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Biomechanical Considerations in the Competitive Swimmer’s Shoulder
Abstract and Figures
Competitive swimming has become an increasingly popular sport in the United States. In 2007, more than 250 000 competitive swimmers were registered with USA Swimming, the national governing body. The average competitive swimmer swims approximately 60 000 to 80 000 m per week. With a typical count of 8 to 10 strokes per 25-m lap, each shoulder performs 30 000 rotations each week. This places tremendous stress on the shoulder girdle musculature and glenohumeral joint, and it is why shoulder pain is the most frequent musculoskeletal complaint among competitive swimmers.
Articles were obtained through a variety of medical search sources, including Medline, Google Scholar, and review articles from 1980 through January 2010.
The most common cause of shoulder pain in swimmers is supraspinatus tendinopathy. Glenohumeral instability and labral tears have also been reported, but a paucity of information remains regarding prevalence and treatment in swimmers.
Because of the great number of stroke repetitions and force generated through the upper extremity, the shoulder is uniquely vulnerable to injury in the competitive swimmer. Comprehensive evaluation should include the entire kinetic chain, including trunk strength and core stability.
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... There are several published papers on shoulder pain in the swimmer [12,19,[24][25][26][27][28][29][30][31][32][33][34][35][36]. To our knowledge, a few studies exist on Masters swimmers [21,32,[37][38][39]. ...
... Several studies have shown how different groups of muscles are enrolled in the various phases of the movement [12,14,19,31,34,43,46] and how muscle fatigue can promote shoulder pain [34,42,[47][48][49][50]. ...
... Furthermore, there is a large body of work in the literature that has investigated the influence of the strength of individual muscle groups on performance and on the risk of injuries [12,14,19,31,34,43,46]. This means that, for a complete examination of the swimmer, the muscle evaluation cannot be ignored. ...
Background: Swimming and, specifically, front crawl, can be included among the “overhead” sports. Overhead sports are a risk factor for some problems of the musculoskeletal system, especially the shoulder. The aim of this study was to assess the incidence of shoulder and neck pain in a Masters Swimming Team and its correlation with the crawl stroke. Methods: This is an observational study through video-analysis of the stroke and a questionnaire. The participants selected for the present study were 61 athletes of a Masters team, whose prevailing training stroke was the front crawl. Their stroke was analyzed during training using a go-pro camera mounted on a sliding trolley on a track, evaluating their technical defects with their trainer. A questionnaire about frequency of shoulder and neck pain during the last five years was administered to all the participants at the study. Results: From the questionnaire, 45 and 55 out of 61 athletes had suffered from shoulder pain and cervical pain, respectively. Both types of pain were correlated with the weekly swimming volume. The swimmers with hyperflexion of the wrist and prolonged internal rotation in the pulling phase had shoulder problems. Those who suffered from current shoulder pain reduced the underwater time. The four swimmers with an excessive body roll during breathing and those who kept their heads extended, reported cervical pain. Conclusions: Shoulder and neck pain could be prevented with the correction of specific technical errors in crawl stroke.
... The literature has shown that an incorrect stroke, with errors in one or the other phase of the movement, can cause shoulder symptoms [14,15]. To our knowledge, only a few articles are published that relate swimming to neck pain [16][17][18][19]. ...
... There are several published papers on shoulder pain in the swimmer [12][13][14][15]20,22,[25][26][27][28][29][30][31][32][33][34][35][36]. To our knowledge, a few studies exist on Masters swimmers [17,32,[37][38][39]. ...
... Several studies have shown how different groups of muscles are enrolled in the various phases of the movement [12,14,15,31,34,43,46] and how muscle fatigue can promote shoulder pain [34,42,[47][48][49][50]. ...
Background: Swimming and, specifically, front crawl, can be included among the "overhead" sports. Overhead sports are a risk factor for some problems of the musculoskeletal system, especially the shoulder. The aim of the study was assessing the incidence of shoulder and neck pain in a Masters Swimming Team and its correlation with the crawl stroke. Methods: It is an observational study through video-analysis of the stroke and a questionnaire. The participants are 61 athletes of a Master team, whose prevailing training stroke was the front crawl were selected for the present study. Their stroke was analyzed during training by a go-pro camera mounted on a sliding trolley on a track, evaluating with their trainer their technical defects. A questionnaire about frequency of shoulder and neck pain during the last five years was administered to all the participants at the study. Results: From the questionnaire, 45 and 55 out of 61 athletes had suffered from shoulder pain and cervical pain, respectively. Both types of pain were correlated with the weekly swimming volume. The swimmers with hyperflexion of the wrist and prolonged internal rotation in the pulling phase had shoulder problems. Those who suffered from current shoulder pain reduced the underwater time. The four swimmers with an excessive body roll during breathing and those who kept their heads extended, reported cervical pain. Conclusions: Shoulder and neck pain could be prevented with the correction of specific technical errors in crawl stroke.
... This association may be explained by the muscles involved in the lat pull-down and freestyle stroke. It is worth noting that for both able-bodied and Paralympic athletes, this on-land exercise (i.e., lat pull-down) involves the activation of the latissimus dorsi muscle, which is an important muscle in swimming related to swimming propulsion and upper body strength during the freestyle stroke [42,43]. ...
... By examining multiple regression analysis in the bench press, it has been shown that mean swimming velocity can be predicted by the normF@Pmax and V@Pmax (42.3% and 65.8%, respectively). Notably, this exercise is important to optimize pectoral major shoulder and triceps muscle strength, which has an influence on the early and late pull phase in freestyle technique [43]. ...
This study aimed to identify the relationship between dryland tests and swimming performance in elite Paralympic swimmers. Fifteen competitive swimmers (age: 27.4 ± 5.4 years, height: 1.70 ± 6.8 m, body mass: 67.9 ± 9.2 kg; 9 males, 6 females) performed a lat pull-down and a bench press incremental load test to determine maximum power (Pmax), the strength corresponding to maximum power (F@Pmax), and the barbell velocity corresponding to maximum power (V@Pmax) from the force–velocity and power–velocity profiles. These outcomes were also normalized by the athlete’s body mass. Swimming performance was carried out from the best result in a 100 m freestyle race registered during an international competition. Lat pull-down F@Pmax was significantly associated with 100 m freestyle chronometric time (ρ = −0.56, p < 0.05), and lat pull-down V@Pmax presented a relationship with mean swimming velocity (ρ = 0.71, p < 0.01). Similarly, bench press F@Pmax and the normalized F@Pmax were significantly related to the mean swimming velocity (ρ = −0.51, ρ = −0.62, p < 0.05). Stepwise multiple regression showed that lat pull-down V@Pmax, bench press normF@Pmax, and V@Pmax accounted for 40.6%, 42.3%, and 65.8% (p < 0.05) of the mean swimming velocity variance. These preliminary results highlighted that simple dryland tests, although with a moderate relationship, are significantly associated with 100 m freestyle swimming performance in elite Paralympic swimmers.
... In animal models, the pattern of muscle contraction elicited during swimming could explain the differences found between femur and tibia cortical geometry. In humans, freestyle kicking during swimming primarily recruits the hip flexors and extensors, since knee flexion and extension generates a less propulsive force [99,100]. Gluteus maximus, biceps femoris and rectus femoris, which all have insertions at the femur, are more intensely recruited than gastrocnemius and tibialis anterior during the swimming kick [101]. ...
Background
The effect of swimming on bone health remains unclear, namely due to discrepant findings between studies in humans and animal models.
Objective
The aim of this systematic review and meta-analysis is to identify the available evidence on the effects of swimming on bone mass, geometry and microarchitecture at the lumbar spine, femur and tibia in both humans and rodent animal models.
Methods
The study followed PRISMA guidelines and was registered at PROSPERO (CRD4202236347 and CRD42022363714 for human and animal studies). Two different systematic literature searches were conducted in PubMed, Scopus and Web of Science, retrieving 36 and 16 reports for humans and animal models, respectively.
Results
In humans, areal bone mineral density (aBMD) was similar between swimmers and non-athletic controls at the lumbar spine, hip and femoral neck. Swimmers' tibia diaphysis showed a higher cross-sectional area but lower cortical thickness. Inconsistent findings at the femoral neck cortical thickness were found. Due to the small number of studies, trabecular microarchitecture in human swimmers was not assessed. In rodent models, aBMD was found to be lower at the tibia, but similar at the femur. Inconsistent findings in femur diaphysis cross-sectional area were observed. No differences in femur and tibia trabecular microarchitecture were found.
Conclusion
Swimming seems to affect bone health differently according to anatomical region. Studies in both humans and rodent models suggest that tibia cortical bone is negatively affected by swimming. There was no evidence of a negative effect of swimming on other bone regions, both in humans and animal models.
... The power generated by the shoulder during swimming can be seen by swimmers having the largest IRD shoulder strength of the sports disciplines studied. This large shoulder strength could have issues if not balanced by the TRS, as a lower contribution of trunk stabilizing muscles during swimming can lead to shoulder pain and injury (Heinlein and Cosgarea, 2010;Matsuura et al., 2022). Coaches can optimise performance of their swimmers and reduce injury risk by analysing the shoulder-trunk relationships. ...
Introduction: Trunk and shoulder strength are consistently shown to be involved in performance limitations, as well as contributing to stability, power output, and reducing the risk of injury. Although their biomechanical interaction is a critical aspect for athletes, there is limited research on the relationship between trunk and shoulder strength in sports where upper body mechanics are critical for optimal performance.
Purpose: This study examined the differences and relationships between trunk rotational strength and shoulder rotational strength among athletes participating in mixed martial arts (MMA), tennis, swimming, and baseball.
Methods: Maximal voluntary contraction tests were performed to evaluate strength of 39 professional adult male athletes from disciplines of MMA (n = 6), tennis (n = 11), swimming (n = 11) and baseball (n = 11). Peak force data were used in sports comparison and relationship analysis between trunk and shoulder rotation strength parameters.
Results: The findings revealed a complex and significant relationship between trunk and shoulder strength, with unique patterns for each athletic discipline. Tennis players exhibited a strong correlation between trunk bilateral differences and internal shoulder rotation, while other disciplines demonstrated a more balanced use of trunk asymmetry. Swimmers displayed the best interactions between trunk and shoulder overall, emphasizing the aquatic environment’s biomechanical demands. In MMA, the strongest correlation was between shoulder internal and external rotation with the trunk, mainly due to the number of defensive movements in addition to offensive ones. Baseball pitchers showed a significant correlation between internal/external shoulder rotation strength ratio and trunk asymmetry.
Conclusion: While no differences in peak force variables were found, unique relationships between trunk and shoulder rotational performance were discovered. The results suggest a long-term sport-specific adaptation of the trunk-shoulder interaction in sports that require upper limb power movements. It seems, that the relationship between the various parameters of trunk and shoulder was influenced by the movement stereotype of each sport. Therefore, recognition of sport-specific interactions is critical to the development of effective training programs that enhance performance and potentially reduce injury risk in different sports. Researchers and practitioners should focus on longitudinally monitoring fluctuations in TRS and SRS relationships throughout each sport season and examining potential associations with injury incidence.
... Functional Training in Swimmer's Shoulder: 7 The dynamic stabilizers of the shoulder complex must activate consistently and in unison for best athletic performance. Strengthening exercises should replicate the functional requirements associated with sport-specific skills. ...
Background: The purpose of this study was to investigate the effectiveness of 6-week Serratus Anterior trainingVersus Subscapularis training in improving the performance in a Swimmer’s Shoulder.Purpose: To compare the effect of Serratus Anterior strength training versus Subscapularis strength training onshoulder pain in terms of performance in Swimmer’s.Materials and Methods: Subjects were randomly assigned into two groups i.e. Group A and B. The subjects wereassessed using an assessment form, UQYBT, DASH score, and 50 meters (m) freestyle sprint for disability andevaluate performance before the commencement of treatment and also reassessed after 6 weeks of treatment.The sample of 40 subjects has been randomized into either Group A (Serratus Training) or Group B (SubscapulisTraining) in a 1:1 ratio.Results: The study results suggest that Group B has an effect on performance improvement in Swimmers withshoulder pain after a 6-week intervention. The mean 50m sprint scores in Group A before treatment is 29.9960 andit is decreased to 29.0425.Conclusion: Hence, this study concludes that the mean difference of Group B is slightly more effective than GroupA in terms of performance in swimmers’ shoulders in all standard measures.
... week [6]. It is proposed that numerous shoulder movement repetitions can contribute to joint inflammation and pain [7]. ...
Biomechanics and training load monitoring are important for performance evaluation and injury prevention in elite swimming. Monitoring of performance and swim stroke parameters is possible with inertial measurement units (IMU) but has not been validated in para-swimmers. The purpose of this study was to validate a single IMU-based system to accurately estimate pool-swam lap time, stroke count (SC), stroke duration, instantaneous stroke rate (ISR), and distance per stroke (DPS). Eight Paralympic athletes completed 4 × 50 m swims with an IMU worn on the sacrum. Strokes cycles were identified using a zero-crossing algorithm on the medio-lateral (freestyle and backstroke) or forward-backward (butterfly and breaststroke) instantaneous velocity data. Video-derived metrics were estimated using Dartfish and Kinovea. Agreement analyses, including Bland–Altman and Intraclass Correlation Coefficient (ICC), were performed on all outcome variables. SC Bland–Altman bias was 0.13 strokes, and ICC was 0.97. ISR Bland–Altman biases were within 1.5 strokes/min, and ICCs ranged from 0.26 to 0.96. DPS Bland–Altman biases were within 0.20 m, and ICCs ranged from 0.39 to 0.93. A single-IMU system can provide highly valid performance and swim stroke monitoring data for elite para-swimmers for the majority of strokes, with the exception of backstroke. Future work should improve bilateral stroke detection algorithms in this population.
... 2 In competitive swimming, the strong propulsive force generated by the upper limbs account for 80%-90% of the swim velocity and the shoulder moves into internal rotation, extension, and adduction at the glenohumeral joint during the pull-through phase. 3 Thus, the eccentric shoulder external rotation has been characterized as counteracting the propulsive internal rotation, thereby providing dynamic stabilization of the glenohumeral joint. 4 In addition, electromyographic findings in competitive swimmers without shoulder pain supported this argument. ...
Objective: Swimming is a sport that requires a considerable strength, endurance,
mobility and stability of the upper body. Therefore, the aim of this study was to
compare the effects of dry-land and in-water core stability training programs on
swimmers’ upper body balance and performance.
Methods: The available statistical sample of this study included 28 swimmers from
city of Sabzevar who were divided randomly into three groups of dry-land (10
swimmers), in-water (10swimmers) and control (8 swimmers). Data analysis was
done by split-plot ANOVA to compare intra- and inter-group variables and Bonferroni
post-hoc test was also utilized to compare group means within two groups.
Results: The results showed that four-week core stability exercises on dry-land led
to 50m swimming time improvements as well as upper body balance of dominant
and non-dominant limbs. There was no significant improvement in 50m for dryland
group and no significant improvement in stroke rate for both experimental
groups.
Conclusion: Based on the findings of this study, it is suggested that coaches and
swimmers utilize exercises used in this study in order to improve upper body balance
as well as swimming performance in their training program.
Keywords: Upper quarter balance, Core stability, Swimming, Performance
This study was supported in part by the School of Health Related Professions Research and Development Fund, University of Pittsburgh, Pittsburgh, PA A common complaint of competitive swimmers is shoulder pain. The purposes of this study were to: 1) provide normative data on shoulder flexibility in swimmers, 2) determine if a correlation exists between flexibility and shoulder pain, and 3) determine the correlation between strength and endurance ratios to shoulder pain. The subjects were 28 Division I collegiate swimmers and four club swimmers. Shoulder flexibility measurements were obtained bilaterally using a universal goniometer. Strength and endurance ratios were obtained bilaterally using the Cybex II(R) isokinetic dynamometer and the Upper Body Exercise Table(R). The swimmers completed a questionnaire that included a shoulder pain performance scale. The Pearson product moment correlation coefficient and multiple regression (R) analysis were the applied statistics. The results demonstrated that no significant correlation (p > 0.001) existed between shoulder flexibility, strength ratios, and shoulder pain. There was a significant (p </= 0.001) negative Pearson's correlation between endurance ratios of external rotation, abduction, and shoulder pain in competitive swimmers. A multiple R of 0.78 was obtained for the combination of external rotation and abduction endurance ratios to shoulder pain, which was significant (p </= 0.001). Clinical implications suggest that when evaluating swimmers, clinicians need to be aware of the importance of assessing the endurance ratios of the shoulder abductors and the external rotators at faster speeds. With decreased endurance ratios, competitive swimmers may be more likely to develop shoulder pain. J Orthop Sports Phys Ther 1992;16(6):262-268.
The incidence of shoulder pain was studied in 168 male and female swimmers, aged 12 to 23, representing four universities and two clubs. A simple test of shoulder flexibility was administered in October, and team-wide incidence of swimmer's shoulder for the coming winter season was predicted. The predictions proved to be about 93% accurate, clearly showing a strong correlation between lack of flexibility and incidence of swimmer's shoulder. In males, increased incidence of shoulder pain was also related to increased intensity and duration of weight training. The incidence of shoulder pain was not directly dependent on stroke, distance, or sex, with one exception: At a given level of flexibility, butterfly swimmers showed a higher incidence of shoulder pain than other swimmers.
This paper compares the muscle firing patterns of 12 shoulder girdle muscles in competitive butterfly swimmers with painful and normal shoulders. Seven of the 12 muscles revealed statistically significant differences between the two populations. The posterior deltoid demonstrated more activity in the painful shoulders during hand entry while the upper trapezius and serratus anterior exhibited less activity. This alteration in muscle firing patterns allowed for the humerus to be positioned for a wider hand entry, which decreased the pain of impingement of the supraspinatus on the coracoacromial arch. Correspondingly, there was significantly less activity in the supraspinatus. The teres minor and serratus anterior revealed significantly less muscle action throughout pulling as they respectively failed to balance the humeral rotation and did not reverse their origins and insertions to pull the body over the arm. Also, the subscapularis and infraspinatus displayed increased activity in the painful shoulders as they depressed the humeral head to avoid impingement. There were no significant differences between the two groups in the rhomboids, pectoralis major, latissimus dorsi, or the anterior and middle deltoids. From this information, accurate preventative and rehabilitative exercise programs for the competitive butterfly swimmer can be developed.
(C) Lippincott-Raven Publishers.
Shoulder pain is the most common orthopaedic complaint of competitive swimmers. Epidemiological studies have reported the incidence and recurrence rates of shoulder pain to be as high as 80% among top US competitors.16 Although the precise origin of pain may be elusive, the term “swimmer’s shoulder” has been used to describe the inflammation resulting from dynamic impingement of the rotator cuff and coracoacromial arch. Long training seasons, repetitive overhead arm motion, overuse fatigue, increased glenohumeral laxity, and poor swimming technique may all contribute to the shoulder pain that frequently occurs in this unique group of athletes.2,10,11,15,17
In this report, we present a female Division I collegiate swimmer with shoulder pain secondary to a symptomatic os acromiale. This patient’s presentation serves to provide clinicians a sentinel reminder to consider all potential causes of shoulder pain in competitive athletes, particularly in the setting of a more common, confounding diagnosis.
Unlabelled:
Congenital instability of the shoulder is a form of multidirectional instability not caused by a traumatic event. It is believed that excess laxity may be responsible for an overly elastic capsule and, therefore, can contribute to multidirectional instability. Minor microtraumatic events can progressively lead to the development of pain and lead to instability. The current preferred treatment is largely nonoperative with extensive rehabilitation of the dynamic restraints of the shoulder complex. In recalcitrant cases, operative intervention to restore stability may be necessary. It is of paramount importance to notice the directions of instability and to address each of them. Surgical procedures include open capsular shift, as well as arthroscopic capsular plication. Because multidirectional instability can be difficult to diagnose, this article will attempt to provide the clinician with a better understanding of the pathophysiology involved in this condition, the necessary steps for diagnosis, and considerations for treatment. A comprehensive guide to both nonoperative and operative treatment is reviewed in this article, as well as the surgical techniques used to decrease the capsular volume.
Level of evidence:
Level 5.
The authors conclude that swimmer's shoulder is a result of repetitive arm motion in the position of abduction, forward flexion, and internal rotation. This produces impingement in the vulnerable avascular region of the supraspinatus and biceps tendons. Local treatment includes ice, ultrasound, isokinetic strengthening activities, and transcutaneous stimulation. Oral anti-inflammatory medication may be helpful in the short term. Surgical relief measures include coraco-acromial ligament division and anterior acromioplasty. The apprehension shoulder in swimming is produced by subluxation of the shoulder anteriorly and may be relieved by a change in the style of the turn as well as surgical intervention, buttressing the anterior capsule of the shoulder. Breast stroker's knee is a result of inflammation of the tibial collateral ligament which is stressed by the knee going from flexion to extension with a valgus stress and external rotation. Local remedies include ice, ultrasound, and rest. Inflammation of the extensor tendons along the dorsum of the foot is common in the flutter and backstroke kick, and is relieved by local measures and perhaps the judicious use of steroid injection.
The purpose of this paper is to describe the patterns of activity of 12 shoulder muscles in painful shoulders, and compare those patterns of activity with normal shoulders. The results show significant differences in 7 of the 12 muscles. Those muscles included the anterior deltoid, middle deltoid, infraspinatus, subscapularis, upper trapezius, rhomboids, and the serratus anterior. There were no significant differences between muscle activity patterns of normal versus painful shoulders in the latissimus dorsi, pectoralis major, teres minor, supraspinatus, or the posterior deltoid. This information will contribute to the development of muscle conditioning programs to optimize performance and prevent injury, as well as develop programs for scientific rehabilitation strengthening.
The shoulder in swimming is subjected to multiple factors that can lead to a high injury rate. To prevent injury, one must understand the biomechanics of swimming. This paper describes the electromyographic and cinematographic findings of 12 shoulder muscles in competitive swimmers without shoulder pain. The results show the three heads of the deltoid and the supraspinatus functioning in synchrony to place the arm at hand entry and exit, the rhomboids and upper trapezius to position the scapula for the arm, the pectoralis major and latissimus dorsi to propel the body, the subscapularis and serratus anterior as muscles with constant muscle activity, the teres minor functioning with the pectoralis major, and the infraspinatus active only to externally rotate the arm at midrecovery. This information is important to design optimal preventative and rehabilitative exercise programs.
Impingement syndrome is an ill-defined term for a variety of disorders of the shoulder that manifest as anterior shoulder pain, especially during overhead activities. These disorders each have a common pathologic course that includes rotator cuff tendinitis (RCT), and, if untreated, may proceed to cuff rupture. RCT has at least two distinct etiologies. Primary impingement of the supraspinatus tendon on the coracoacromial arch is responsible in the majority of nonathletic cases. Overhead movements in sports are prone to developing secondary mechanical impingement because of an instability pattern that is common in this population. Information from this review and clinical practice permits differentiation of the two distinct etiologies of RCT which is important in treatment planning. Much work still needs to be done in defining the microscopic pathology of RCT.
Shoulder pain is the most common orthopaedic problem in competitive swimming. In a group of 137 of this country's best swimmers, 58 had had symptoms of "swimmer's shoulder." Population characteristics of this group indicated that symptoms increased with the caliber of the athlete, were slightly more common in men, and were related to sprint rather than distance swimming. The use of hand-paddle training exacerbated symptoms, which were more common during the early and middle season. Consideration of shoulder mechanics in swimming reveals that freestyle, butterfly, and backstroke require similar motions; a swimmer using any of these strokes is susceptible to developing shoulder pain. Swimmer's shoulder represents chronic irritation of the humeral head and rotator cuff on the coracoacromial arch during abduction of the shoulder, the so-called impingement syndrome. Treatment included stretching, rest, ice therapy, oral antiinflammatory agents, judicious use of injectable steroids, and surgery as a last resort.