthingham20 for bilateral shoulder IR, shoulder ER,
 Shoulder Pain and Disability in D1 Female Swimmers 67
scapular depression and adduction, and scapular adduc-
tion in a randomized order to minimize the effects of
fatigue. Thirty seconds rest occurred between trials,
and a 1-minute rest period occurred between testing
positions. Each measurement was taken twice and the
average was used for data analysis. Intratester reliability
was previously established during pilot testing for all
shoulder-girdle strength measures (ICC3,1 = .72.99, SEM
= 0.801.35% MVIC).
Core endurance was assessed with the side-bridge
test21 (Figure 1) and the prone-bridge test22 (Figure 2)
used previously by Tate et al.3 Participants were asked to
hold each test for as long as they could, and duration was
recorded in seconds. To ensure proper technique for the
Figure 1 Side bridge test.
Figure 2 Prone bridge test.
core-endurance tests, a 12-in ruler was held by the tester
vertically from the mat to the lowest portion of the hip.
If the hip lowered, the participant was provided verbal
instructions to try to resume the correct straight position.
If the hip dropped a second time, the test was ended.
Participants performed 1 trial of each core-endurance
position in a randomized order: prone, dominant side,
nondominant side. Reliability of core-stability-related
measures has been previously reported (ICC2,1 = .74.96,
SEM = 8.3210.29 s).23
Bilateral pectoralis minor muscle length was assessed
in both a resting and a stretched position using the PALM
palpation meter (Performance Attainment Assoc, St Paul,
MN). Pectoralis minor length was obtained by placing
68Harrington, Meisel, and Tate
the PALMs caliper tips on the medial coracoid process
and the fourth intercostal space adjacent to the sternum.24
Testing positions of rest (Figure 3) and stretch (Figure
4) were selected based on previously reported method-
ology.3 Normalized pectoralis minor length at rest and
stretch was obtained by dividing the pectoral length by
the participants height and multiplying by 100. This
normalization has been previously used by Borstad and
Ludewig25 and termed the pectoralis minor index. Reli-
ability and validity of the PALM to measure pectoralis
minor length have been previously established (ICC3,1 =
.98.99, SEM = 0.320.29 cm).24
Statistical Analysis
Participants were divided into groups based the Penn
Shoulder Score strenuous numeric rating score and a total
score for swimming disability using the DASH sports
module (range 420, with 4 indicating no swimming
disability).3 Participants were classified as positive for
pain and disability if the following 2 criteria were met:
The DASH sports module score was >6/20 points and the
Penn Shoulder Score strenuous numeric rating score was
4/10. In addition, our groups were further categorized by
whether the combination of pain and disability occurred
on the dominant or nondominant arm. If these criteria
were not met, participants were classified as negative. The
cutoff markers were created to compare those with no or
minimal shoulder pain and disability with those incur-
ring substantial shoulder pain and disability. We used the
Figure 3 Testing position for pectoralis minor length
at rest.
same cutoff as Tate et al3 for the DASH sports module,
as a score of 6 or more requires at least mild difficulty in
3 of the 4 areas surveyed. However, we used a different
cutoff for pain because the swimmers in our study had
higher levels of pain during strenuous activity (swim-
ming).3 In addition, of the 37 participants in our study,
only 8 participants (21%) reported no pain (0/10) in either
their dominant or nondominant shoulder with strenuous
activity, whereas in the Tate et al cohort a greater per-
centage of swimmers had no reported pain (0/10) in the
dominant (39%) or nondominant (47%) shoulder.3 For
the other 29 participants in our study, the responses for
pain with strenuous activity varied from 1/10 to 9/10.
Due to the low number of swimmers reporting 0/10 pain
with strenuous activity and the high prevalence of pain
in competitive swimmers, we needed to create a cutoff
that emphasized a clear distinction between those with
and those without significant shoulder pain and disability.
The Penn Shoulder Score strenuous numeric rating score
has been shown to have a standard error of measurement
(SEM) of 1.0 and a minimal detectable change of 1.4.26
Therefore, a score of 4/10 on the Penn Shoulder Score
for pain with strenuous activity was selected to represent
significant pain, as it is well above the SEM but includes
70% of the response options (4/1010/10). The following
2 comparisons were made: + or for pain and disability in
the dominant arm and + or for pain and disability in the
nondominant arm. Means and standard deviations were
calculated per group for all variables of ROM, shoulder
strength, core endurance, and pectoralis minor length.
Figure 4 Testing position for pectoralis minor length when
stretched.

Based on previous literature and the variables we
were most interested in (pectoralis minor length and IR
ROM), it was estimated that 9 to 16 participants (effect
size = 0.71 and 0.94; positive for pain and disability
and negative for pain and disability) were required in
each group for this study to obtain a power of .80.3 A
1-way analysis of variance (ANOVA) was conducted to
determine if differences existed between the groups on
the dominant extremity (+ for pain and disability or for
pain and disability) on each of the dependent variables of
ROM, shoulder strength, core endurance, and pectoralis
minor length. The same analysis was conducted on each
dependent variable between the groups on the nondomi-
nant extremity (+ for pain and disability or for pain
and disability). SPSS statistical software (version 19.0,
SPSS Inc, Chicago, IL) was used to analyze all data.
Statistical significance levels for all comparisons was
set a priori at = .05.
Results
A total of 37 Division I female swimmers participated in
this study. The number of participants grouped as + was
12 for dominant arm and 14 for nondominant arm, 8 of
which were + on both the dominant and nondominant
arms. Participant demographics can be seen in Table 1.
The ANOVA revealed a statistically significant difference
between groups (+ or ) on the dominant arm for pectoralis
minor length at rest (F1,35 = 10.265, P = .003) and stretch
(F1,35 = 5.164, P = .029), with significantly decreased
muscle length at both rest and stretch for the + participants
as shown in Table 2. No other statistically significant
measures were found for the other dependent variables on
either the dominant or nondominant arm. (Table 3)
Discussion
This purpose of this study was to determine if differ-
ences exist in shoulder ROM, upper-extremity strength,
core endurance, and pectoralis minor length in Division
Table 1 Participant Demographics by Group,a Mean (SD)
Dominant Arm
Participants, n 25
Age, y 19.52 (1.16)
Height, cm 169.84 (7.34)
Weight, kg 65.6 (7.86)
Body-mass index, kg/m2 22.8 (2.36)
Experience competing, y 11.76 (2.01)
Time swum per week, h 9.44 (2.57)
a Group indicates absence () or presence (+) of shoulder pain and disability.
Shoulder Pain and Disability in D1 Female Swimmers 69
I female swimmers with and without shoulder pain and
disability. Our results were in partial agreement with our
hypotheses and indicate that NCAA Division I female
swimmers who reported shoulder pain and disability
demonstrated decreased resting and stretched pectoralis
minor length on their dominant arm when compared with
female swimmers who did not report significant shoulder
pain and disability on their dominant arm. However, our
results did not indicate a difference between strength or
ROM between the 2 groups. This is in agreement with a
study conducted by Beach et al,2 who also did not find a
correlation between pain and shoulder ROM or strength
in NCAA Division I swimmers. It is important to note that
all participants were currently competing at the NCAA
Division I level during data collection, which on average
required 18.8 hours of swimming each week. It is possible
that individuals with impaired strength and ROM are not
be able to tolerate the intense demands of such rigorous
practice and hence do not compete at this elite level, but
prospective studies would be needed to determine this.
Shortened pectoralis minor length has been associ-
ated with altered scapular kinematics. A change in scapu-
lar resting position has been hypothesized to decrease
subacromial space due to increased anterior tilt and IR
of the scapula.25 Most studies have not examined muscle
length as a factor that can contribute to shoulder pain but
instead focused on overall shoulder ROM. Our observa-
tions were in partial agreement with the study conducted
by Tate et al,3 which demonstrated that resting length of
the pectoralis minor was significantly reduced in high
school swimmers who had pain and disability, although
the Tate et al study did not include a cohort of female
Division I athletes.
While we are not aware of a reported clinical mean-
ingful difference using the PALM to measure pectoralis
minor length, the significant differences found in the
current study on the dominant arm (0.68 cm for stretch
and 0.53 cm for rest) are greater than the reported
measurement error of 0.32 cm.24 Our findings of signifi-
cant differences in pectoralis muscle length at rest and
stretch on the dominant arm indicate that muscle length
Nondominant Arm
+ P + P
12 n/a 23 14 n/a
19.58 (1.31) .88 19.61 (1.27) 19.43 (1.09) .66
170.50 (7.50) .71 170.85 (7.34) 168.18 (7.20) .29
62.9 (3.62) .27 64.64 (8.21) 64.83 (3.92) .94
21.7 (1.91) .17 22.14 (2.46) 22.99 (1.85) .28
9.83 (4.61) .08 10.91 (2.76) 11.50 (3.81) .59
8.75 (1.36) .77 18.78 (2.43) 18.75 (1.65) .97
70Harrington, Meisel, and Tate

Table 2 Dominant-Arm Clinical Measures by Group

Measure Groupa Mean (SD) 95% CI P Effect size
External-rotation range of motion, .40 0.30
+ 101.92 (7.84) 96.99, 106.84
99.40 (8.65) 95.99, 102.81
Internal-rotation range of motion, .21 0.44
+ 69.25 (10.19) 63.65, 74.86
64.96 (9.26) 61.08, 68.84
Bridge prone, s .67 0.16
+ 84.87 (18.90) 69.17, 100.57
88.95 (29.72) 78.07, 99.83
Bridge dominant arm, s .67 0.15
+ 55.85 (16.56) 45.38, 66.32
58.55 (18.44) 51.30, 65.81
Internal-rotation strength, % body weight .76 0.11
+ 0.20 (0.03) 0.18, 0.22
0.20 (0.03) 0.19, 0.21
External-rotation strength, % body weight .68 0.14
+ 0.16 (0.03) 0.14, 0.17
0.16 (0.02) 0.15, 0.17
Scapular depression and abduction strength, % body weight .41 0.30
+ 0.19 (0.04) 0.17, 0.21
0.20 (0.04) 0.18, 0.21
Scapular adduction strength, % body weight .27 0.38
+ 0.19 (0.04) 0.17, 0.21
0.20 (0.03) 0.19, 0.22
Pectoralis rest, cm .003* 1.12
+ 9.54 (0.49) 9.26, 9.82
10.07 (0.47) 9.88, 10.27
Pectoralis stretch, cm .03 0.86
+ 11.57 (0.59) 11.07, 12.07
12.25 (0.96) 11.91, 12.60
a Group indicates absence () or presence (+) of shoulder pain and disability.

*Significant difference.

may play a key role in contributing to shoulder pain and
disability in Division I female swimmers.25 Borstad and
Ludewig25 reported that individuals with shortened pec-
toralis minor are at a greater risk for shoulder impinge-
ment with increased exposure to elevation, force, and
repetition. Collegiate swimmers are exposed to each of
these factors repeatedly throughout each practice and
competition. Since competitive swimmers are unable
to alter their exposure to shoulder elevation, force, and
repetition, increasing pectoralis minor length may be
an important modifiable variable that could potentially
increase the subacromial space and possibly decrease risk
of shoulder pain in swimmers. To date, there has been
limited research on pectoralis minor stretching interven-
tions in swimmers with shoulder pain and disability using
a valid and reliable clinical tool.
The term swimmers shoulder was first coined by
Neer and Welsh27 in 1977 to describe secondary shoul-
der impingement in swimmers who breathe to 1 side.
Secondary impingement is used to describe shoulder
 Shoulder Pain and Disability in D1 Female Swimmers 71

Table 3 Nondominant-Arm Clinical Measures by Groupa

Measure Groupa Mean (SD) 95% CI P Effect size
External-rotation range of motion, .76 0.10
+ 95.64 (12.94) 88.73, 101.55
94.50 (9.47) 89.89, 99.11
Internal-rotation range of motion, .16 0.49
+ 64.86 (8.02) 60.22, 69.49
69.02 (8.84) 65.40, 72.64
Bridge prone, s .70 0.13
+ 89.86 (31.26) 75.31, 104.40
86.27 (23.78) 74.93, 97.62
Bridge nondominant arm, s .58 0.19
+ 57.69 (20.08) 46.57, 68.80
61.54 (20.71) 52.87, 70.21
Internal-rotation strength, % body weight .79 0.09
+ 0.20 (0.04) 0.18, 0.22
0.19 (0.04) 0.18, 0.21
External-rotation strength, % body weight .71 0.14
+ 0.16 (0.02) 0.14, 0.17
0.15 (0.02) 0.14, 0.16
Scapular depression and abduction strength, % body weight .18 0.48
+ 0.19 (0.04) 0.17, 0.22
0.21 (0.05) 0.19, 0.23
Scapular adduction strength, % body weight .29 0.38
+ 0.20 (0.04) 0.18, 0.23
0.22 (0.04) 0.20, 0.24
Pectoralis rest, cm .45 0.28
+ 9.89 (0.49) 9.58, 10.19
10.03 (0.50) 9.80, 10.27
Pectoralis stretch, cm .94 0.03
+ 11.95 (0.76) 11.52, 12.37
11.97 (0.79) 11.64, 12.30
a Group indicates absence () or presence (+) of shoulder pain and disability.

pain resulting from overuse and is typically reversible.
Allegrucci et al28(p309) further defined secondary impinge-
ment in swimmers as resulting from either disruption
of static stabilizers . . . or fatigue and weakness of the
dynamic stabilizers. Unfortunately, this definition
does not consider the impingement occurring from
tightening or shortening of dynamic stabilizers. This
agonistantagonist muscle imbalance between tight
pectoral muscles and elongated weak scapular muscles
has been addressed in several swimming intervention
studies aimed to reduce the postural abnormalities found
in swimmers.2931 Although those studies incorporated
stretching of the pectorals and scapular strengthening,
none of them measured pectoralis minor muscle length
directly with a validated technique or used an entirely
female subject pool, so direct comparisons with our study
are not possible.
While the cited studies incorporated pectoral stretch-
ing in an intervention program designed to alter posture
and scapular kinematics in elite swimmers, the results
have been varied.2931 Hibberd et al29 found no significant
scapular kinematic differences among the intervention
72Harrington, Meisel, and Tate
and control groups. Although neither the Kluemper et
al30 nor Lynch et al31 study assessed pectoral length
using the same method as in our study, both reported
favorable improvements in forward shoulder translation
and shoulder posture after the interventions. The latter
study also reported that 79% of their intervention group
had improvement in shoulder pain after the intervention
program.31 Results also showed a decrease in forward
shoulder translation without differences in scapular-mus-
cle strength.31 Forward shoulder translation, a component
of posture, is believed to be caused by a muscle imbalance
between a lengthened middle trapezius and a shortened
pectoralis minor.31 Therefore, it could be inferred that the
improvement in posture found in the Lynch et al31 study
may be related to lengthened pectoral musculature. While
a cause-and-effect relationship cannot be determined
from their data, reduced pain ratings were also found with
a pectoral-stretching program. Prospective studies using
direct pectoral measures may provide better understand-
ing of the mechanisms responsible for the reduction in
shoulder pain.
A recent study by Williams et al32 is the first com-
petitive swimming study to our knowledge to consider
both scapular kinematics, which has been considered an
indirect muscle-length measurement, and direct muscle-
length measurement. Participants were divided into either
a control group, an intervention group that received a
focused pectoralis minor stretch, or an intervention group
that received a gross pectoral stretch.32 There were no
significant changes in scapular kinematics, but significant
gains in pectoral length were found in the group who
performed the gross pectoral stretch.32 Based on these
findings, it may be inferred that changes in pectoralis
minor muscle length may not be detected when evaluat-
ing scapular kinematics but can be distinguished with
direct measurements of the muscle length, indicating
that these 2 methods of measurement are not equivalent.
Nevertheless, more research is needed to determine the
most effective method of increasing pectoralis minor
muscle length and its effect on decreasing shoulder pain
in competitive female swimmers.
This current study found no significant differences
between upper-extremity strength, core endurance, and
shoulder ROM in either the dominant or nondominant
arm. We found no significant difference on the nondomi-
nant arm for resting or stretched pectoralis minor muscle
length. These nonsignificant differences could be due to
the limitations in this study that include a small sample
size and utilizing only 2 Division I swim teams. It is pos-
sible that some swimmers underreported their pain and
were not included in the appropriate group. As Hibberd et
al29(p263) state, Swimmers have been taught that shoulder
pain is normal in the sport, and shoulder pain is often
unreported until it is debilitating. We cannot exclude the
fact that other factors that were not measured in this study,
such as joint laxity and stroke technique, may contribute
to shoulder pain and disability in this population. It is
important to highlight that there was no preferred breath-
ing pattern in any group and it remains unclear why those
with pain and disability on the nondominant arm did not
demonstrate a significant decrease in pectoralis minor
length. Since this was a cross-sectional study, cause and
effect are unable to be determined. Therefore, it is not
known if a shortened pectoralis minor influenced shoul-
der pain and disability or whether pectoralis tightness
emerged as a result of the shoulder pain and disability. To
determine this relationship, future research should use a
prospective, longitudinal design. Additional recommen-
dations include a larger sample size, a blinded researcher,
and a repeated pectoralis minor measure (before and after
pectoral stretching) using a valid, reliable, and standard-
ized clinical tool such as the PALM. This would help
make more definitive conclusions regarding the effect of
pectoral muscle length on shoulder pain in competitive
swimmers.
Conclusion
This study found that there is a significant difference
in dominant-arm resting and stretched pectoralis minor
muscle length between NCAA Division I female swim-
mers with and without shoulder pain and disability. This
is the first known study to use a validated clinical tool
to measure pectoralis minor length directly in female
Division I swimmers with shoulder pain and disability.
To better evaluate female swimmers with shoulder pain or
prospectively screen these competitive athletes, rehabili-
tation professionals should use a direct measurement of
pectoralis minor muscle length with a valid and reliable
tool such as the PALM palpation meter. Further research
is needed to explore possible interventions to lengthen
the pectoralis minor muscle.
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Appendix
Appendix A

Sports and Symptom Survey Form

University _____________ Gender

Age Height ___ Weight ________

Dominant Hand: (circle one) RIGHT LEFT What is your primary stroke? _________________

How many years have you done competitive swimming?

Average months per year spent swimming?

Average months per year spent weight training?

1. Estimate the average number of hours you swim in a week during the competitive or training season (For
example 5 practices, 2 hours each = 10 hrs) _____________

2. Average # of practices per week during the competitive or training season ________

3. What side do you normally turn to breath? (circle one) LEFT RIGHT or BOTH

4. Do you train with paddles? (circle one) YES or NO

5. How far into your season are you? (circle one) BEGINNING MIDDLE or END

6. Have you had any shoulder pain or symptoms in the past week? (circle one) YES or NO
If yes, please circle the location: (circle one) RIGHT LEFT or BOTH

7. Have you ever had a traumatic injury to your shoulder? (circle one) YES or NO
If yes, please circle the type of injury: DISLOCATION FRACTURE (shoulder or collar bone) or
DIRECT TRAUMA (fall, hit, etc)
If yes, please list the injury and date this occurred: ____________________________

8. Does your shoulder feel unstable or do you feel like it ever slips out of place? (circle one) YES or NO

9. Which activities do you regularly participate in? (circle all that apply) Walking/running
Biking/spinning Exercise classes (yoga/pilates) Gym/lift weights Triathlon
Other (list)__________________________________________
 Shoulder Pain and Disability in D1 Female Swimmers 75

Symptoms and Functional Ability

The following questions relate to the impact of any shoulder problem you may have while swimming.
Please circle the number that best describes your physical ability in the past week.

Did you have any difficulty:

No Mild Moderate Severe Unable
difficulty difficulty difficulty difficulty
10. Using your usual technique 1 2 3 4 5
for swimming
11. Swimming because of shoulder pain 1 2 3 4 5
12. Swimming as well as you would like 1 2 3 4 5
13. Spending your usual amount of time swimming or 1 2 3 4 5
practicing swimming
______________________________________________________________________________________________

For the questions below, please circle the number closest to your level of pain or satisfaction. If both
shoulders are painful, please circle a number for each side and use R for right and L for left above the
number.
0 1 2 3 4 5 6 7 8 9 10
EXAMPLE
No Worst
Pain Pain
Possible

14. Pain at rest with your arm by your side: 0 1 2 3 4 5 6 7 8 9 10

No Worst
Pain Pain
Possible

15. Pain with normal activities : 0 1 2 3 4 5 6 7 8 9 10

(eating, dressing, bathing) No Worst
Pain Pain
Possible

16. Pain with strenuous activities 0 1 2 3 4 5 6 7 8 9 10

(sports, reaching, lifting) No Worst
Pain Pain
Possible

17. SATISFACTION: How satisfied are you with the current level of function of your shoulder(s)?

0 1 2 3 4 5 6 7 8 9 10
Not Very
Satisfied Satisfied

18. How would you describe your shoulder related symptoms? (Check only one)
_____ I have no pain or shoulder symptoms
_____ Pain/ache only after heavy workouts
_____ Pain/ache (not disabling) during and after workouts
_____ Disabling pain during and after workouts that interferes with your athletic performance
_____ Shoulder pain preventing competitive sport participation

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