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Abstract
Shoulder pain is the most common musculoskeletal complaint in competitive swimmers. Problems with the shoulders of swimmers resemble that of the disabled thrower's shoulder, but the clinical findings and associated dysfunctions are not quite the same. Therefore, swimmers with shoulder pain should be evaluated and treated as a separate clinical entity, aimed toward underlying pathology and dysfunction. Balanced strength training of the rotator cuff, improvement of core stability, and correction of scapular dysfunction is central in treatment and prevention. Technical and training mistakes are still a major cause of shoulder pain, and intervention studies that focus on this are desirable. Imaging modalities rarely help clarify the diagnosis, their main role being exclusion of other pathology. If nonoperative treatment fails, an arthroscopy with debridement, repair, or reduction of capsular hyperlaxity is indicated. The return rate and performance after surgery is low, except in cases where minor glenohumeral instability is predominant. Overall, the evidence for clinical presentation and management of swimmer's shoulder pain is sparse. Preliminary results of an intervention study show that scapular dyskinesis can be prevented in some swimmers. This may lead to a reduction of swimmer's shoulder problems in the future.
... Head tilt angle, cervical angle, and shoulder protraction-retraction angles were smaller and thoracic angle was larger in the swimmers' group. Incorrect posture and abnormalities can be corrected and pain can be reduced by targeted training intervention [2,24]. ...
... Several publications [2,3,16,17,24,[27][28][29][30][31] highlighted that dry-land training could have a beneficial effect on the restoration of normal shoulder posture and muscle balance in competitive swimmers, but less information is available on whether pain is reduced, if at all, and most of these studies have selectively treated shoulder muscles. For swimmers the results of earlier publications [2,3,16,17,24,[29][30][31][32] suggested that preventive interventions to improve postural change applied core training combined with shoulder strengthening and stretching exercises may improve posture and decrease the presence of shoulder pain. ...
... Several publications [2,3,16,17,24,[27][28][29][30][31] highlighted that dry-land training could have a beneficial effect on the restoration of normal shoulder posture and muscle balance in competitive swimmers, but less information is available on whether pain is reduced, if at all, and most of these studies have selectively treated shoulder muscles. For swimmers the results of earlier publications [2,3,16,17,24,[29][30][31][32] suggested that preventive interventions to improve postural change applied core training combined with shoulder strengthening and stretching exercises may improve posture and decrease the presence of shoulder pain. These previous studies highlight the importance of core strengthening in the prevention of shoulder pain as a way to create/build the proximal stability necessary for the optimal biomechanical function of the upper limbs. ...
The aim of our study was to investigate the effects of a 24-week-long training program on changes in static body posture, as well as the characteristics of anterior shoulder pain in youth swimmers, and the relationship between changes in whole-body posture and the frequency and intensity of anterior shoulder pain. Competitive young swimmers (n = 54, 13.9 ± 1.79 years) were divided into experimental group and control group and both groups performed their usual swimming training. In addition, the experimental group performed a 24-week-long whole-body posture correction program. Before and after the implemented training, whole-body posture was analyzed using the PostureScreen (version 13.7) mobile application, and subjective intensity of pain was determined using the swimmer’s functional pain scale. Significant changes were found between the two groups in numerous measured postural parameters. A significant reduction in the prevalence of shoulder pain and score of the pain scale was observed after the posture correction program in the experimental group. Our results may imply that more optimal biomechanical conditions may indirectly reduce the incidence of swimmer’s shoulder in terms of prevention. Analysis and monitoring of body posture of swimmers using an on-field mobile application continuously, and the application of preventive training programs, may help to avoid developing injuries.
... The term ''swimmer's shoulder'' covers a spectrum of consecutive or coexisting pathologies, with rotator cuff-related pain to be the most common finding [8]. Kennedy and Hawkins [3] proposed that the avascularity zones of the supraspinatus and bicipital tendon in the adducted position of the arm are the explanation of swimmer's shoulder. ...
... However, when the arm is at the side in the adducted position, there is a constant area of avascularity extending 1 cm. proximal directly to the point of insertion of the supraspinatus and in the intracapsular portion of the bicipital tendon when it passes over the head of the humerus [3] Bak reported that the main factor in the development of a swimmer's shoulder seems to be the high training volume during growth in the absence of a well-designed and balanced dryland training program, affecting the muscular balance and the scapular motion [8]. A clear consensus is lacking as to the causes of shoulder pain in swimmers. ...
... Other reports suggest that the impingement is produced by glenohumeral instability or muscular imbalance of the scapular stabilizers (secondary impingement). [6,10,11] Indeed, the muscular electric activity is different in the shoulders with pain during the swimming [8,12]. Essentially, there are various causes or contributor factors accepted to cause shoulder pain in swimmers. ...
Shoulder pain is the most important symptom that affects competitive swimmers, with a prevalence between 40 – 91%, and it constitutes a special syndrome called the “swimmer’s shoulder”. This syndrome, described by Kennedy and Hawkins in 1974 consists in discomfort after swimming activities in a first step. This may progress to pain during and after training. Finally, the pain affects the pro23wsq2wgress of the athlete.
... It initially starts with mild discomfort that remains during and after training, which ends up affecting the athlete's progress (McMaster, 1999;Sein et al., 2010). Bak (2010) proposes taking a break as a first tactic, cutting back on training and using an ice pack only when pain occurs during swimming. Another important tool is the coach's analysis and technical corrections of the specific movement in this sport during training. ...
... Thus, the reason for this study is based on some authors who recommend a musclestrengthening program to keep the shoulder healthy and avoid fatigue and shoulder injuries (Bak, 2010;Tate et al., 2012). In addition, evaluations of muscle activation, such as through surface electromyography, can address the requirements of the main muscles involved (Hug, 2011). ...
The aim of this study was to evaluate maximum voluntary contraction through surface electromyography in stabilizer shoulder muscles, as well as the clinical evaluation of shoulder injury in the pre, post, and detraining stages of specific training in child swimmers. Twelve competitive swimmers volunteered for this study. Anthropometric measurements, clinical examination, electromyography (with Delsys® data acquisition system), and pain intensity levels were performed. Clinical examination and EMG data were compared using repeated-measures ANOVA with Bonferroni correction pre, post, and after detraining. The intervention program lasted for 12 weeks. The pain group presented higher pain intensity values compared to the post-intervention program. Most of the tests presented lower values at the detraining compared to the baseline. After the intervention, pain levels significantly decreased in five tests. Muscle strengthening work is highly recommended because it improves the swimmer's shoulder performance, reducing injuries and decreasing pain intensity after 12 weeks of intervention.
... Progressive Rehabilitation for Adolescent Female Swimmer with Subakromiyal Pain (Impression) Syndrome may fatigue the posterior RC (infraspinatus and teres minor) and periscapular muscles, which may be exposed to more stress on the posterior capsule to maintain joint stability through the swimming stroke and may lead to IRROM deficiency and narrowing of the acromiohumeral distance (AHD) Su et al., 2004;Torres and Gomes, 2009). The term "swimmer's shoulder" comprises the combination of hypovascularity of the RC tendons (especially supraspinatus), muscle fatigue (especially serratus anterior), poor stroke mechanics, and the progressive instability of a hypermobile glenohumeral joint, and scapular dyskinesis with subacromial pain syndrome (Bak, 2010;Kenal and Knapp, 1996;Sajadi et al., 2019). Swimmer's shoulder is common in swimming, as at least 55% of all injuries in competitive swimmers affect the shoulder (McFarland and Wasik, 1996). ...
... The main factor in the development of a swimmer's shoulder seems to be the high training volume during growth in the absence of a balanced dryland training program (Porter et al., 2020). Most swimming strokes consist of a pull-through phase that generates speed and a recovery phase where the arm is over the water (Bak, 2010). Yanai and Hay demonstrated that impingement on average occurred 24.8% of the stroke time (Yanai and Hay, 2000). ...
Shoulder injuries are common in competitive youth swimmers because of sport-specific changes in upper extremity physical characteristics and acromio-humeral distance (AHD). These physical alterations could cause abnormal scapular kinematics and positioning. Subacromial pain syndrome (SPS), scapular dyskinesis, and SLAP lesions require a multiphase approach. A 14-years-old female athlete who has been swimming for 7 years had SPS symptoms for 14 months. She also had scapular dyskinesis and suspected SLAP lesion. She received 15 treatment sessions. We conducted a progressive and comprehensive rehabilitation program consisting of electrotherapy, thermal agent, mobilization techniques, posterior shoulder stretching exercises, upper and lower extremity strengthening, proprioception, scapular stabilization, and core stabilization exercises, rhythmic stabilization exercises, plyometric exercises, and the advanced thrower’s 10 program. Internal rotation range of motion (IRROM) with bubble inclinometer, pain with Visual Analog Scale, and AHD with ultrasonographic imaging were assessed before treatment and at the end of the 9th and 15th treatment sessions. Before treatment, IRROM was 52°, AHD was 10.67 mm, and pain intensity at rest and during swimming was 0 and 3.1 cm, respectively. After 9 treatment sessions, IRROM was 55.6°, AHD was 11.62 mm, pain intensity at rest and during swimming was 3.7 cm and 5.1 cm, respectively. At the end of the treatment, IRROM was 58.33°, AHD was 12.02 mm, pain intensity at rest and during swimming was 0 cm. A progressive and challenging rehabilitation program may positively change the scapular and glenohumeral kinematic patterns leading to an increase in AHD and IRROM, therefore a decrease in pain.
... 3,4 Durante a fase de recuperação, a capacidade de rotação do tronco associada a retração da escápula promove a proteção da bolsa sinovial subacromial, do tendão do supraespinhoso e do labrum glenoideu posterior e superior, estruturas mais frequentemente em risco nos nadadores. 6 A discinésia escapular é um sinal frequente em nadadores com dor no ombro associada a sobreuso e pode ser causada por inibição do padrão de ativação muscular dos músculos estabilizadores da escápula. 9-12 Perante um volume de treino elevado, os nadadores ficam sujeitos a fadiga muscular. ...
... coce e consequentemente o risco de lesão do ombro por erros técnicos. Como tal, a monitorização do treino e a correção de erros em gestos técnicos é essencial para a prevenção de lesões.6 ...
Swimming is common around the world, especially in the summer. Some of these invididuals are professional swimmers, turning them more susceptible to injury. A competitive swimmer performs
more than one million rotations of the shoulder per week and is therefore prone to overuse injuries, especially of glenoumeral joint. The main risk factor is the high training volume by increasing early
muscle fatigue and consequently the risk of shoulder injury due to technical errors. The knowledge of the swimming biomechanics allows to identify possible technical errors at its typical movements,
opening the door to create efficient injury prevention strategies related specifically to the technical exercices of the swimmer.
... Shoulder pain is the most frequent musculoskeletal complaint in swimming, affecting from 40 to 91% of athletes (Matzkin et al., 2016), and 20-35% of competitive swimmers experience a time-loss injury each year (Gaunt and Maffulli, 2012). Adolescent swimmers are exposed to an increased risk of injury when transitioning from one to two practices daily with a high training volume (Bak, 2010;Wolf et al., 2009). The high injury rate in swimmers could be due to swimming mechanics consisting of specific repetitive motion. ...
... Until now, the literature on rotator muscle imbalance and its association with shoulder injury in swimmers was mainly based on conventional concentric ratios (Bak, 2010;Batalha et al., 2013;Bradley et al., 2016). However, external rotators are less likely to be involved in their concentric mode as external rotation is the least used motion in swimming and is mostly involved in the nonpropulsive phase (Manske et al., 2015). ...
Muscle strength imbalances between the internal and external rotators of the shoulder are frequent in swimmers, but their role in shoulder injury remains unknown. We aimed to evaluate the association of shoulder rotator strength and injury in elite adolescent swimmers. Eighteen adolescent swimmers performed preseason isokinetic tests of the internal and external rotator muscles in concentric (con) and eccentric (ecc) modes. Conventional (conER:conIR and eccER:eccIR) and functional ratios (eccER:conIR and eccIR:conER) were calculated. Thirteen swimmers completed a weekly questionnaire about swimming habits and shoulder injuries throughout the season. Preseason testing showed a significant negative association between the functional eccER:conIR ratio and years of practice (p < 0.05). Over the season, 46% of athletes experienced at least one shoulder injury. At the end of the season, peak torques increased for both internal and external rotator muscles strength, but only concentrically, resulting in a decrease in the eccER:conIR functional ratio (p < 0.05). The receiver operating characteristic curve analysis highlighted good predictive power for the preseason functional eccER:conIR ratio, as values below 0.68 were associated with a 4.5-fold (95% CI 1.33-15.28, p < 0.05) increased risk of shoulder injuries during the season.
... load monitoring, review, swimming soft-tissue injury, pain, and dissatisfaction. 3,7,10 Shoulder pain is particularly frequent 11,12 and, with prevalence rates reported as high as 91%, 7 is a major cause of missed practice. 13 The establishment of a high injury incidence and the increasing demands of swim-training programs make monitoring of the swimmer's training load a key concept requiring further investigation. ...
... 38,40,41,45,49 Finally, several subjective markers have been investigated for their use as an indirect measurement of the training intensity. The 15-grade scale (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) for rating of perceived exertion (RPE) 55 is such a marker which allows the athlete to rate its own perception of endured stress and effort during training based on a single rating. The session RPE (sRPE) is a similar subjective marker, which is based on the RPE scale and was proposed to further simplify the quantification of training load. ...
The high incidence of injury during swim‐training as well as the increasing demands of the sports make monitoring of the swimmer’s training load a key concept requiring further investigation. Research has previously introduced numerous methods for the purposes of monitoring the swimmer’s training load, but a narrative review discussing the strengths and limitations of each method is lacking. Consequently, this narrative review aims to summarize the monitoring strategies that have been applied in sports medicine research on competitive swimmers. This knowledge can assist professionals in the field in choosing which method is appropriate in their particular setting. The results from this study showed that external training load was predominantly obtained through real‐life observation of the swimmers’ training volume. However, research has investigated a number of internal load monitoring tools, including blood lactate, training heart rate and perceived effort of training. To date, blood lactate markers are still considered most accurate and especially recommended at higher levels of competitive swimming or for those at greater risk of injury. Further, mood state profiling has been suggested as an early indicator of overtraining and may be applied at the lower competitive levels of swimming. Professionals in the field should consider the individual, the aim of the current training phase and additional logistical issues when determining the appropriate monitoring strategy in their setting.
... Non-operative treatments may be advantageous for athletes who continuously practice overhead activities. In overhead athletes (e.g., baseball pitchers), the shoulder joint is predisposed to incur altered configurations of the GH joint, ROM deficits, and muscle weakness, resulting in an SD whose grade of injury increases with the level of the competition [151][152][153][154][155][156]. In elite athletes with common internal impingement, researchers have found that treatments focused on intense nonoperative approaches provide better outcomes than other treatments and that physical training protocols might be integrated into their usual daily exercises [157][158][159]. ...
... Rehabilitation and/or prevention protocols for swimmers should include such exercises as cross-training and core endurance training aimed at stretching the posterior muscles and pectoralis in order to reduce exposure and gain strength [166]. However, in the same class of athletes, training has been found to induce SD in previously pain-free swimmers [155,156,167]. For tennis players with internal impingement, rehabilitation programs should integrate kinetic chain training from the initial phases; angular and translational mobilizations should be carried out to reacquire IR and to posteriorly stretch the GH joint. ...
Background: This study intends to summarize the causes, clinical examination, and treatments of scapular dyskinesis (SD) and to briefly investigate whether alteration can be managed by a precision rehabilitation protocol planned on the basis of features derived from clinical tests. Methods: We performed a comprehensive search of PubMed, Cochrane, CINAHL and EMBASE databases using various combinations of the keywords “Rotator cuff”, “Scapula”, “Scapular Dyskinesis”, “Shoulder”, “Biomechanics” and “Arthroscopy”. Results: SD incidence is growing in patients with shoulder pathologies, even if it is not a specific injury or directly related to a particular injury. SD can be caused by multiple factors or can be the trigger of shoulder-degenerative pathologies. In both cases, SD results in a protracted scapula with the arm at rest or in motion. Conclusions: A clinical evaluation of altered shoulder kinematics is still complicated. Limitations in observing scapular motion are mainly related to the anatomical position and function of the scapula itself and the absence of a tool for quantitative SD clinical assessment. High-quality clinical trials are needed to establish whether there is a possible correlation between SD patterns and the specific findings of shoulder pathologies with altered scapular kinematics.
... Los programas preventivos tienen un papel esencial en el cuidado continuo del deportista y cada vez se hace más presente la planificación del entrenamiento con programas específicos y medidas generales de prevención de lesiones, teniendo un gran impacto en el rendimiento general de los equipos temporada tras temporada (Olmo, 2000). Bak (2010), menciona que el exceso de entrenamiento del gesto deportivo en la natación supera a los demás deportes, por lo que representa un riesgo mayor de uso excesivo y fatiga, lo que a su vez aumenta la susceptibilidad a errores técnicos. Por ello recomienda que los nadadores de altos niveles, con una carga de más de 5 sesiones de entrenamiento por semana, deben realizar ejercicios en tierra seca para prevenir los efectos del entrenamiento, en su postura corporal, estabilidad y fuerza. ...
... De manera preventiva se debe insistir en un aprendizaje correcto de la técnica de nado, detección precoz de la fatiga, aumentos graduales en el volumen e intensidad del estilo de pecho, tomar descansos del entrenamiento de este estilo durante al menos 2 meses al año, realizar adecuados calentamientos tanto en los entrenamientos como en las competencias e intercalar el entrenamiento con otros estilos de nado que no impliquen tanta tensión en la rodilla (Bak, 2010). ...
... The term "swimmer's shoulder" is known to many swimmers. It involves a range of sequential or simultaneous injuries (5). Bak divided the swimmer's shoulders into five main groups and stated that in four types, there is almost always SD (5). ...
... It involves a range of sequential or simultaneous injuries (5). Bak divided the swimmer's shoulders into five main groups and stated that in four types, there is almost always SD (5). The prevalence and related complications to this are a significant issue. ...
... The enhanced shoulder laxity may provide a competitive advantage by allowing swimmers to achieve ideal body positions to reduce drag and generate larger stroke lengths. Consequently, the increased shoulder laxity leaves them more prone to relying on the dynamic stabilizers of the shoulder to control the improper translation and ultimately producing instability, impingement, and shoulder pain [106]. The main propulsive mechanism of swimming is the upper extremity, generated by powerful pectoralis major and latissimus dorsi muscles. ...
... The main propulsive mechanism of swimming is the upper extremity, generated by powerful pectoralis major and latissimus dorsi muscles. With the development of muscle fatigue, the potential strength imbalance of opposing musculature is intensified, leading to further destabilization of the humeral head, scapular dyskinesis, and rotator cuff tendinopathy [106]. Scapular dyskinesis has been thought to predispose patients to impingement by placing the scapula in a relative abducted, protracted, and lateral displaced position during activity [107]. ...
Although it is unknown when sports were first played indoors, we know that sports have been around for over 15,000 years, with the first documented event as a footrace between two cavemen. Progress in architecture and technology have allowed for outdoors competition to transition into indoor sporting events. In modern day, indoor sports continue to represent a high proportion of athletic events as many outdoor sports are being played under the confines of an indoor facility. Indoor sports allow for a healthy alternative to playing outdoors all year round. Participation can occur during any time of the year and training has subsequently improved. Indoor sports participation is also on the rise as heat and cold illness awareness has increased. Participating in sports in an indoor environment can place unique demands and challenges on the athlete, coaches, healthcare team, and administration.
... This finding suggests a high potential for impingement, without considering the supraspinatus tendon thickness and relationship to the subacromial space. Shoulder pain in swimmers is theorized to be commonly associated with impingement of the supraspinatus tendon in the subacromial space, called "swimmer's shoulder" (Bak, 2010;Struyf et al., 2017;Tovin, 2006). ...
... The swimmer's shoulder may lead to a greater supraspinatus tendon thickness as a result of an increase in resistance loads and a chronic effect of exercise (0.5 and 1 million arm cycles per year). This increase in tendon thickness may also be related to the changes in flexibility and stiffness around the shoulder and the trunk reported in swimmers (Struyf et al., 2017), as well as associated with the decreased subacromial space (Bak, 2010). The swimming stroke may also relate to the cause of increased tendon thickness because the supraspinatus tendon has an increased chance of impingement due to arm positions during the freestyle stroke . ...
Objective:
To characterize disabled swimmers in comparison to an able-bodied swimmers for (1) supraspinatus tendon thickness, (2) subacromial space and (3) occupation ratio.
Design:
Cross-Sectional Study.
Setting:
Research laboratory.
Participants
Disabled swimmers with upper (DSw-Upper) (n=8) and lower (DSw-Lower) (n=7) extremity disorders. The DSw-Upper were classified in sports class S7-S8, while DSw-Lower in S9-S10. The control group had 15 able-bodied swimmers.
Main outcome measures
Ultrasound images of (1) supraspinatus tendon in short axis and long axis, (2) subacromial space, and (3) occupation ratio.
Results
A thicker supraspinatus tendon in short axis was observed in DSw-Upper versus C-Sw (p=0.012) and DSw-Upper versus DSw-Lower (p=0.018); and in long axis for DSw-Upper versus CSw (p=0.0001), and DSw-Upper versus DSw-Lower (p=0.002). There was a greater occupation ratio in DSw-Upper versus DSw-Lower in short axis (p=0.013) and long axis (p=0.035).
Conclusions
The present study showed a thicker supraspinatus tendon and greater occupation ratio with the tendon occupying more of the subacromial space that may predispose upper extremity disabled swimmers to tendon disorders such as subacromial impingement syndrome. Ultrasound examination can be used to assess shoulder tendon characteristics and the relationship to the subacromial space, to determine potential for injury and training load monitoring.
... Researchers approach the relationship between competitive swimming and shoulder pain from many different angles [25,26]. In our questionnaire survey, we likewise attempted to collect comprehensive relevant information about shoulder pain. ...
Purpose
The training load required at elite level can lead to shoulder pain even among the youngest swimmers, thus, besides modern water training plans and swimming technique development, the planning of dryland training with a preventive approach is of the utmost importance. The aim of the present study was to map kinetic patterns and sports injury risk factors among young competitive swimmers (between 9 and 12 years of age) and to investigate the effectiveness of a complex injury prevention programme on dry land.
Materials and methods
A total of 37 swimmers (19 girls and 18 boys, aged 10.8 ± 1 yrs) participated in the research. We performed a physical examination using the PostureScreen11.1 application, a digital goniometer, a manual dynamometer, and functional and diagnostic orthopaedic tests. The swimmers were divided into a trained group and a control group. A three-month complex injury prevention programme was developed for the trained group. We analysed our data using Statistica for Windows.
Results
We found that 19% of the swimmers had experienced shoulder pain since starting swimming. We also found several postural faults, a reduction in the rotational arc of motion in the shoulder joint, rotational muscle imbalance, serratus anterior weakness, and scapular dyskinesia. Following the programme, swimmers in the trained group showed significant improvement in the rotational arc of the shoulder joint, internal rotational range of motion, rotational muscle strength, and upper limb stability. Progress was also made in many other areas, although these results were not significant.
Conclusions
As shoulder pain and its risk factors can be observed even among the youngest competitors, a dryland training plan tailored to this group can reduce the occurrence of sports injuries.
... Altered scapular muscle activity and kinematics were related to shoulder pain, such as subacromial impingement (Ludewig & Cook, 2000;Ludewig & Reynolds, 2009). Scapular dyskinesis (SD) was defined as altered scapular kinematics caused by scapular muscle dysfunction and has been reported to be more common in patients with subacromial impingement syndrome and overhead athletes (Bak, 2010;Hickey et al., 2018;Kibler & Sciascia, 2010). Hickey et al. reported that SD increases the risk of shoulder pain, including subacromial impingement syndrome (Hickey et al., 2018). ...
Scapular dyskinesis (SD) indicates dysfunction of the scapular muscle activity during the arm elevation, resulting in altered scapular kinematics. This study examined whether SD alters scapular muscle activity and kinematics during swim stroke motion. Seventeen swimmers (mean age: 13 ± 1 years) were divided into SD (n = 8) and control (n = 9) groups. Scapular muscle activity (the upper, middle, and lower trapezius and the serratus anterior muscle) and kinematics data were collected and time-normalised (0–100%) during swim stroke motion by swim-bench on land. Scapular kinematics were calculated for upward rotation, internal rotation, posterior tilt, and arm elevation angles. To compare patterns of muscle activity and kinematics with and without SD, statistical parametric mapping unpaired t-test was used. The scapular upward rotation angle was decreased in SD compared to control in the 0–10% of the swim stroke phase (p = 0.041, t* = 3.018), and the internal rotation angle was increased in 0–15% of the phase (p = 0.033, t* = 2.994). Scapular posterior tilt and muscle activity showed no significant differences. These results suggested that SD altered scapular upward rotation and internal rotation at the initial phase of the swim stroke motion in adolescent swimmers and might potentially provoke a risk of subacromial impingement.
... In so-called "overhead athletes," which include swimmers, injuries to this joint complex have a high prevalence (Gaunt and Mafulli, 2012;Wanivenhaus et al., 2012). However, the incidence of shoulder pain in swimmers is around 38%, with between 29% and 91% of swimmers having experienced this symptom during their sporting career (Bak, 2010). This could be explained by the fact that in water, propulsion is based on the upper limbs, in contrast to land sports where the lower limbs are predominantly used (Sein et al., 2010). ...
Background: During the repetitive execution of the swimming strokes, the muscles responsible for the internal rotations of the shoulders tend to become stronger compared to the muscles that oppose these movements. The aim of this study was to analyse the effect of a strengthening program for the shoulder rotator muscles using elastic band exercises in a diagonal Kabat pattern (D2 for flexion) in swimmers, to develop an effective, quick and easy-to-implement protocol for preventive training routines.
Methods: A randomized controlled trial design was carried out. Internal and external rotation range of movement, isometric strength of the muscles responsible for internal and external rotation of the shoulder, scapular movements, was measured at the beginning of the study and after 8 weeks post-intervention. A total of 22 male swimmers participated in the study and were randomly assigned to either an experimental group ( n = 11) or a control group ( n = 11). The experimental group underwent a 8-week shoulder-strength program using elastic bands, while the control group focused on aquatic training.
Results: The strength-training program resulted in an improvement in the isometric strength of the muscles responsible for external rotation and a better balance between the shoulder rotator muscles in the experimental group. However, these improvements have not been significant ( p > 0.05).
Conclusion: The strengthening exercise program showed minimal improvement in shoulder rotation strength and range of motion. These findings suggest that the prescribed shoulder-strengthening exercise could be a quick-beneficial dry-land training option to improve external rotation shoulder strength or range of motion, but more studies with larger sample sizes and more weeks of treatment are needed to determine the efficacy of this protocol.
... [16] Klaus Buck mentions that shoulder joint injury are still widely spread among swimmers, which may negatively affect performance levels, as these injuries stand in the way of achieving all the desired goals that swimmers and coaches alike seek to achieve in all areas of different sports competitions. [17] Yuiko Matsuura and others confirm that shoulder joint injuries rank second directly in terms of recurrence and complaints after knee joint injuries, and juniors are more susceptible to the occurrence and recurrence of shoulder joint injuries than adults, as they appear frequently and continuously in sports in which performance requires repetitive movements of the arm. Overhead swimming like a dolphin. ...
The research aims to identify the effect of Rehabilitation Exercises Program With Use of Therapeutic Massage, Electrical Stimulation to Restore the Efficiency of the Rotator Cuff Muscles of the Shoulder Joint for Dolphin Swimmers, and this is achieved through the following subobjectives: Developing the muscle strength of the muscle groups working on the shoulder joint, improving the flexibility of the shoulder joint by increasing the range of motion in the positive direction (flexion and extension), reducing the degree of pain caused by inflammation of the shoulder joint, The experimental method was used in the experimental design of one group by applying Pre and Post measurements, and the research sample was chosen intentionally from young dolphins swimming with pain in the shoulder joint in Dakahlia Governorate, and those who frequented the fitness centers At Mansoura Sports Stadium, numbering (10) juniors and their ages range from 10 Between (13-15) years old and registered in Egyptian Swimming Federation for the 2021/2022 training season, Homogeneity was performed on the research sample in the basic measurements (age, height, weight, training age, arm length, shoulder width, body mass index), as well as homogeneity in the variables of muscle strength, shoulder joint flexibility and pain degree for the sample under investigation, The most important results indicated that the rehabilitation exercise program that includes strength and flexibility training with the use of therapeutic massage and the proposed electrical stimulation led to the development of balanced muscle strength of the working (motor) and opposite (reverse) muscles near the affected shoulder joint, as well as increasing the range of motion of the shoulder joint for dolphin swimmers in It also helped reduce the sensation of pain in the affected shoulder joint, and restore the relative recovery of the rotator muscles affected by inflammation in the shoulder joint of dolphin swimmers , The researchers recommend the need to educate injured swimmers to undergo rehabilitation sports programs after injury, as it helps them to return quickly to practice specialized sports activity as soon as possible and at a level close to their level before the injury .
... It has been reported that SD exercises with electrical stimulation, performed to 120 • shoulder abduction, enhance the distance of the spine from the scapula [49]. In overhead athletes (e.g., baseball pitchers), the shoulder joint is predisposed to experience alterations in glenohumeral joint pattern, ROM deficits, and muscle weakness, leading to SD whose magnitude of impairment increases with the level of competition [50][51][52][53][54][55]. Because of the variety and rapidity of shoulder changes, overhead athletes must be constantly monitored during the competitive season [56]. ...
Scapular dyskinesis (SD) is a condition of loss of normal mobility or function of the scapula. SD is frequently observed in patients with other shoulder disorders, such as rotator cuff (RC) tears. This study evaluates the different presentations in clinical outcomes and range of motions (ROMs) in patients suffering from RC tears with and without SD. A total of 52 patients were enrolled, of which 32 patients with RC tears and SD (group A) and 20 patients with RC tears without SD (group B). Statistically significant differences between the groups in terms of clinical outcomes were identified. There were statistically significant differences in terms of flexion (p = 0.019), extension (p = 0.015), abduction (p = 0.005), and external rotation at 90° (p = 0.003) and at 0° (p = 0.025). In conclusion, this prospective study demonstrated that SD influences the clinical presentation of patients with RC tears in terms of clinical outcomes and ROMs, apart from internal rotation. Further studies will need to show whether these differences occur regardless of SD type.
... Supraspinatus tendinopatisi elit yüzücülerde sıkça görülmektedir. [20] Impingement sendromu serbest stil ve kelebek yüzenlerde daha çok görülür. [19] Bu yüzden yüzücülerde rehabilitasyonun ana amacı trapez alt ve orta parça, serratus anterior kaslarının kuvvetlendirilmesi ve pektoral kasların uzatılmasıdır. ...
... Shoulder pain is one of the most prevalent musculoskeletal symptoms presented by elite swimmers; it ranged from 40% to 91% as reported in previous studies (Bak & Faunø, 1997;Ciullo, 1986;Hawkins & Kennedy, 1980;McMaster, 1999;Rupp et al., 1995). Researchers suggested that pain could be attributed by the tremendous stress exerted on shoulders during training (Bak, 2010;Fredericson et al., 2009;Kennedy et al., 1978). As such, this kind of sports related injury were identified and the term 'swimmer shoulders' had been widely used in the past five decades (Kennedy et al., 1978). ...
Shoulder pain is common among elite swimmers due to the tremendous stress over shoulders during swimming. Supraspinatus muscle is one of the major prime movers and stabilizers of shoulder and is highly susceptible to overloading and tendinopathy. An understanding of the relationship between supraspinatus tendon and pain; and between supraspinatus tendon and strength would assist health care practitioners for developing training regime. The objectives of this study are to evaluate 1) the association between structural abnormality of supraspinatus tendon and shoulder pain and 2) the association between structural abnormality of supraspinatus tendon and shoulder strength. We hypothesized that structural abnormality of supraspinatus tendons positively associated with shoulder pain and negatively associated with shoulder muscle strength among elite swimmers. 44 elite swimmers were recruited from the Hong Kong China Swimming Association. Supraspinatus tendon condition was evaluated using diagnostic ultrasound imaging and shoulder internal and external rotation strength was evaluated by the isokinetic dynamometer. Pearson’s R was used to study the correlation between shoulder pain and supraspinatus tendon condition and to evaluate the association between isokinetic strength of shoulders and supraspinatus tendon condition. 82 shoulders had supraspinatus tendinopathy or tendon tear (93.18%). However, there was no statistically significant association between structural abnormality of supraspinatus tendon and shoulder pain. The results showed that there was no association between supraspinatus tendon abnormality and shoulder pain and there was a significant correlation between left maximal supraspinatus tendon thickness (LMSTT) and left external rotation/ concentric (LER/Con) and left external rotation/ eccentric (LER/Ecc) shoulder strength (p < 0.05) while internal rotation/ external rotation (IR/ER) ratio can also be a significant predicator on LMSTT >6mm (R2 = 0.462, F = 7.016, df = 1, p = 0.038). Structural change of supraspinatus tendon was not associated with shoulder pain, but could be a predictor on MSTT >6mm in elite swimmers.
... Studies on SS and related factors were frequently retrospective, with previous research reporting reduced endurance, lack of coordination or weakness of shoulder muscles, lack of scapular stability, poor posture, lack of trunk stability, and changes in shoulder and spinal mobility [11][12][13][14] . ...
This study aimed to investigate whether muscle coordination differs between swimmers with and without a history of swimmer's shoulder (SS). Muscle synergies, which can assess muscle coordination, in young elite male swimmers were analyzed using surface electromyography (EMG). Twenty elite swimmers who swam the butterfly stroke were included in this study (SS n=8; control n=12). Four muscle synergies in both groups were identified. Synergy #1, which is involved in the early pull, and Synergy #3, which is involved in the early recovery, were shown to be different synergies in both groups. In the SS group, the contribution of the internal oblique, external oblique, and rectus abdominis, which are involved in stabilizing the trunk, was low during the early pull. In the early recovery, the SS group had lower contributions of the serratus anterior, upper trapezius, and lower trapezius involved in stabilizing the shoulder girdle, and a lower contribution of the erector spinae presenting in the control group. In the rehabilitation is desirable to introduce exercises to obtain coordination of the upper limb and abdominal muscles in the early pull phase, and coordination of the periscapular muscles and erector spinae in the early recovery phase.
... In swimming and water polo, the movement structures are similar, thus injuries of the spine, shoulder joint, and knee joint are common. According to some authors, the most common injury in swimmers is a shoulder injury [1,2], which occurs in 40-91% of cases [3]. Knee injuries are the second most common in swimming [4]. ...
Study aim : This study aimed to determine the knowledge and skills of swimming coaches in providing first aid and cardiopulmonary resuscitation (CPR).
Material and methods : The sample consisted of 59 swimming coaches who responded to non-standardized questionnaire. The collected data were processed by the statistical program IBM SPSS (20.0), using the Chi-square test with cross-tabulation, with a level of statistical significance p ≤ 0.05.
Results : Obtained data showed a statistically significant difference in the knowledge of swimming coaches about first aid and CPR in relation to coaching experience (p = 0.025); in the knowledge of providing first aid and CPR between coaches who have a certificate of first aid and CPR and those who do not (p = 0.006) and in first aid and CPR knowledge between coaches who have renewed their first aid and CPR knowledge and those who did not (p = 0.045).
Conclusion : Based on the findings of the present study, swimming coaches included in this research did not have enough knowledge and skills in first aid and CPR, which makes swimming programs unsafe. By obliging swimming coaches to acquire and constantly improve their knowledge and skills in first aid and CPR, the environment for all swimming programs would become safer.
... Numerous authors (Ramsi et al, 2004;Walker et al, 2012;Batalha et al, 2013Batalha et al, , 2015aBatalha et al, , 2015bGaudet et al, 2018) indicate that swimming techniques may be the cause of shoulder muscle strength misalignment and advocate the introduction of compensatory programmes, due to the disruption of the agonist/antagonist ratio. The literature (Richardson et al, 1980;McMaster and Troup, 1993;Weldon and Richardson, 2001;Blanch, 2004;Wolf et al, 2009;Bak, 2010;Habechian et al, 2018) cites rotator cuff strength imbalance as one of the risk factors for shoulder injury in swimmers. ...
Strength training is an important part of the preparation of competitive athletes. The subject of interest of the scientists connected of sports swimming was the level of strength ability of the competitors practising this sport and the influence of this ability on the final sports result. The purpose of this review is to describe and consider the impact of strength training of the shoulder muscles in sports swimming. A literature review was conducted in Embase, Medline PubMed, DOAJ, EBSCO and Google databases. Basic search terms are: training in sports swimming, strength tests, evaluation of muscle properties, rotation of the arm, strength measurement methods. Results: 235 results were found and 148 professional publications were selected and analysed. A thorough review of scientific publications indicates that strength parameters of the shoulder girdle muscles played a very important role on the sports performance of swimmers. The programmes combining swim training with 'on land' strength improvement or electrical stimulation are more effective than swim training alone. Significant fatigue of the rotator muscles can impair shoulder stability and result in injury. Increased strength in the internal rotation movement may result pathological conditions of the shoulder.
... The shoulders and upper extremities represented nearly 90% of the propulsive power for all main swim ming strokes [1]. Shoulder adduction, internal rotation (IR), and extension movements were relevant and highly reproduced in the swimming technique dur ing the propulsive phases of different strokes [2,3]. Adult (23.1 ± 3.5 years old) elite swimmers had higher maximal isometric strength of the shoulder flexion, extension, abduction, and adduction muscles, and larger lean mass of both arms measured by using dualen ergy Xray absorptiometry in comparison with recrea tional adult swimmers aged 20.8 ± 2.1 years [4]. ...
Purpose
The aim of our study was to evaluate shoulder joint flexibility, shoulder muscle peak isometric force, and submaximal force differentiation ability after warm-up exercises, as well as to compare the peak isometric force and submaximal force differentiation ability before and after a 4.5-km free-style swimming trial in swimmers and triathletes.
Methods
Overall, 15 qualified young male swimmers, 15 triathletes, and 14 controls participated. Their shoulder active range of motion (ROM) in internal rotation (IR), external rotation, flexion, extension, abduction were measured. The peak force and the ability to reproduce the submaximal forces of IR and extension muscles were compared before and after 4.5-km free-style swimming in aerobic regimen.
Results
Swimmers and triathletes presented larger ROM in flexion and abduction in both arms, and in IR in the non-dominant shoulder than controls. IR and extension muscle isometric peak forces were higher in swimmers and triathletes compared with controls. Strength side asymmetry was not observed in any group. Only triathletes’ IR force was higher in the dominant than in the non-dominant shoulder. The submaximal force reproduction error did not differ among the groups. The peak forces and submaximal force reproduction errors did not change after the 4.5-km swim but caused IR and extension muscles peak force side asymmetry, with stronger muscles in the dominant shoulder.
Conclusions
Free-style swimming at 4.5 km in aerobic regimen induced shoulder IR and extension muscle peak force side asymmetry without any decrease of their absolute values or significant worsening in the submaximal force reproduction error.
... Manual, counter stabilization of the scapula to the anterior humeral movement was not possible which caused some difficulty in determining an end point of translation. Given that excessive anterior laxity is commonly described in MDI, 32 future studies should consider different positioning to allow for scapular stabilization to determine if there is increased anterior laxity in this population. This study used unique methods to classify participants with distinct clinical features of MDI to determine if this would yield evidence of biomechanical differences as well. ...
Background
Clinical laxity tests are commonly used together to identify individuals with multidirectional instability (MDI). However, their biomechanical validity in distinguishing distinct biomechanical characteristics consistent with MDI has not been demonstrated.
Objective
To determine if differences in glenohumeral (GH) joint laxity exist between individuals diagnosed with multidirectional instability (MDI) and asymptomatic matched controls without MDI.
Methods
Eighteen participants (9 swimmers with MDI, 9 non-swimming asymptomatic matched controls without MDI) participated in this observational study. Participants were classified as having MDI with a composite laxity score from three laxity tests (anterior/posterior drawer and sulcus tests). Single plane dynamic fluoroscopy captured joint motion with 2D-3D joint registration to derive 3D joint kinematics. Average GH translations occurring during the laxity tests were compared between groups using an independent sample's t-test. The relationship of composite laxity scores to overall translations were examined with a simple linear regression. Differences of each laxity test translations between groups was analyzed with a two-way repeated measures ANOVA.
Results
Mean composite translations for swimmers were 1.7 mm greater (p = 0.04, 95% Confidence Interval (CI): 0.1, 3.3 mm) compared to controls. A moderate association occurred (r² = 0.40, p = 0.005) between composite laxity scores and composite translation. Greater translations for the posterior drawer (-2.4 mm, p = 0.04, 95% CI: -0.1, -4.6) and sulcus tests (-2.7 mm, p = 0.03, 95% CI: -0.3, -5.0) existed in swimmers compared to controls.
Conclusion
Significant differences in composite translation existed between symptomatic swimmers with MDI and asymptomatic control participants without MDI during GH joint laxity tests. The results provide initial biomechanically based construct validity for the clinical criteria used to identify individuals with MDI.
... It has been reported that fatigue due to swimming training can restrict range of movement (ROM) of the shoulder 6) . Restricted shoulder ROM, including scapular dyskinesis, in swimmers causes shoulder pain and associated dysfunctions, such as subacromial impingement, labral damage, os acromiale, and suprascapular nerve entrapment 7,8) . ...
[Purpose] The physical functions related to swimming should be evaluated to enhance competitive performance and prevent sports injuries. This study aimed to determine the physique, range of motion, and gross muscle strength of the limbs among hemiplegic para swimmers. [Participants and Methods] Three male para swimmers with hemiplegia and five male para swimmers with impaired vision were included in the study. The limb circumference, range of motion, quadriceps flexibility, and gross muscle strength were evaluated. The hemiplegic swimmers and swimmers with impaired vision were compared using an unpaired t-test. [Results] The maximum values of the upper and forearm circumferences; the range of motion for shoulder flexion, external rotation, ankle dorsiflexion on the paretic side; and the single-leg sit-to-stand test of the dominant limb were significantly lower in hemiplegic swimmers than in swimmers with impaired vision. [Conclusion] Hemiplegic swimmers had decreased upper limb circumferences on the paretic limb; the range of motion for shoulder flexion, external rotation, and ankle dorsiflexion on the paretic limb; and muscle strength on the dominant lower limb.
... competitive swimming and the typical nature of injuries reported in men's swimming, it is unsurprising that the 3 most reported specific injuries were in fact biceps tendonitis (shoulder), shoulder impingement, and rotator cuff tendinitis. 17,18 It is important to note that swimming athletes may also experience concomitant shoulder injuries due to the multifactorial etiology (strength imbalances, glenohumeral joint laxity, scapular dyskinesia) of overuse shoulder pain. [18][19][20] On the basis of the existing literature surrounding the prevalence of shoulder injury, 13 the necessary stress and strain on the shoulder to be competitive-and the difficulty in implementing injury prevention programs for a multifactorial injury that is often overuse-may involve multiple anatomical structures and involve individualized muscular imbalances and form variations. ...
Context:
The National Collegiate Athletic Association (NCAA) has sponsored men's swimming and diving since 1937.
Background:
Routine examinations of men's swimming and diving injuries are important for identifying emerging injury-related patterns.
Methods:
Exposure and injury data collected in the NCAA Injury Surveillance Program during the 2014-2015 through 2018-2019 academic years were analyzed. Injury counts, rates, and proportions were used to describe injury characteristics, and injury rate ratios were used to examine differences in injury rates.
Results:
The overall injury rate was 1.56 per 1000 athlete-exposures (AEs) for swimmers and 1.52 per 1000 AEs for divers. Shoulder (27.0%) injuries accounted for the largest proportion of all swimming injuries, and most injuries were attributed to overuse mechanisms (42.6%). Shoulder (23.3%) and trunk (23.3%) injuries accounted for the largest proportion of all diving injuries, and most injuries resulted from surface contact (32.6%).
Conclusions:
Findings were consistent with existing literature on swimming and diving. The need for continued surveillance, coupled with more robust participation by swimming and diving programs was also highlighted.
... A precise assessment of the role that each individual joint has in the full shoulder ROM is something that is rarely done in the typical busy clinical setting [17]. The main exception is glenohumeral internal rotation in subjects with GIRD, a problem that affects overhead athletes such as swimmers [3,7,23] and tennis [7,8,23] players; in these subjects an imbalance between glenohumeral internal and external rotation causes symptoms and a precise assessment of isolated GH-ROM is needed. In other problems, such as adhesive capsulitis in which the glenohumeral joint is selectively affected, a precise measurement of the isolated GH-ROM could be useful, as it is well-recognized that subjects with adhesive capsulitis use their scapulothoracic joint to compensate for GH-ROM loss, making precise assessment of the clinical course of the disease difficult, as an improvement in FS-ROM could be attributed to progressive healing of the capsular problem but it might also be due to increased scapulothoracic compensation. ...
Purpose
To evaluate the intra and interobserver reproducibility of a new goniometric method for evaluating the isolated passive range of motion of the glenohumeral joint in an outpatient setting.
Methods
This is a prospective observational study on healthy subjects. The Glenohumeral ROM Assessment with Scapular Pinch (GRASP) method is a new method for assessing the isolated range of motion (ROM) of the glenohumeral joint (GH) by a single examiner with a clinical goniometer. It measures the isolated glenohumeral passive abduction (GH-AB), passive external rotation (GH-ER) and internal rotation (GH-IR) with the arm at 45º of abduction.
These three GH ROM parameters were measured in both shoulders of 30 healthy volunteers (15 males/15 females, mean age:41.6[SD = 10.3] years). The full shoulder passive abduction, passive external rotation and internal rotation 45º of abduction were measured by the same examiners with a goniometer for comparison. One examiner made two evaluations and a second examiner made a third one. The primary outcome was the intra- and interobserver reproducibility of the measurements assessed with intraclass correlation coefficients (ICC) and the Bland–Altman plot.
Results
The intra-observer ICC for isolated glenohumeral ROM were: 0.84 ± 0.07 for GH-ABD, 0.63 ± 0.09 for GH-ER, and 0.61 ± 0.14 for GH-IR. The inter-observer ICC for isolated glenohumeral ROM were: 0.86 ± 0.06 for GH-ABD, 0.68 ± 0.12 for GH-ER, and 0.62 ± 0.14 for GH-IR. These results were similar to those obtained for full shoulder ROM assessment with a goniometer.
Conclusion
The GRASP method is reproducible for quick assessment of isolated glenohumeral ROM.
Level of evidence
III
... The main risk factor for shoulder injuries is the repetitive cyclical movement of the glenohumeral joint, with a positive correlation with training time and distance 12 . Likewise, these repetitive and continuous movements generate great fatigue 3 and friction between the different structures of the joint that leads to inflammation and pain 50 . As such, the fatigue caused in the agonist musculature may cause a biomechanical alteration in the movement of the shoulder that can trigger an injury 3,12 . ...
Objective
To carry out a systematic review to update the scientific evidence on the incidence and prevalence of injuries in the swimming discipline, as well as the location, type and mechanism of the injuries, and to assess whether studies are meeting methodological recommendations for data collection and injury surveillance.
Literature Survey
The databases of Pubmed and Sportdiscus were used to search for studies that describe the epidemiology of injuries in adult swimmers between 2010 to March 2020.
Methodology
Of the 864 articles identified, 14 studies were finally included in this review. The methodological quality of the studies was analysed with the Strobe scale and PRISMA guidelines were followed.
Synthesis
The results showed a high prevalence of shoulder, knee and lower back injuries among swimmers due to overuse. These injuries were mainly short‐term tendon‐muscles, there were reported data differences between genders.
Conclusions
Despite the publication of an injury surveillance single and multi‐sport events document and a consensus on data collection and injury surveillance in swimming, there are huge methodological limitations that do not allow firm conclusions. As such, more epidemiological studies following guidelines for data collection and injury surveillance are needed to establish differences by gender, age group, and swimming stroke.
... Several studies have suggested strengthening exercises for scapular and posterior cuff muscles and stretching for pectoral muscles to address the muscle imbalances and flexibility deficits that have been reported to occur as a result of swim training. 1,12,15,18 In addition to dryland training, rate of distance progression is another aspect that could play a role in reducing the reported disability. The National Athletic Trainers' Association recommends that training distance should only increase by 10% each week to permit adequate tissue adaptation. ...
Background
Competitive swimmers incur shoulder pain and injury. Physical characteristics such as shoulder ROM and endurance, and tissue adaptations such as posterior capsule thickness (PCT) may be risk factors in addition to high training volume.
Hypothesis/Purpose
1) to identify the most provocative special test and prevalence of positive special tests for shoulder impingement tests in a group of collegiate swimmers, 2) to assess shoulder pain and disability, IR and external rotation (ER) and HADD ROM and posterior shoulder endurance longitudinally over a competitive collegiate season, and 3) Determine if there is a relationship between swimming yardage, supraspinatus tendon organization and posterior capsule thickness.
Methods
Thirty Division III swimmers were tested poolside at beginning (T1), middle (T2) and end (T3) of their season. Dependent variables included pain & disability, shoulder ROM, posterior shoulder endurance test (PSET), and PCT. ANOVA’s with follow-up t tests compared measures over time and Pearson correlation coefficients were performed.
Results
Despite increased swimming yardage, disability was reduced from T1 to T3 (p=.003). There was a reduction in bilateral IR and HADD ROM from T1 to T3. PSET increased on right from T1 to T3 (p=.014). There was a significant positive correlation between swimming yardage at T1 & T2 and PCT at T3 (p=.034, p=.028).
Conclusion
A loss of shoulder IR and HADD was observed across the season concurrent with less swimming related disability which may indicate a favorable adaptation. Improved PSET over the season is consistent with prior research linking endurance and less pain and disability.
... Shoulder pain is the most common complaint for competitive swimmers at any level, the prevalence of which is reported to be between 40% and 91% (Wanivenhaus et al., 2012). The term 'swimmer's shoulder' covers a spectrum of consecutive or coexisting pathologies, with rotator cuff-related pain being the most common (Bak, 2010). The specific shoulder movements involved in front crawl (i.e., freestyle) and butterfly swimming, through repetitive stress, are believed to cause impingement of the supraspinatus and biceps tendons and provide the primary mechanism for the development of rotator cuff pathology (Gaunt & Maffulli, 2012;Yanai et al., 2000). ...
Several studies have identified body roll as an important variable that affects shoulder pain due to its potential to modify upper limb kinematics. This study aimed to investigate potential differences in body roll between swimmers with and without shoulder pain. Twenty-four competitive swimmers participated in the study, 12 with unilateral shoulder pain and 12 without. Body roll was measured using two tri-axial accelerometers, one at the shoulder and one at the hip, during three trials of 100 m front crawl swimming at three different speeds. The results showed no significant difference in peak body roll angle between groups for the breathing side at the shoulders or hips. However, for the non-breathing side, swimmers with shoulder pain rolled significantly less at the hips (49º vs 57º, p = 0.018, r = 0.931) while no significant difference was found at the shoulders. These findings suggest that a potential relationship between hip rotation and shoulder pain may exist, such that hip roll is diminished to the non-breathing side in swimmers with unilateral shoulder pain. Given that a cause–effect relationship cannot be inferred from this cross-sectional study, future studies should attempt to identify the mechanisms that link body roll to the aetiology and pathomechanics of shoulder pain.
... • With a recent change in coach (and therefore likely changed training loads). • After increased use of hand paddles 12,13 . • With the use of drag increasing training devices (bags, elastic cords, dragsuits etc.). ...
Doha is hosting the 12th FINA World Swimming Championships (25 metres) this month. With the number of keen young competitive and senior recreational swimmers in Doha on the increase, it is important to focus on common swimming injuries and how they relate to training and possible technique errors. In this clinically-oriented paper, we will provide you with a practical approach to managing common shoulder injuries in swimmers. This paper is aimed at the clinician who understands injury pathology, but is without much experience or training in swimming-specific biomechanics. We'll concentrate on shoulder injury in this article and address other swimming-related injuries in a future edition. The key is an integrated, multidisciplinary approach between the clinicians and the coaching team. Don't get stuck in the maze of pathology-driven diagnoses and management approaches. Functional and technical aspects-including possible swimming technique errors-are important considerations in the management of swimming injuries. Bear in mind though that currently this approach is largely eminence (not evidence) based. Swimming is a very technical sport and swimming fast is a highly skilled activity. Similarly, swimming-related injury can be related to technique flaws. We can improve our clinical management by understanding what creates efficiency in the swimming technique and then assessing how the technique of the injured swimmer presenting in your clinic may deviate from this. Typically, most clinicians have little training in the importance of stroke technique and how it relates to performance and injury. SWIMMING AND SHOULDER INJURY Shoulder injuries are the most common injuries in swimming with a prevalence of 47 to 90% 1-3. Shoulder pain forces 10 to 31% of swimmers competing at national or international level to stop training for some time 1,3,4. A significant number of swimmers have chronic shoulder injuries; these injuries are sometimes career-threatening or even career-ending. What is the reason for the high prevalence of shoulder injuries in swimmers? There is not enough good quality research for us to be able to make any definitive statements. A history of previous shoulder injury is one of the few known risk factors for developing another shoulder injury 5 .
... The patients with adhesive capsulitis experience more pain compared to other shoulder conditions. The movements are usually restricted to a characteristic pattern with proportional greater passive loss of shoulder shoulder external rotation and abduction than any other movement 3,4 . ...
... 11 This excessive exposure to swimming has been linked to overtraining 12,13 and increases the risk of soft tissue injury, pain, and dissatisfaction. 11,[14][15][16] Shoulder pain is particularly frequent, [17][18][19] and, with prevalence rates reported as high as 91%, 15 is a major cause of missed practice. 20 Given the high prevalence of shoulder pain across the life span of the swimmer and the high levels of swim training that come with increased competitive levels, 11,21,22 practice guidelines for reducing injury are necessary. ...
Background
Competitive swimmers are exposed to enormous volumes of swim training that may overload the soft tissue structures and contribute to shoulder pain. An understanding of training factors associated with the injury is needed before practice guidelines can be developed.
Objectives
To investigate the relationship between swim-training volume and shoulder pain and to determine swim-training volume and shoulder pain prevalence across the life span of the competitive swimmer.
Data Sources
Relevant studies within PubMed, Web of Science, and MEDLINE.
Study Selection
Studies that assessed the relationship between a defined amount of swim training and shoulder pain in competitive swimmers.
Data Extraction
Twelve studies (N = 1460 participants) met the criteria. Swimmers were grouped by age for analysis: young (<15 years), adolescent (15–17 years), adult (18–22 years), and masters (23–77 years).
Data Synthesis
Adolescent swimmers showed the highest rates of shoulder pain (91.3%) compared with other age groups (range = 19.4%–70.3%). The greatest swim-training volumes were reported in adolescent (17.27 ± 5.25 h/wk) and adult (26.8 ± 4.8 h/wk) swimmers. Differences in exposure were present between swimmers with and those without shoulder pain in both the adolescent ( P = .01) and masters ( P = .02) groups. In adolescent swimmers, the weekly swim-training volume ( P < .005, P = .01) and years active in competitive swimming ( P < .01) correlated significantly with supraspinatus tendon thickness, and all swimmers with tendon thickening experienced shoulder pain.
Conclusions
Evidence suggests that swim-training volume was associated with shoulder pain in adolescent competitive swimmers (level II conclusion). Year-round monitoring of the athlete's swim training is encouraged to maintain a well-balanced program. Developing athletes should be aware of and avoid a sudden and large increase in swimming volume. However, additional high-quality studies are needed to determine cutoff values in order to make data-based decisions regarding the influence of swim training.
... Shoulder pain (SP) has been described as the most common musculoskeletal disorder in competitive swimmers (Wanivenhaus et al., 2012) causing an impact on training, competition and swimming goals (McLaine et al., 2018). In several cohort studies, SP prevalence in swimmers is high, and may range from 40 to 91% depending on the age group and definition (McMaster, 1999;Bak, 2010;Sein et al., 2010). ...
The prevalence of shoulder pain (SP) among competitive swimmers is high, and may profoundly restrict their ability to compete. This prospective cohort study investigated the association between 3 blocks of performance factors (anthropometric characteristics, sport experience and training regimen) and the presence of SP. The aims of the present study were: (a): to determine the profile of shoulder flexibility in young swimmers, (b) to analyze whether a restricted range of movement (ROM) could be a predictor of subsequent SP in young swimmers. 24 competitive young swimmers were measured in the 2016 pre-season. Measures of passive maximal shoulder extension (SE), flexion (SF), horizontal abduction (SHAB), abduction (SAB), horizontal adduction (SHADD), external (SER) and internal (SIR) rotation ROMs were taken. SP was prospectively monitored during the subsequent season using questionnaires. The data was analyzed via a binary logistic regression and ROC curves were calculated. At the follow-up, 16 swimmers (50%) had developed unilateral SP. Only reduced SHAB ROM was associated with SP [SP group 36.6° vs. pain-free group 41.5°; p = 0.005, d = -0.96 (moderate effect sizes)]. Using the coordinates of the curves, the angle of SHAB ROM that most accurately identified individuals at risk of developing SP was determined to be 39° (sensibility 0.656 and 0.375 specificity). Swimmers with limited ROM (≤39°) have 3.6 times higher risk of developing SP than swimmers with normal ROM (>39°). This study clearly shows that low range of SHAB is a risk factor for developing SP in competitive young swimmers. In the studied data, a SHAB range of 39° was found to be the most appropriate cut-off point for prognostic screening.
Adaptive water sports provide an excellent resource and opportunity for athletes with a disability with varying types and levels of impairment to participate on both the recreational and competitive stage. Through modifications and adaptations, athletes are able to navigate courses and obstacles on and in the water in a fashion similar to those of athletes without disabilities. Furthermore, it serves as a physical outlet for athletes to develop endurance, strength, and flexibility while encouraging mental growth and maturation regarding their impairments. Adaptive water sports continue to grow in interest among disabled athletes and are gaining traction within the spotlight of the competitive adaptive sporting realm.
The subscapularis muscle, which is the strongest muscle of the rotator cuff, plays important roles in shoulder biomechanics and stability. The emergence of a significant percentage of subscapular tendon tears in rotator cuff tears with advancing arthroscopic techniques has brought the importance of subscapular repair to the agenda along with different dynamics to the arthroscopic perspective. Patient training will reduce postoperative patient morbidity in addition to physical examination, imaging, and medical and surgical approaches to the treatment.
This study aimed to investigate whether muscle synergy differs between swimmers with and without swimmer's shoulder in the butterfly technique. Muscle synergies, which can assess muscle coordination, were analyzed using surface electromyography. Twenty elite swimmers were included in this study (swimmer's shoulder: n = 8; control: n = 12). The motions involved in executing the butterfly technique were classified into the early pull-through, late pull-through, and recovery phases. Muscle synergy data analyzed using the nonnegative matrix factorization method were compared between the two groups.
The swimming velocities were 1.66 ± 0.09 m・s ⁻¹ and 1.69 ± 0.06 m・s ⁻¹ for the control and swimmer's shoulder groups, respectively. Four muscle synergies in both groups were identified: synergy #1, which was involved in the early pull; synergy #2, involved in the late pull; synergy #3, involved in the early recovery; and synergy #4, involved in pre- and posthand entry. Compared to the control group, the swimmer's shoulder group had a small contribution from the pectoralis major ( p = 0.032) and a high contribution from the rectus femoris during the early pull phase ( p = 0.036). In the late pull phase, the contribution of the lower trapezius muscle in the swimmer's shoulder group was low ( p = 0.033), while the contribution of the upper trapezius muscle in the pre- and postentry phases was high ( p = 0.032). In the rehabilitation of athletes with swimmer's shoulder, it is therefore important to introduce targeted muscle rehabilitation in each phase.
Objectives
The aim of this study is to determine the prevalence of abnormal anatomical change present on MRI in elite swimmers' shoulders compared to age-matched controls.
Design
Descriptive epidemiological study.
Methods
Sixty (aged 16–36 years) elite Australian swimmers and 22 healthy active, age and gender matched controls (aged 16–34 years). All participants completed a demographic, and training load and shoulder pain questionnaire and underwent shoulder MRI. Tests for differences in the population proportion was used for comparison between swimmers dominant and non-dominant shoulders and those of the controls.
Results
Subscapularis and supraspinatus tendinopathy was the most common tendon abnormality identified in swimming participants, being reported in at least one shoulder in 48/60 (73 %) and 46/60 (70 %) swimmers, respectively. There was no significant difference between dominant and non-dominant shoulders for either tendinopathy, however, grade 3 tendinopathy was significantly more prevalent in subscapularis than in supraspinatus (P < 0.01). Compared with controls, significantly more abnormalities were reported in swimmers' shoulders in both subscapularis and supraspinatus tendons along with the labrum and acromioclavicular joint. Pathology was not a predictor of current pain.
Conclusions
This data confirms that tendon abnormality is the most common finding in elite swimmers' shoulders. Furthermore, that subscapularis tendinopathy is not only as common as supraspinatus but has a greater prevalence of grade 3 tendinopathy. With significant varied abnormalities including tendinopathy being so common in both symptomatic and asymptomatic shoulders of swimming athletes', clinicians should consider imaging findings alongside patient history, symptom presentation and clinical examination in determining their relevance in the presenting condition.
Shoulder problems are common in the female overhead athlete. Detailed information about the function of the rotator cuff and other shoulder stabilizers is documented for some, but not all, sports in which female athletes compete. There is detailed electromyographic information on the function of the rotator cuff for female swimmers, volleyball players, and the windmill pitch in women's fast pitch softball. This chapter will review what is currently known about the function of the rotator cuff in female overhead sports and the known injury patterns with respect to the rotator cuff.
While there is some information suggesting benefit to injury prevention exercises, this remains a relatively understudied area, in contrast to the literature for anterior cruciate ligament injury prevention in the female athlete.
After a review of the most recently published literature we will explain the most common injuries, the causes that produce them and treatment options in swimmers, open-water swimmers, and divers.
Context
Evidence concerning a systematic, comprehensive injury risk assessment in the elite swimming population is scarce.
Objective
To evaluate the quality of current literature regarding clinical assessment techniques used to evaluate the presence and/or development of pain/injury in elite swimmers and to categorize objective clinical assessment tools into relevant predictors (constructs) that should consistently be evaluated in injury risk screens of elite swimmers.
Data Sources
PubMed, Embase, Scopus, CINAHL, SPORTDiscus, PEDro, and the Cochrane Library Reviews were searched through September 2018.
Study Selection
Studies were included for review if they assessed a correlation between clinic-based objective measures and the presence and/or development of acute or chronic pain/injury in elite swimmers. All body regions were included. Elite swimmers were defined as National Collegiate Athletic Association, collegiate, and junior-, senior-, or national-level swimmers. Only cohort and cross-sectional studies were included (both prospective and retrospective); randomized controlled trials, expert opinion, and case reports were excluded, along with studies that focused on interventions, performance, or specific swim-stroke equipment or technology.
Study Design
Systematic review and qualitative analysis.
Level of Evidence
Level 3.
Data Extraction
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were utilized at each phase of review by 2 reviewers; a third reviewer was utilized for tie breaking purposes. Qualitative analysis was performed using the Methodological Items for Non-Randomized Studies (MINORS) assessment tool.
Results
A total of 21 studies assessed the presence and/or development of injury/pain in 3 different body regions: upper extremity, lower extremity, and spine. Calculated average MINORS scores for comparative (n = 17) and noncomparative (n = 4) studies were 18.1 of 24 and 10.5 of 16, respectively. Modifiable, objectively measurable injury risk factors in elite swimmers were categorized into 4 constructs: (1) strength/endurance, (2) mobility, (3) static/dynamic posture, and (4) patient-report regardless of body region.
Conclusion
Limited evidence exists to draw specific correlations between identified clinical objective measures and the development of pain and/or injury in elite swimmers.
Objectives
This study aimed to clarify the trends of injury occurrence in the Japan national swim team for 15 years and to evaluate the effectiveness of the lumbar injury prevention project. It also aimed to verify the incidence of swimming-related injuries among swimmers by sex, age and swimming style.
Methods
The target group comprised 488 swimmers who participated in the Olympics, Asian Games and Universiade from 2002 to 2016; we compiled data for the total number of injuries in each body part. The lumbar injury prevention project started in 2008 and included two components (deep trunk muscle exercises and evaluation of lumbar disc degeneration using MRI). We analysed the prevalence of lumbar injury before (2002–2008) and after (2009–2016) implementation of the lumbar injury prevention project by χ ² test. We compared age, sex and swim strokes between the injured and non-injured groups by χ ² test and unpaired t-test.
Results
The most common injury site was the lower back, followed by the shoulder and knee. The lumbar injury prevalence was significantly lower after implementation of the prevention project (23.5% vs 14.8%; p<0.05). Shoulder injuries were common in backstroke swimmers. The injury rate was significantly higher in female than in male swimmers. The injured group was significantly older than the non-injured group.
Conclusions
Lumbar injury prevention intervention might be effective to prevent lower back injury in swimmers. Injury risk factors included female and old age; younger female athletes should prevent the development of injuries as they mature.
Shoulder pain in Masters swimmers can be due to technical or training errors. The swimmer presenting with shoulder pain should undergo a thorough interview and clinical examination. Pain location may point to one of the four common pain syndromes. Clinical examination should include assessment of dysfunctions of the scapula-thoracic joint and the kinetic chain since this may play a major role in etiology and, therefore, in the intervention and subsequent preventive exercise programme. Interpretation of imaging diagnostics should be done with care. Most cases resolve with nonoperative intervention focusing on scapular and kinetic chain dysfunctions. At least four different clinical entities exist that can lead to shoulder pain in swimmers. When nonoperative treatment fails, arthroscopic treatment directed towards the structural pathology should be considered. In most cases a peel back or a SLAP lesion is present, and a biceps tenodesis seems to have a better prognosis for full return to sports than anatomic repair.
Although swimming is a whole-body activity, shoulder problems can be quite common in competitive swimmers. The propulsion for swimming comes largely from the upper body but the lower body and trunk play an important supporting role. The swimming shoulder kinetic chain (SSKC) describes the generation of swimming propulsion using the whole body. Effective swimmers will use the SSKC in their stroke, so effective strength and conditioning programs should also include the SSKC. A series of swim-specific exercises utilising the SSKC are presented that focus on the shoulder but can form the basis of a whole-body swimming strength and conditioning program.
Swimmers have a significant potential for shoulder injuries due to the unique nature of the different strokes involved in swimming as well as the high volume of repetitions needed during training. Swimmer’s shoulder is a term that can represent numerous shoulder pathologies. These include impingement syndrome, rotator cuff tendinitis, labral injuries, instability secondary to ligamentous laxity or muscle imbalance/dysfunction, neuropathy from nerve entrapment, and anatomic variants. In order for the athlete to return to the sport in an appropriate and timely manner, the clinician must be able to differentiate between these different etiologies.
“Swimmer’s shoulder” is a blanket term describing shoulder pain in competitive swimmers which commonly arise from microtraumas due to overuse, fatigue, and/or poor stroke mechanics. The differential diagnosis of shoulder pain in swimmers includes subacromial impingement, rotator cuff tendinopathy, labral pathology, suprascapular nerve entrapment, or any combination thereof. Additionally, injury may be accompanied or exacerbated by structural abnormalities including scapular dyskinesis, glenohumeral hyperlaxity, excess subluxation, glenohumeral internal rotation deficit (GIRD), or muscle strength imbalances. Given this multifactorial etiology, it is imperative that coaches and clinicians be well-versed in the prevention, diagnosis, and appropriate operative and non-operative management of the various shoulder pathologies possible in competitive swimmers.
Background and Aims: The ability to anticipate the injury is as important as its assessment and treatment; thus, it is recommended to include the analysis of performance in pre-season screening tests. Using the functional assessment prior to participating in the event could be reducing the incidence of injury and act as a preventive factor. One of the vulnerable regions of the body is shoulder and the method for assessing upper extremity and shoulder is using shoulder functional assessment test. The aim of the present study was to compare the scores of shoulder screening test between overhead and non-overhead athletes. Materials and Methods: Participants were 100 girl athletes (with the age range 15-25 years) who volunteered to participate. The participants included overhead (volleyball) and non-overhead (futsal) athletes. Both groups of athletes were assessed using shoulder functional tests (Howe, 2015). Each item of the test was measured three times and the average was considered as an ultimate score. Also, participants' forward head and round shoulder was measured using the photogrametry. Independent T-test and k-squared test were used for data analyses. Significant level was set at 0.05. Results: T-test showed a significant difference between functional scores obtained from volleyball players and those of futsal players (p₌0.003). However, the results of k-squared test showed significant differences in pectoralis minor and levator scapula muscles length test. Also, the results showed that the futsal players had more dysfunction compared with volleyball players. Conclusion: Upper quarter screening in pre-season trainings can be an appropriate guide for the trainer for diagnosis and correction of athletic movement disorders. In the current study, the results of screening test between futsal and volleyball groups indicates weakness in both of them, but the group that has more forward head and shoulder disorder (futsal) had weaker performance. It is therefore concluded that in shoulder function, the presence of abnormalities with high intensity is probably more important than the type of sport.
Despite the recognized importance of proper 3-dimensional motion of the scapula in throwers, minimal research has quantified scapular position and orientation in throwing athletes.
Throwing athletes exhibit scapular position and orientation differences when compared to nonthrowing control subjects.
Descriptive laboratory study.
Scapular position and orientation during scapular plane humeral elevation were assessed with electromagnetic tracking in a group of 21 throwing athletes and 21 control subjects. Scapular upward/downward rotation, internal/external rotation, anterior/posterior tipping, elevation/depression, and protraction/retraction were assessed.
The throwing athletes demonstrated significantly increased upward rotation, internal rotation, and retraction of the scapula during humeral elevation. No differences in anterior/posterior tipping and elevation/depression were present.
The results indicate that throwing athletes have scapular position and orientation differences compared to non-throwing athletes. This suggests that throwers develop chronic adaptation for more efficient performance of the throwing motion.
Clinicians evaluate scapular position, orientation, and movement in throwing athletes as part of the evaluation of shoulder injuries associated with the throwing motion. The current study provides clinicians with an understanding of the types of adaptations that may be observed in normal, healthy throwing athletes.
Alterations in glenohumeral range of motion, including increased posterior shoulder tightness and glenohumeral internal rotation deficit that exceeds the accompanying external rotation gain, are suggested contributors to throwing-related shoulder injuries such as pathologic internal impingement. Yet these contributors have not been identified in throwers with internal impingement.
Throwers with pathologic internal impingement will exhibit significantly increased posterior shoulder tightness and glenohumeral internal rotation deficit without significantly increased external rotation gain.
Case control study; Level of evidence, 3.
Eleven throwing athletes with pathologic internal impingement diagnosed using both clinical examination and a magnetic resonance arthrogram were demographically matched with 11 control throwers who had no history of upper extremity injury. Passive glenohumeral internal and external rotation were measured bilaterally with standard goniometry at 90 degrees of humeral abduction and elbow flexion. Bilateral differences in glenohumeral range of motion were used to calculate glenohumeral internal rotation deficit and external rotation gain. Posterior shoulder tightness was quantified as the bilateral difference in passive shoulder horizontal adduction with the scapula retracted and the shoulder at 90 degrees of elevation. Comparisons were made between groups with dependent t tests (P < .05).
The throwing athletes with internal impingement demonstrated significantly greater glenohumeral internal rotation deficit (P = .03) and posterior shoulder tightness (P = .03) compared with the control subjects. No significant differences were observed in external rotation gain between groups (P = .16).
These findings could indicate that a tightening of the posterior elements of the shoulder (capsule, rotator cuff) may contribute to impingement. The results suggest that management should include stretching to restore flexibility to the posterior shoulder.
The importance of function of the central core of the body for stabilisation and force generation in all sports activities is being increasingly recognised. ‘Core stability’ is seen as being pivotal for efficient biomechanical function to maximise force generation and minimise joint loads in all types of activities ranging from running to throwing. However, there is less clarity about what exactly constitutes ‘the core’, either anatomically or physiologically, and physical evaluation of core function is also variable.
‘Core stability’ is defined as the ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment in integrated athletic activities. Core muscle activity is best understood as the pre-programmed integration of local, single-joint muscles and multi-joint muscles to provide stability and produce motion. This results in proximal stability for distal mobility, a proximal to distal patterning of generation of force, and the creation of interactive moments that move and protect distal joints. Evaluation of the core should be dynamic, and include evaluation of the specific functions (trunk control over the planted leg) and directions of motions (three-planar activity). Rehabilitation should include the restoring of the core itself, but also include the core as the base for extremity function.
Shoulder pain in elite swimmers is common, and its pathogenesis is uncertain. HYPOTHESIS/STUDY DESIGN: The authors used a cross-sectional study design to test Jobe's hypothesis that repetitive forceful swimming leads to shoulder laxity, which in turn leads to impingement pain.
Eighty young elite swimmers (13-25 years of age) completed questionnaires on their swimming training, pain and shoulder function. They were given a standardised clinical shoulder examination, and tested for glenohumeral joint laxity using a non-invasive electronic laxometer. 52/80 swimmers also attended for shoulder MRI.
73/80 (91%) swimmers reported shoulder pain. Most (84%) had a positive impingement sign, and 69% of those examined with MRI had supraspinatus tendinopathy. The impingement sign and MRI-determined supraspinatus tendinopathy correlated strongly (r(s)=0.49, p<0.00001). Increased tendon thickness correlated with supraspinatus tendinopathy (r(s)=0.37, p<0.01). Laxity correlated weakly with impingement pain (r(s)=0.23, p<0.05) and was not associated with supraspinatus tendinopathy (r(s)=0.14, p=0.32). The number of hours swum/week (r(s)=0.39, p<0.005) and weekly mileage (r(s)=0.34, p=0.01) both correlated significantly with supraspinatus tendinopathy. Swimming stroke preference did not.
These data indicate: (1) supraspinatus tendinopathy is the major cause of shoulder pain in elite swimmers; (2) this tendinopathy is induced by large amounts of swimming training; and (3) shoulder laxity per se has only a minimal association with shoulder impingement in elite swimmers. These findings are consistent with animal and tissue culture findings which support an alternate hypothesis: the intensity and duration of load to tendon fibres and cells cause tendinopathy, impingement and shoulder pain.
Restoration of control of dynamic scapular motion by specific activation of the serratus anterior and lower trapezius muscles is an important part of functional rehabilitation. This study evaluated activation of those muscles in specific exercises.
Specific exercises will activate key scapular-stabilizing muscles in clinically significant amplitudes and patterns.
Controlled laboratory study.
Muscle activation amplitudes and patterns were evaluated in the serratus anterior, upper trapezius, lower trapezius, anterior deltoid, and posterior deltoid muscles with electromyography in symptomatic (n = 18) and asymptomatic (n = 21) subjects as they executed the low row, inferior glide, lawnmower, and robbery exercises.
There were no significant differences in muscle activation amplitude between groups. Muscle activation was moderate across all of the exercises and varied slightly with the specific exercise. The serratus anterior and lower trapezius were activated between 15% and 30% in all exercises. Upper trapezius activation was high (21%-36%) in the dynamic exercises (lawnmower and robbery). Serratus anterior was activated first in the low row and last in the lawnmower and robbery. The upper trapezius and lower trapezius were activated first in the lawnmower and robbery.
These specific exercises activate key scapular-stabilizing muscles at amplitudes that are known to increase muscle strength.
These exercises can be used as part of a comprehensive rehabilitation program for restoration of shoulder function. They activate the serratus anterior and lower trapezius-key muscles in dynamic shoulder control-while variably activating the upper trapezius. Activation patterns depended on scapular position resulting in variability of amplitude and activation sequencing between exercises. Inferior glide and low row can be performed early in rehabilitation because of their limited range of motion, while lawnmower and robbery, which require larger movements, can be instituted later in the sequence.
The shoulder is the joint most subjected to repetitive microtrauma in swimming. This results in clinical manifestations of subacromial encroachment. The anatomy, radio-graphic changes, clinical findings, and histopathology of this disease process are discussed. The role of conservative exercises used in prevention as well as the role of surgical decompression of the subacromial space is explained.
The common problem of shoulder pain in swimmers is caused by instability of the glenohumeral joint. The instability stems from demands placed on the shoulder that allow for increased performance but simultaneously reduce the humeral head's ability to remain centered in the glenoid. These demands include: 1) the beneficial effects of increased shoulder range of motion; 2) the beneficial effects of increased internal rotation and adduction strength; and 3) the beneficial effects of prolonged, fatiguing, shoulder-intensive training. Treatment is aimed at increasing stability by modifying these demands and reducing the inflammation, which can lead to scarring and perpetuation of pain.
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.
We did an anterior capsulolabral reconstruction for recurrent subluxation or dislocation of the shoulder in 75 athletes after failure of conservative therapy. Average follow-up was 39 months (range 28 to 60 months). The results were 77% excellent, 75% good, 3% fair, and 5% poor. Seventy-five percent of the professional and 100% of the college baseball players returned to their previous level of competition. Seventy-seven percent of the professional pitchers were able to return to professional pitching. The range of motion at follow-up was full in 79% of the athletes. No infections or nerve injuries occurred. The anterior capsulolabral reconstruction procedure combined with an early rehabilitation program appears to provide an improved outcome compared with previously reported procedures for anterior instability of the shoulder in athletes.
The impingement syndrome with shoulder pain is a well known problem in many sports, such as swimming. Anterior acromioplasty or only resection of the coracoacromial ligament have been used for the patients who do not respond to noninvasive therapy. In this retrospective study, the long-term results after resection of the coracoacromial ligament were evaluated. Of 30 operated patients, 25 were examined on average 4 years after surgery. Almost all were active athletes at the elite professional level (national team) or the league competitive level. Their mean age was 23 years at the time of the operation and the dominant symptom was shoulder pain on effort. At follow-up 21 (84%) were judged as excellent or good and 4 (16%) as fair or poor. Resection of the coracoacromial ligament without acromioplasty is a simple surgical procedure and a useful solution to an otherwise therapy-resistant impingement shoulder pain in athletes.
The purposes of this study were to (1) assess the inter-rater reliability and validity of 2 clinical assessment methods of categorizing scapular dyskinesis and (2) quantify the frequency of asymmetry of bilateral scapular motion in injured and uninjured shoulders by use of 3-dimensional (3D) kinematic analysis.
We evaluated 56 subjects, 35 with shoulder injury and 21 with no symptoms. Two blinded evaluators categorized the scapular motion of all subjects to determine inter-rater reliability using 2 observational methods ("yes/no" and "4 type") to evaluate scapular dyskinesis. Subjects were also instrumented with electromagnetic receivers to assess bilateral 3D scapular kinematics to determine the presence of dyskinesis and establish criterion validity of the 2 methods.
The inter-rater percent agreement and the degree of this agreement as measured by kappa statistic showed that the yes/no method produced a higher inter-rater percent agreement (79%, kappa = 0.40) than the 4-type method (61%, kappa = 0.44). The yes/no method had a higher sensitivity (76%) and positive predictive value (74%) when compared with the 3D criterion. A chi(2) analysis found significantly more multiple-plane asymmetries in symptomatic subjects (54%) in flexion compared with asymptomatic subjects (14%) (P = .002).
The yes/no method allows multiple-plane asymmetries to be considered in clinical assessment and therefore renders this a good screening tool for the presence of scapular dyskinesis. Kinematic analysis shows that asymmetries are common in symptomatic and asymptomatic populations. Testing in flexion showed a higher frequency of multiple-plane scapular asymmetries in the symptomatic group.
Identification of scapular dyskinesis is a key component of the shoulder examination. The clinician's ability to establish the presence or absence of scapular dyskinesis by observation is enhanced using a simple yes/no method especially when testing subjects in shoulder forward flexion. Although scapular asymmetries appear to be a prevalent finding, dyskinesis in the presence of shoulder symptoms should be considered a potential factor contributing to the dysfunction in the presence of shoulder symptoms should be considered a potential factor contributing to the dysfunction.
Unlabelled:
There is a growing body of literature associating abnormal scapular positions and motions, and, to a lesser degree, clavicular kinematics with a variety of shoulder pathologies. The purpose of this manuscript is to (1) review the normal kinematics of the scapula and clavicle during arm elevation, (2) review the evidence for abnormal scapular and clavicular kinematics in glenohumeral joint pathologies, (3) review potential biomechanical implications and mechanisms of these kinematic alterations, and (4) relate these biomechanical factors to considerations in the patient management process for these disorders. There is evidence of scapular kinematic alterations associated with shoulder impingement, rotator cuff tendinopathy, rotator cuff tears, glenohumeral instability, adhesive capsulitis, and stiff shoulders. There is also evidence for altered muscle activation in these patient populations, particularly, reduced serratus anterior and increased upper trapezius activation. Scapular kinematic alterations similar to those found in patient populations have been identified in subjects with a short rest length of the pectoralis minor, tight soft-tissue structures in the posterior shoulder region, excessive thoracic kyphosis, or with flexed thoracic postures. This suggests that attention to these factors is warranted in the clinical evaluation and treatment of these patients. The available evidence in clinical trials supports the use of therapeutic exercise in rehabilitating these patients, while further gains in effectiveness should continue to be pursued.
Level of evidence:
Level 5.
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.
Shoulder pain in the overhand or throwing athlete can often be traced to the stabilizing mechanisms of the glenohumeral joint. During the physical examination, signs of impingement will often be obvious, whereas subluxation signs are subtle. Use of the Apprehension Test followed by the Relocation Test has proved to be the most sensitive means of detecting occult anterior glenohumeral subluxation. When subluxation is suspected, an examination under anesthesia and orthroscopy are the most helpful next step. Patients can be classified into one of four groups on the basis of the results of the examinations. If conservative rehabilitation fails, then surgery may be considered.
The shoulder is the joint most subjected to repetitive microtrauma in swimming. This results in clinical manifestations of subacromial encroachment. The anatomy, radiographic changes, clinical findings, and histopathology of this disease process are discussed. The role of conservative exercises used in prevention as well as the role of surgical decompression of the subacromial space is explained.
The diagnosis of swimmer's shoulder has long connoted a malady usually perceived to be impingement syndrome. However, as greater understanding of shoulder mechanics and diagnosis has been applied to the shoulder of swimmers, it is apparent that they too suffer from a variety of problems common to all overhead sports. This paper describes the functional instability problem of labral damage in the swimmer. Isolated labrum damage is part of a spectrum of anterior shoulder problems. This lesion is particularly disturbing to the swimmer, and its successful management through arthroscopic means is a boon. Correct diagnosis is paramount if a treatment is to be successful. The lesion in swimmers is described as well as its diagnosis by examination and computerized tomography (CT) arthrography.
Diagnostic and operative arthroscopies of the hip joint have been performed from an anterior approach after extension of the joint. The force needed to achieve a sufficient visualization of the hip joint was studied. In an anesthetized patient 300 Newtons (N) to 500 N was required, whereas up to 900 N was needed in an unanesthetized subject to achieve sufficient joint extension. Hip arthroscopy has been performed with a standard 5 mm Storz arthroscope. Alternatively, fluid and gas was used. It was possible to achieve good visualization of the anterior parts of the hip. Gas gave better information about the degree of degenerative arthritis while fluid was preferable for operative arthroscopy, eg, arthroscopic synovectomy. Synovial biopsies, removal of loose bodies, and partial arthroscopic synovectomy have been performed. The advantage was a very short time of rehabilitation. No serious complications occurred.
Shoulder pain caused by a impingement syndrome commonly affects an athlete's performance. Thirty-five shoulders in 33 athletes had an impingement syndrome treated by an anterior acromioplasty after failure of conservative treatment. Thirty-one of 35 shoulders (89%) were subjectively judged improved by the patients from their preoperative status. The moderate and severe pain was reduced from 97% of the shoulders preoperation to 20% postoperation. The pain at rest and with activities of daily living was reduced from 71% of the shoulders preoperation to 9% postoperation. However, only 15 of 35 operated shoulders (43%) allowed return to the same preinjury level of competitive athletics, and only four of 18 athletes involved in pitching and throwing returned to their former preinjury status. This operation is satisfactory for pain relief but does not allow an athlete to return to his former competitive status. A prolonged rehabilitation program may improve the results.
Athletes, particularly those who are involved in sporting activities requiring repetitive overhead use of the arm (for example, tennis players, swimmers, baseball pitchers, and quarterbacks), may develop a painful shoulder. This is often due to impingement in the vulnerable avascular region of the supraspinatus and biceps tendons. With the passage of time, degeneration and tears of the rotator cuff may result. Pathologically the syndrome has been classified into Stage I (edema and hemorrhage), Stage II (fibrosis and tendonitis), and Stage III (tendon degeneration, bony changes, and tendon ruptures). The impingement syndrome may be a problem for the young, active, and competitive athlete as well as the casual weekend athlete. The "impingement sign" which reproduces pain and resulting facial expression when the arm is forceably forward flexed (jamming the greater tuberosity against the anteroinferior surface of the acromion) is the most reliable physical sign in establishing the diagnosis. Flexibility exercises, strengthening programs, and special training techniques are a preventive and treatment requirement. Rest and local modalities such as ice, ultrasound, and antiinflammatory agents are usually effective to lessen the inflammatory reaction. Surgical decompression by resecting the coracoacromial ligament or a more definitive anterior acromioplasty may rarely be indicated.
The objective was to study prevalence and underlying pathology of "swimmer's shoulder". Twenty-two competitive swimmers of national "D-Kader" (elite development swimmers) were evaluated by means of questionnaire, clinical examination and isokinetic testing of external rotation and internal rotation. At the examination current interfering pain necessitating a cessation or reduction of practice was found in 5 (23%) athletes. At isokinetic testing 8 (36%) athletes complained of shoulder pain. Any history of pain was seen in 14 (64%) swimmers. A positive impingement sign was noted in 11 (50%) athletes. Apprehension sign which is indicative of anterior instability was found in 11 (50%) swimmers. Clinical equivalents of dysfunction of scapulothoracic muscles such as scapular winging (5 athletes) and shoulder protraction (12 athletes) were noted. For comparison of results of isokinetic testing a control group of non-swimmers was selected matching the group of swimmers exactly in terms of age, sex and dominant side. External rotation/internal rotation ratio of peak torque and total work at 60 deg/sec and 180 deg/sec was significantly lower in swimmers than in controls. The ratio was independent of sex, dominant side, history of pain and pain at examination. During internal rotation competitive swimmers produced significantly higher peak torques and total work than controls. There was no significant difference in external rotation. In conclusion there are several different abnormalities of function contributing to the pathology of "swimmer's shoulder":--Laxity of anterior-inferior capsuloligamentous structures with atruamatic anterior instability due to repetitive overload.--Impingement with rotator cuff tendinitis.--Muscular imbalance of the rotator cuff muscles and scapulothoracic dysfunction.
We clinically evaluated 36 competitive swimmers who had shoulder pain; the majority were women. Twenty-three swimmers had unilateral shoulder pain and 13 had bilateral pain, making a total of 49 painful shoulders. Shoulder pain had been present significantly longer in swimmers with bilateral shoulder pain (mean, 104 weeks) than in swimmers with unilateral pain (mean, 33 weeks). Twelve shoulders exhibited signs of impingement without excessive humeral head translation. In 25 shoulders, concomitant signs of impingement and increased glenohumeral translation, together with a positive apprehension sign, were found. Four swimmers, who were generally joint hypermobile, exhibited bilateral impingement signs and excessive humeral head translation, most commonly in the anteroinferior direction. Four shoulders had excessive humeral head translation and apprehension without impingement. Lack of coordination in the scapulohumeral joint was seen significantly more often in symptomatic than in asymptomatic shoulders. Hawkin's test for impingement was more sensitive than Neer's test. Swimmers with shoulder pain have variable clinical findings. The majority demonstrate signs of impingement and increased humeral head translation in the anteroinferior direction together with a positive apprehension sign. This nontraumatic instability might result from wearing of the anteroinferior capsuloligamentous complex. The different clinical findings might represent different stages of the same condition.
To evaluate differences in shoulder strength and range of motion between painful and pain-free shoulders we examined two matched groups of athletes. Fifteen competitive swimmers were allocated to two groups. Group 1 consisted of seven swimmers with unilateral shoulder pain related to swimming (Neer and Welsh phase I to II). The control group (Group 2) consisted of eight swimmers with no present or previous history of shoulder pain. Concentric and eccentric internal rotational torques were reduced in painful shoulders in between-group comparisons as well as in side-to-side comparisons. The decrease in internal rotational torque resulted in significantly greater concentric and eccentric external-to-internal rotational strength ratios of the painful shoulder in Group 1 swimmers compared with the controls. Furthermore, the functional ratio (eccentric external rotation:concentric internal rotation) was significantly greater in the painful shoulder in both between-group and side-to-side comparisons. Both groups of swimmers exhibited increased external range of motion and reduced internal range of motion compared with normalized data, but no between-group or side-to-side differences were detected. Our findings suggest that prevention or rehabilitation of swimmer's shoulder might not solely involve strengthening of the external rotators of the shoulder joint. Attention might also be drawn toward correction of a possible deficit in internal rotational strength. Changes in shoulder range of motion seem unrelated to the occurrence of shoulder pain.
Sports medicine literature often refers to "swimmer's shoulder." Increasingly, however, it is evident that swimmer's shoulder is a spectrum of maladies whose underlying origins may be incidental to athletic activity. Those dealing with the treatment of swimmers should have a thorough understanding of the differential diagnosis of the shoulder, the age range of competitive swimmers, and the effects of the aging process, and age-related disease processes and should consider the possibilities of neoplasm, degenerative diseases, and acquired processes such as arthritis or metabolic diseases.
The purpose of this study was to determine the technical causes of shoulder impingement experienced by front-crawl swimmers.
The shoulder movements exhibited during performance of the front-crawl stroke were measured using three-dimensional videography, and the instances at which each shoulder was experiencing impingement were identified.
On average, impingement occurred 24.8% of the stroke time (%ST). In one or more phases of the stroke cycle, each subject experienced impingement in some trials and not in other trials. This suggests that stroke technique, and not just anatomical differences, accounted for individual susceptibility to shoulder impingement. No significant difference was found between the mean values for %ST for slow and fast stroking speeds and for trials with and without hand paddles. Use of a unilateral breathing technique was often associated with a small magnitude of tilt angle (an effect of the scapular elevation/abduction on one side and depression/adduction on the other side) on the breathing side; in such cases a high incidence of shoulder impingement was observed for the shoulder on the ipsilateral side. Swimmers at high risk of experiencing shoulder impingement had three characteristics in their stroking techniques: (a) a large amount of internal rotation of the arm during the pull phase, (b) a late initiation of external rotation of the arm during the recovery phase, and (c) a small amount of tilt angle.
A swimmer should be able to reduce the risk of developing shoulder impingement by altering the technique to eliminate the three characteristics.
Treatment of shoulder pain includes the following: 1. Avoid all painful activities. 2. A 2-week course of nonsteroidal anti-inflammatory medication and ice. 3. Decreased anterior capsule stretching and increased posterior capsule stretching. 4. Increased rotator cuff exercise with emphasis on external rotators. 5. Scapular-positioning muscle exercises and increasing body roll. Shoulder pain can be prevented by the following: 1. Avoid all painful activities, and notify coach of shoulder pain immediately. 2. Do not use nonsteroidal anti-inflammatory medications or ice on a chronic basis. 3. Spend equal time stretching the posterior and anterior capsules. 4. Perform general rotator cuff exercises. 5. Perform scapular-positioning muscle exercises, with emphasis on body roll. [figure: see text] Shoulder pain in swimmers is common and can be debilitating. Most of the pain is caused by instability, which stems from swimming-specific demands that increase performance but decrease shoulder stability. These sport-specific demands are (1) increased shoulder range of motion, (2) increased internal rotation and adduction strength, and (3) prolonged, fatiguing, shoulder-intensive training. Instability leads to [figure: see text] inflammation and pain and can become a self-perpetuating process. Treatment consists of patient education, cessation of all activities that cause pain, activity modifications to increase shoulder stability, and pharmacologic treatment of the inflammation. In patients who do not improve using this regimen, surgery can be of benefit, either to reduce capsular laxity or to remove chronic inflammation and scar tissue. The patient must be aware of the risk of decreased performance.
PROLOGUE: Several years ago, when we began to question microinstability as the universal cause of the disabled throwing shoulder, we knew that we were questioning a sacrosanct tenet of American sports medicine. However, we were comfortable in our skepticism because we were relying on arthroscopic insights, clinical observations, and biomechanical data, thereby challenging unverified opinion with science. In so doing, we assembled a unified concept of the disabled throwing shoulder that encompassed biomechanics, pathoanatomy, kinetic chain considerations, surgical treatment, and rehabilitation. In developing this unified concept, we rejected much of the conventional wisdom of microinstability-based treatment in favor of more successful techniques (as judged by comparative outcomes) that were based on sound biomechanical concepts that had been scientifically verified. Although we have reported various components of this unified concept previously, we have been urged by many of our colleagues to publish this information together in a single reference for easy access by orthopaedic surgeons who treat overhead athletes. We are grateful to the editors of Arthroscopy for allowing us to present our view of the disabled throwing shoulder. Part I: Pathoanatomy and Biomechanics is presented in this issue. Part II: Evaluation and Treatment of SLAP Lesions in Throwers will be presented in the May-June issue. Part III: The "SICK" Scapula, Scapular Dyskinesis, the Kinetic Chain, and Rehabilitation will be presented in the July-August issue. We hope you find it thought-provoking and compelling.
The purpose of this study was to evaluate prospectively the surgical outcomes of arthroscopic repair of anterior capsulolabral lesions with use of suture anchors in a large series of patients who were followed for two to six years.
We evaluated the results of arthroscopic Bankart repair with use of suture anchors and nonabsorbable sutures in 167 patients with traumatic recurrent anterior instability of the shoulder. The mean age at the time of the operation was twenty-five years. Preoperatively and at the time of follow-up (at a mean of forty-four months), the patients were assessed with three objective outcome measurement tools (the Rowe score, the University of California at Los Angeles [UCLA] shoulder rating scale, and the American Shoulder and Elbow Surgeons [ASES] score) and two subjective measurement tools (pain and function visual analog scales). The recurrence rate, range of motion, and risk factors for postoperative recurrence were evaluated.
All shoulder scores improved after surgery (p < 0.001). According to the Rowe scale, 130 patients (78%) had an excellent score; twenty-nine (17%), a good score; six (4%), a fair score; and two (1%), a poor score. Overall, the rate of postoperative recurrence of instability was 4% (one dislocation, two subluxations, and four positive results on the anterior apprehension test). Postoperative recurrence was related to an osseous defect of >30% of the entire glenoid circumference. In the patients with recurrent postoperative instability, the episodes were less frequent than they had been preoperatively and shoulder function was related to activity level. A revision arthroscopic Bankart repair stabilized three of the four shoulders in which it was performed. One hundred and fifty-two patients (91%) returned to >/=90% of their preinjury activity level. The mean loss of external rotation (and standard deviation) was 2.0 degrees +/- 4.0 degrees.
We found that, in contrast to previous reports on the results of arthroscopic repair, arthroscopic capsulolabral repair with use of suture anchors can provide satisfactory outcomes in terms of recurrence rate, activity, and range of motion.
Although several studies have described magnetic resonance imaging findings in shoulders of asymptomatic volunteers, no such investigation has been performed on asymptomatic dominant and nondominant shoulders of elite overhead athletes.
Asymptomatic dominant shoulders of elite overhead athletes may have a higher incidence of magnetic resonance imaging abnormalities than either their nondominant shoulder or shoulders of asymptomatic volunteers.
Prospective cohort study.
Detailed magnetic resonance imaging scans of asymptomatic dominant and nondominant shoulders of elite overhead athletes were obtained. Three experienced musculoskeletal radiologists interpreted each scan for multiple variables, including rotator cuff appearance. Images from a surgical control group were intermixed to assess accuracy and control for observer bias. A 5-year follow-up interview was performed to determine whether magnetic resonance imaging abnormalities found in the initial stage of the study represented truly clinical false-positive findings or symptomatic shoulders in evolution.
Eight of 20 (40%) dominant shoulders had findings consistent with partial- or full-thickness tears of the rotator cuff as compared with none (0%) of the nondominant shoulders. Five of 20 (25%) dominant shoulders had magnetic resonance imaging evidence of Bennett's lesions compared with none (0%) of the nondominant shoulders. None of the athletes interviewed 5 years later had any subjective symptoms or had required any evaluation or treatment for shoulder-related problems during the study period.
Magnetic resonance imaging alone should not be used as a basis for operative intervention in this patient population.
To evaluate the accuracy of high-resolution ultrasonography compared to arthroscopy in the detection of rotator cuff tears.
Preoperative ultrasonography (US) with a 10-MHz commercially available linear-array transducer and a standardized study protocol was performed in 190 consecutive shoulders in 185 patients with a history of shoulder pain for more than 3 months. The findings at US were classified into intact cuff, partial-thickness, and full-thickness rotator cuff tears, and correlated with findings at shoulder arthroscopy.
US correctly depicted 118 of 124 rotator cuff tears with sensitivity 95%, specificity 94%, PPV 97%, NPV 91% and accuracy 95%, all 94 full-thickness tears (sensitivity 100%, specificity 91%, PPV 91%, NPV 100%, and accuracy 95%), 24 of 30 partial-thickness tears (sensitivity 80%, specificity 98%, PPV 86%, NPV 96%, and accuracy 95%).
US is a highly accurate diagnostic method for detecting full-thickness rotator cuff tears, but is less sensitive in detecting partial-thickness rotator cuff tears.
Physical examination of patients with shoulder injury not involving actual rotator cuff tears frequently demonstrates decreased rotator cuff strength on manual muscle testing. This decrease has been attributed to supraspinatus muscle weakness, but it may be owing to alterations in scapular position.
The position of stabilized scapular retraction, by minimizing proximal kinetic chain factors and providing a stable base of muscle origin, positively influences demonstrated supraspinatus strength.
Controlled laboratory study.
Supraspinatus strength was tested in 20 injured patients and 10 healthy controls in both the empty-can arm position and a position of scapular retraction using a handheld dynamometer. Pain in both maneuvers was measured by use of a visual analog scale.
Paired t tests indicated the scapular retraction position resulted in statistically significantly (P = .001) higher supraspinatus strength values within both groups. There was no significant difference between the 2 positions in visual analog scale scores.
This study shows that demonstrated apparent supraspinatus weakness on clinical examination in symptomatic patients may be dependent on scapular position. The weakness may be owing to other factors besides supraspinatus muscle weakness, such as a lack of a stable base in the kinetic chain or scapula.
The clinical examination that addresses scapular posture and includes scapular retraction will allow more accurate determination of absolute supraspinatus muscle strength and allow efficacious rehabilitation protocols to address the source of the demonstrated weakness.
Shoulder pain is the most common musculo-skeletal complaint in competitive swimmers. It remains one of the shoulder pain syndromes in overhead athletes where no golden standard of treatment exists. Eighteen competitive swimmers who all had undergone shoulder arthroscopy for therapy-resistant shoulder pain were retrospectively evaluated with respect to operative findings and ability to return to their sport after the operation.
The most common finding at arthroscopy was labral pathology in 11 (61%) and subacromial impingement in five shoulders (28%). Operative procedures included debridement in 11 swimmers, partial release of the coraco-acromial ligament in four, and bursectomy in four.
Sixteen (89%) responded to the follow-up evaluation. Nine swimmers (56%) were able to compete at preinjury level after 4 (2–9) months.
Findings at arthroscopy suggest that the term “Swimmer's shoulder” covers a variety of pathologies including labral wearing and subacromial impingement. Arthroscopic debridement of labral tears or bursectomy in swimmers with shoulder pain has a low success rate with regard to return to sport. Further understanding and investigation of this syndromes complex pathophysiology is needed.
The wide spectrum of shoulder instability is difficult to include in 1 classification. The distinction between traumatic, unidirectional, and atraumatic multidirectional instability is still widely used, even though this classification is not sufficiently precise to include all the different pathological findings of shoulder instability. We present "minor instability," which is a pathological condition causing a dysfunction of the glenohumeral articulation, especially in combination with microtrauma, repetitive or not, or after a period of immobilization or inactivity. When "minor shoulder instability" is suspected, the patient's history and detailed clinical examination represent the most important factors when establishing the diagnosis. In particular, the apprehension test stressing the middle glenohumeral ligament (MGHL)/labral complex in the position of midabduction and external rotation may be painful and may even reveal anterior instability or subluxation. Conventional radiographs are negative in most cases, as is magnetic resonance imaging arthrography. It is only after an accurate arthroscopic assessment that the pathological lesion can be found. The major pathological process can be identified at the level of the anterior superior labrum, in particular the MGHL complex, and appears as hyperemia, fraying, stretching, loosening, thinning, hypoplasia, or even absence. It may, however, be difficult to distinguish between a normal variant and a pathological lesion. Clinical symptoms and examination should always be correlated with arthroscopic findings. Recommended treatment is to restore shoulder stability and thereby prevent shoulder pain secondary to the increase in laxity. A reduction in range of motion should be expected during the postoperative phase, at least up to six to nine months. External rotation is usually permanently reduced by a few degrees.
The assumption that subacromial space decreases in patients with thoracic hyperkyphosis arises from sporadic and personal observations. The purpose of this study was to compare width of subacromial space calculated on radiographs and CT scans of a high number of patients with thoracic hyperkyphosis that registered on exams of healthy volunteers. We measured the subacromial space, using Petersson's method, on radiographs of 47 patients with idiopathic or acquired thoracic hyperkyphosis and of 175 healthy shoulder volunteers. Both groups were further distinguished considering gender and age. Females with hyperkyphosis were also divided in two subgroups: those with a kyphotic curve of less (24 patients) or more (19 patients) than 50 degrees , respectively. Subacromial space of all patients and of 21 volunteers was also evaluated using CT. Acromio-humeral space was less wide in patients with hyperkyphosis with respect to coeval volunteers of the same gender; in females and in subjects older than 60. Subacromial width of females with hyperkyphosis whose curve was more than 50 degrees was significantly narrower (p<0.05) than that measured on radiograms or CT scans of females with a less severe spinal deformity. Decrease of subacromial space may be attributed to less posterior tilting of the scapula and to dyskinesis of the scapular movement. Scapular malposition causes an anomalous orientation of the acromion that may contribute to subacromial impingement. Patients with thoracic hyperkyphosis greater than 50 degrees had a subacromial space narrower than that measured in patients with a less severe kyphosis. This suggests that subacromial width is directly related to severity of thoracic kyphosis. Because hyperkyphosis of patients with osteoporotic vertebral fractures may worsen over the time, subacromial decompression could give only temporary shoulder pain relief.
Glenohumeral internal rotation deficit (GIRD) is a significant shoulder problem for throwing athletes. GIRD, however, has not been reported in little league pitchers. The purpose of this study was to investigate GIRD in little leaguers. The range of motion of both shoulders was measured in 25 male little league pitchers. All pitchers underwent motion analyses of their pitching to evaluate shoulder kinematics. GIRD was found in 10 of the 25 pitchers. External rotation in the dominant arm in the GIRD group was not significantly different compared to the contralateral or dominant arm in the non-GIRD group. This biomechanical study showed that the GIRD group had increased external rotation while throwing compared to the non-GIRD group. These findings indicate that GIRD can occur prior to development of the increased external rotation in the dominant arm seen in adult throwers.
Shoulder problems in high level swimmers.
- Rupp
The microvascular pattern of the rotator cuff.
- Ratburn
Diagnostic and operative arthroscopy of the shoulder and elbow joint.
- Erikson