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
Frozen shoulder, correctly known as Adhesive Capsulitis, presents as a combination of shoulder pain and stiffness causing sleep disturbance and marked disability.
In a frozen shoulder the capsule surrounding the shoulder joint is more thickened than normal and it shrinks, adhering to the humerus (arm bone) and itself – hence the name adhesive capsulitis. It is associated with inflammation, causing pain followed by scarring, causing stiffness.
Clinical features of frozen shoulder
Gradual onset of arm pain.
Unable to lie on affected side.
Restriction of movements, usually into elevation and outward rotation.
Diagnosed by a thorough shoulder examination.
X-rays may rule out other causes of shoulder pain but are unable to diagnose a frozen shoulder.
Runs a distinct course which can be broken into 4 phases or simply “pain-predominant” and “stiffness-predominant”.
Phases of frozen shoulder
Phase 1: Usually pain.
Phase 2: Increasing pain and increasing stiffness but still predominantly pain.
Phase 3: Pain abates, leaving stiffness.
Phase 4: Resolution, usually by 2 years.
Who gets frozen shoulder?
Mostly occurs between ages 40 and 60 years.
More common in women and diabetics.
Often appears for no apparent reason but can stem from an injury to the shoulder or following shoulder surgery.
20% of patients will develop it in the other shoulder in the future but almost never occurs again in the same shoulder.
Common shoulder problems
Unable to: Reach above shoulder height
Throw a ball
Quickly reach for something
Reach behind your back e.g. doing up bra, tucking in shirt
Reach out to the side and behind e.g. reaching for seat belt
Sleep on your side
How can physiotherapy help?
Although a frozen shoulder is generally self-limiting, the aim of physiotherapy is to keep the shoulder joint as pain free and mobile as possible. Physiotherapy may also help reduce the time taken to move through each phase.
Phase 1 & 2- pain relieving techniques such as gentle mobilisation, muscle releases, dry needling, taping.
Phase 3- shoulder joint mobilisation and stretches, muscle release techniques, dry needling and exercises to regain range and strength. Treatment should not be too aggressive.
Phase 4- shoulder mobilisation and stretches followed by strength exercises to control and maintain the returning range of movement.
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.
To understand why back pain recurs, we need to first look at why pain occurs to begin with and then how back pain physiotherapy can help. Back pain generally stems from some form of trauma or loading placed on your back, which may occur as a one off incident or be repetitive loading over time. Normally your core muscles will control your spine and allow an even distribution of load in the appropriate tissues. However, in an acute incident or with poor biomechanical control these muscles will not be able to withstand the load placed on them and trauma will occur. This trauma may cause damage to the tissues within your spine including the disc, joints and muscles.
It is essential to determine how and why the injury occurred
Once your back has been subjected to trauma the damage sustained may alter thestructure of your spine, including arthritis within the joints, disc disruption or bone alignment. Whilst physiotherapy will aim to alleviate your pain, regain full spinal movement and prevent further spinal damage it is important to determine why the injury occurred to understand the underlying cause and surrounding factors so that the same incident is not replicated and your back can be appropriately managed in the long term. The most important aspects of this management include altering your biomechanics to optimise your back function, modifying any activities which may aggravate your back, having optimal sleep postures and implementing an exercise routine including stretches and strengthening to maintain appropriate muscular stability and flexibility.
Biomechanical corrections are vital
Biomechanical corrections are vital to allow appropriate load distribution throughout the spinal column. The spinal column is very long, thin and has attachments to the other major structural components within your body. There are many different muscles which attach to it which can pull each individual spinal segment in a different direction. Those with back pain will often be overactive in particular muscle groups and under active in others, particularly their ‘core’ muscles. Your physiotherapist is likely to discuss these with you and may make alterations depending on your particular posture. It is important that following your treatment you continue to maintain these alterations. This may mean the need to continue stretches and specific strengthening exercises longer term to prevent reverting back to previous postures.
Activity modification is often required
Activity modification is often required to prevent re-injuring your back after your injury. Most people will have specific movements or activities which will cause them pain during the recovery from a back injury. It is important to take note of these activities and understand why they are painful so that once your pain is gone you are still aware of activities which are most likely to cause you pain in the future. You may need to modify these activities to prevent ongoing loading of your spine in a particular way, such as changing your work setup so you don’t have to lift from the ground repetitively or altering your desk setup so you can sit or stand during the day to prevent stiffness and slumped spinal postures. And it is important to remember, that whilst you don’t have pain currently, factors that contributed to a back injury in the first place are likely to be the contributing factors in recurrence of an injury.
Sleep postures are vital in the care of your back as such a large proportion of your life is spent in bed. It is important to maintain a neutral spinal position, where your spinal is relatively flat and straight, to prevent unnecessary stress being placed on particular spinal segments. You should make sure that your back has appropriate support from your mattress and pillow and that these are replaced and turned regularly to maintain their optimal shape.
Exercise is a necessary long term part of treatment
Exercise is likely to be given to you as part of your treatment for your back injury and should become part of your long term management. This may include a combination of stretches and strengthening exercises which are required to maintain your spinal alignment and prevent you from reverting back to your previous posture and biomechanics. Clinical Pilates or specific gym exercises are a great medium for this, particularly in a supervised environment where your physiotherapist is able to monitor your posture and positioning at all times to gain the most benefit. Hydrotherapy is also a fantastic way to complete your rehabilitation due to the reduced weight bearing placing less impact on the affected areas and allowing greater flexibity in the warm water. By completing these structured programs the resistance, intensity and difficulty can be regularly monitored and adjusted for people at all stages of rehabilitation.
Seek early intervention if pain recurs
If you feel like your back pain is recurring it is important to seek early intervention. Your physiotherapist will be able to analyse your symptoms and resolve your pain much more quickly if you return earlier and have less associated tissue involvement.