What is Swimmer’s Shoulder?
People who swim regularly may be more likely to injure their shoulders due to the unique techniques used in different swimming strokes and the large number of repetitions they do during training. This high repetition can lead to overuse of the tissue around the shoulder, which can cause injury.
The term “swimmer’s shoulder” was first used in 1974, and it referred to a specific injury where the supraspinatus tendon (a tendon in the shoulder) was getting pinched beneath the coracoacromial arch (part of the shoulder bone structure). This can happen in swimmers because of the repeated movements of lifting and stretching the arm forward.
In more recent times, “swimmer’s shoulder” has become a term used to describe various types of shoulder pain in swimmers. These can include conditions such as impingement syndrome (when a rotator cuff muscle gets squeezed between the shoulder bones), rotator cuff tendinitis (inflammation of the rotator cuff tendons), labral injuries (damage to the rubbery tissue that helps keep the shoulder ball in its socket), instability due to loose ligaments or muscle dysfunction, nerve entrapment (when a nerve is squeezed), and anatomic variants (unique, individual variations in physical structure). In order for a swimmer to safely and quickly return to their sport, the healthcare provider needs to identify which of these issues is causing the pain.
What Causes Swimmer’s Shoulder?
Swimming is a unique sport because it mostly involves the use of your upper body, with about 90% of the movement coming from the strength of your shoulders. For someone to swim professionally, they need to swim around 60,000 and 80,000 meters per week, which is about 30,000 strokes per arm. This requires a lot of movement from the shoulder, often in extreme ranges and with a lot of force.
Several factors can cause shoulder issues for swimmers. These can include physical issues, mindset, training practices, and lifestyle habits. Physical issues might include the endurance and strength of shoulder muscles, shoulder posture, perception of where your body is in space (also called proprioception), instability in the shoulder joint, or abnormal movements of the shoulder blade.
Training factors might include how much you swim, your swimming technique, how long you’ve been swimming, whether you compete, your flexibility, and whether you do other forms of exercise to supplement your swimming. The cause of shoulder pain for swimmers is often due to several factors. This can include instability or looseness in the shoulder, overuse of certain shoulder muscles, pressure on the tendons under the shoulder blade, abnormal movements of the shoulder blade, or just differences in your body’s anatomy.
Looseness and instability in the shoulder joint is something usually seen in competitive swimmers. This happens when the shoulder bones move too much, which is usually prevented by certain parts of our shoulders called ligaments and labrum, and the muscles of the shoulder or rotator cuff. This increased movement in the shoulder puts a lot of strain on the shoulder muscles, which can cause problems.
Competitive swimmers do a lot of shoulder rotations every day. Because of this, certain muscles that are active for most of the swimming stroke can get tired out. When these muscles are fatigued, it can affect how your shoulder moves and can lead to shoulder pain and secondary impingement, which is compression or pressure on the shoulder structures.
This compression commonly happens in competitive swimmers due to muscle fatigue and looseness in the shoulder joint. This extra movement in the shoulder joint puts pressure on the shoulder muscle tendons. The compression can occur under the shoulder blade during forward and inward rotation of the arm (during the recovery phase of the stroke), or inside the joint, during forward bending, inward rotation, and bringing the arm towards the body (during the arm entry phase of the stroke).
When certain shoulder muscles are tired out, they’re no longer able to oppose the action of a major chest muscle, the pectoralis major. This puts strain on the front part of the shoulder joint, which can lead to abnormal shoulder blade movements, secondary compression, shoulder blade tears, and shoulder pain. Unusual shoulder blade movement can also lead to entrapment of a nerve near the shoulder blade if there’s contraction of a shoulder muscle and over-flexibility.
Risk Factors and Frequency for Swimmer’s Shoulder
Swimmer’s shoulder is a condition that can affect people who frequently participate in swimming activities. The number of swimmers who experience this condition can vary widely. Some studies suggest that the numbers range between 3% and 70%. This condition is defined by shoulder pain that can interfere with a swimmer’s training or their ability to improve. Approximately 35% of skilled and senior-level swimmers are said to be affected by this. It’s even reported that about 91% of swimmers will experience this condition at some point in their swimming career. As a result, many swimmers have to skip training sessions and even miss important competitions.
- Swimmer’s shoulder is a common condition in swimming and affects somewhere between 3% and 70% of swimmers, varying per study.
- It is characterized by shoulder pain that interrupts training or progress.
- About 35% of advanced and senior-level swimmers suffer from swimmer’s shoulder.
- A staggering 91% of swimmers may experience this condition throughout their sports career.
- This condition often results in swimmers missing training sessions and important competitive events.
Signs and Symptoms of Swimmer’s Shoulder
Swimmer’s shoulder is a condition that primarily causes pain in the front of the shoulder, which often becomes worse when the shoulder is moved. This pain can sometimes prevent swimmers from training or competing. To diagnose this condition, a detailed physical examination of the shoulder is necessary. This includes checking the shoulder for any muscle wasting and imbalance, and measuring the range of shoulder movement. Specifically, doctors pay attention to a decrease in the inward rotation of the joint of the shoulder and either an increase or decrease in outward rotation, as these are important indicators of shoulder pain in swimmers.
Examining the resting position of the scapula, or shoulder blade, and its movement can help spot any irregular motion. A strength test might cause pain and, in serious cases, the shoulder might not be able to resist the force applied by a doctor during the test.
Additional tests can provide more information. These can include the apprehension/relocation test and the sulcus test, which can show if the shoulder is unstable. The Hawkins test is also useful in identifying if the area below the highest part of the shoulder is pinched or compressed. If the patient’s laxity test shows positive results, meaning the shoulder is unusually flexible, the doctor should also examine other joints to exclude a condition that affects the whole body.
Testing for Swimmer’s Shoulder
While shoulder conditions can often be diagnosed through a physical examination, sometimes further tests using special technology are needed to make a certain diagnosis. These tests can include image exams like an X-ray, ultrasound, MRI, or CT scan.
Starting with an X-ray can help doctors check for any changes in the structure of your shoulder. Sometimes, X-rays can also show other issues, like if a tendon in your shoulder is hardening.
If your sports medicine doctor needs more information after the X-rays, they might order an MRI. This is a more advanced type of imaging that can view muscles, tendons, ligaments, and cartilage in your shoulder in more detail. It can also help find any hidden causes for your shoulder problem, such as lumps of fluid or a cyst.
If your pain seems like it could be coming from multiple sources or there’s a chance you have a labral or tendon tear (damage to the rubbery tissue or the flexible band of tissue in your shoulder joint), an MRI with a dye injection may be used.
However, it’s important to read these images with care. Continuous movement, like in sports, can sometimes cause damage that doesn’t necessarily hurt but might still show up in an image.
Treatment Options for Swimmer’s Shoulder
If a swimmer initially feels pain in their shoulder, it’s important to focus on reducing the inflammation. Ice packs, nonsteroidal anti-inflammatory drugs (NSAIDs, a type of pain reliever), and rest may help control the pain. However, if the discomfort continues or gets worse, they should consider taking NSAIDs and resting for about a week to 10 days. This might be challenging if the injury happens in the middle or late part of the competitive season. Cutting down the swim distances to a level that doesn’t cause pain can help with recovery. In certain cases, shoulder problems like impingement (when shoulder muscles rub against the top part of your shoulder blade), tendinitis (inflammation of a tendon), or scapular dyskinesis (abnormal movement of the shoulder blade) can be treated with a corticosteroid injection. This can help in diagnosing the problem and reducing pain.
Performing stretches focused on the back part of the ‘capsule’ (a group of ligaments surrounding the shoulder joint) can help prevent and treat impingement. Overstretching the front part of the capsule while under-stretching the back can lead to imbalances that make impingement worse. To stretch the back of the capsule, swimmers can cross one arm over their chest and keep it in place with the other arm.
Swimmers often develop strong muscles that pull their arms inwards and rotate them towards the body due to the nature of their sport. This can lead to overgrowth of certain muscles, which may push the ball of the joint forward, causing instability. Therefore, exercises that strengthen the ‘rotator cuff’ (group of muscles and tendons that stabilize the shoulder) can help re-balance these muscles, reducing impingement. As muscle strength and endurance increase, swimmers may try exercises that mimic their sport, followed by short-distance swims at slower speeds. However, they should make sure that their pain is manageable and they are gradually working back to their competition level.
In some cases, surgery might be the best option when there is a structural abnormality in the shoulder. Some swimmers might choose to manage the symptoms without surgery so they can keep competing until the pain starts affecting their everyday life. If a swimmer has repeated issues with their shoulder moving too much in every direction, a shoulder tightening procedure might be needed. Athletes should note that they may need to permanently reduce their training volume to avoid pain. For athletes who see only limited improvement from physical therapy, surgery can be considered to explore the shoulder and remove any scarred, inflamed, or enlarged tissue while maintaining the structural integrity of the shoulder. For swimmers with a tear in the ‘labrum’ (a type of cartilage found in the shoulder joint) who haven’t improved with non-surgical treatment, the options are to trim (debride) or repair the labrum.
What else can Swimmer’s Shoulder be?
When identifying the cause of shoulder pain or other related issues, doctors might consider the following health conditions:
- Multidirectional instability (a shoulder condition that could make your shoulder dislocate in several directions)
- Partial tear on either side of the rotator cuff (a group of muscles and tendons that keep the shoulder joint stable)
- Posterior inferior humeral ligament avulsion (a type of shoulder injury where the ligament pulls off a part of the bone)
- Rheumatoid arthritis (a chronic inflammatory disorder affecting the joints)
- Shoulder dislocation
- Subacromial bursitis (an inflammation of the small sac of fluid located under the top part of the shoulder)
- Superior labrum lesions (injuries to the shoulder joint)
- Supraspinatus tendonitis (inflammation or damage to the supraspinatus tendon in the shoulder)
- Thoracic outlet syndrome (a condition causing pain in the neck and shoulder, numbness and tingling of the fingers)
What to expect with Swimmer’s Shoulder
Most people find great relief from their symptoms after non-surgical treatments for swimmer’s shoulder. After a few months of effective physical therapy, athletes can typically go back to their sports. However, some individuals may need surgery if the non-surgical methods are not successful or are not expected to fully relieve their symptoms.
Depending on the type of surgery and the individual’s comfort, they can resume swimming activities. However, for some types of surgery, like a procedure called capsular plication used for multi-directional instability, the person might need to permanently reduce their training volumes to avoid discomfort.
Possible Complications When Diagnosed with Swimmer’s Shoulder
After having surgery, some potential complications can occur. These include:
- Getting an infection
- Continued pain after the surgery
- A reduction in shoulder movement, resulting in stiffness
- Need for prolonged rehabilitation
Preventing Swimmer’s Shoulder
If you want to reduce the risk of getting swimmer’s shoulder, which can be caused by various physical risk factors, exercises can be a great preventative tool. Certain workout routines have been shown to decrease the risk of swimmer’s shoulder.
According to a recent study, strength training routines consisting of fewer than six exercises performed out of the water can improve the strength and endurance of the shoulder muscles (also known as the rotator cuff muscles). These exercises can lessen the impact of some physical risk factors that can lead to swimmer’s shoulder. This type of routine should ideally be done 2 to 3 times per week for a period of six weeks.
Similarly, it’s been found that some programs that include both stretching and strengthening exercises can help improve the posture of your shoulder, which can also lower the risk of swimmer’s shoulder. So, while your doctor monitors your health, these activities could potentially help you avoid this condition.
