Elite and competitive swimmers log between 60,000 and 80,000 meters weekly — swimming the length of an Olympic-sized pool 1,200 times — which places significant stress on their shoulder joints. “The upper body provides 90 percent of the propulsive force to move through the water. Due to the amount of force generated and the range of motion required to swim efficiently, the shoulder needs to have perfect mechanics to avoid injury,” says Dr. Elizabeth Matzkin, lead study author of a literature review in the August issue of Journal of the American Academy of Orthopaedic Surgeons and assistant professor of orthopaedic surgery at Harvard Medical School.
Swimming is an endurance sport but “swimmer’s shoulder” — a broad non-medical term often used to describe a variety of shoulder injuries — can affect swimmers at all levels. According to the literature review authors, many shoulder injuries are preventable with proper technique, training, stretching, and strengthening.
Shoulder pain affects 40 to 91 percent of competitive swimmers. Overuse and poor shoulder mechanics can cause muscle imbalances, decreased range of motion of the shoulder, and less efficient swim strokes, all placing athletes at greater risk for further injury. The most common swimming-related injuries include:
Impingement — As swimmers becomes fatigued, the pectoralis muscles (commonly known as “pecs”) compensate for tired muscles, which can cause the peak of the shoulder blade to rub (impinge) against the rotator cuff (tendon and bursa), stress the anterior (front of the body) ligaments, and create tears in the tissue that holds the top of the arm bone in place.
Scapular dyskinesis — Intense, repetitive rotation of the shoulder blade over the chest wall can overstretch and loosen the upper back muscles that keep the shoulder bones in a healthy position. Abnormal shoulder mechanics (scapula dyskinesis) can cause pain near the collarbone when the upper chest muscles tighten to compensate for the loosened upper back muscles.
Glenohumeral internal rotation deficit (GIRD) — Intense, repetitive rotation of the shoulder blade can cause the front shoulder ligaments to overstretch and loosen. This can cause the soft tissues and muscles in the back to tighten to compensate for the loosened front shoulder muscles while limiting the internal rotation of the shoulders, which puts swimmers at greater risk for rotator cuff tears. Swimmers must maintain some shoulder looseness to remain competitive. However, about 20 percent of competitive swimmers have hyperlaxity — the ability of joints to move beyond the normal range of motion — which increases the likelihood of greater shoulder instability and susceptibility to pain.
Possible and often subtle signs of shoulder injuries among swimmers may include:
A dropped elbow during the recovery phase of the freestyle stroke.
Excessive body roll, which may signify shoulder pain.
Drooping of the affected shoulder.
“Injury prevention is best accomplished by proper training. Most importantly, swimmers need to stretch, especially the posterior shoulder capsule, and avoid muscle imbalance by strengthening both the rotator cuff and the scapular stabilizer muscle groups,” says Dr. Matzkin. When a swimmer experiences shoulder pain, a thorough physical examination is important to diagnose the source of the pain, whether there is atrophy in the shoulder or reduced strength in the shoulder joint.
Treatment may include nonsurgical (e.g., a combination of ice, stretching, and anti-inflammatory medication, focused rehabilitation to reduce pain) or surgical (e.g., for structural injuries to manage pain rather than to enhance athletic performance) options to potentially prevent future injuries.
Elizabeth Matzkin, Kaytelin Suslavich, David Wes. Swimmer’s Shoulder. Journal of the American Academy of Orthopaedic Surgeons, 2016; 24 (8): 527 DOI: 10.5435/JAAOS-D-15-00313
Dry needling involves the application of very fine sterilised acupuncture needles into muscle and surrounding tissues to assist in the release of myofascial trigger points, reduce tightness and spasm, improve muscle function and relieve pain. It is commonly used as an adjunct to physiotherapy and myotherapy techniques to improve treatment outcomes.
There are two types of Dry Needling, the first called Superficial Dry Needling (SDN) works by inserting the needle only 5-10mm under the skin. Secondarily is Deep Dry Needling (DDN) where the needle is inserted to the depth required to penetrate the targeted myofascial trigger point.
How does it work?
Myofascial trigger points are hyper-irritable, taut bands within muscles, which are painful to touch and can contribute to muscle shortening, weakness and pain (both locally and referred). They often develop following muscle, joint or nerve injury and sometimes persist well after the initial tissue injured has healed. This leads to persistent pain and discomfort.
Dry needling releases these trigger points by encouraging local blood flow to the trigger point and by modulating nerve pathways that erroneously cause them to persist. The needling also stimulates your body’s own endorphin system to provide pain relief and help allow the muscle to relax.
Dry needling can be extremely effective in the treatment of:
Needles used in dry needling are much thinner than those you receive when you see your GP for an injection and so usually cause much less discomfort. This does vary depending on what techniques your therapist uses. You may also experience the very satisfying response of the muscle twanging and releasing quickly. A sure sign of a successful trigger point release.
The initial treatment is conservative to determine the patient’s response. This varies from person to person. It is expected that there will be some post treatment soreness during the first 24-48hrs and sometimes minor bruising is experienced.
What sorts of conditions can Dry Needling be beneficial for?
Dry needling can produce excellent results as an adjunct to standard physiotherapy and manual therapy treatment. It can be used in both acute and chronic painful conditions.
Dry needling can be extremely effective in the treatment of:
Back, neck and shoulder pain
Hand and wrist pain
Tendinopathy pathologies i.e. Tennis elbow, Achilles pain
Many other musculoskeletal injuries (You can discuss dry needling with your therapist to see if it may be useful for your condition)
What is the difference between Dry Needling and Acupuncture?
Dry needling revolves around Western Medicine philosophy and involves inserting needles into muscular trigger points palpated by your therapist and consistent with your area of pain.
Acupuncture is based on ancient Eastern Medicine, with needle placement over specific points along meridian lines or ‘energy’ lines which are thought to associate with particular illness and disease.
Exercise therapy is as effective as surgery for middle aged patients with a common type of knee injury known as meniscal tear (damage to the rubbery discs that cushion the knee joint), finds a study in The BMJ this week.
The researchers suggest that supervised exercise therapy should be considered as a treatment option for middle aged patients with this type of knee damage.
Every year, an estimated two million people worldwide undergo knee arthroscopy (keyhole surgery to relieve pain and improve movement) at a cost of several billion US dollars. Yet current evidence suggests that arthroscopic knee surgery offers little benefit for most patients.
So researchers based in Denmark and Norway carried out a randomised controlled trial to compare exercise therapy alone with arthroscopic surgery alone in middle aged patients with degenerative meniscal tears.
A randomised controlled trial is one of the best ways for determining whether an intervention actually has the desired effect.
They identified 140 adults (average age 50 years) with degenerative meniscal tears, verified by MRI scan, at two public hospitals and two physiotherapy clinics in Norway. Almost all (96%) participants had no definitive x-ray evidence of osteoarthritis.
Half of the patients received a supervised exercise programme over 12 weeks (2-3 sessions each week) and half received arthroscopic surgery followed by simple daily exercises to perform at home.
Thigh muscle strength was assessed at three months and patient reported knee function was recorded at two years.
No clinically relevant difference was found between the two groups for outcomes such as pain, function in sport and recreation, and knee related quality of life. At three months, muscle strength had improved in the exercise group.
No serious adverse events occurred in either group during the two-year follow-up. Thirteen (19%) of participants in the exercise group crossed over to surgery during the follow-up period, with no additional benefit.
“Supervised exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term,” say the authors. “Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no radiographic evidence of osteoarthritis to consider supervised structured exercise therapy as a treatment option.”
How did this situation — widespread practice without supporting evidence of even moderate quality — come about, ask two experts in a linked editorial? “Essentially, good evidence has been widely ignored,” say Teppo Järvinen at the University of Helsinki and Gordon Guyatt at McMaster University in Canada.
“In a world of increasing awareness of constrained resources and epidemic medical waste, what we should not do is allow the orthopaedic community, hospital administrators, healthcare providers, and funders to ignore the results of rigorous trials and continue widespread use of procedures for which there has never been compelling evidence,” they conclude.
1.Nina Jullum Kise, May Arna Risberg, Silje Stensrud, Jonas Ranstam, Lars Engebretsen, Ewa M Roos. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ, 2016; i3740 DOI: 10.1136/bmj.i3740