With ninety percent of the driving forces coming from the upper body, it is little surprise that swimmer’s shoulder is a common condition in swimming. The shoulder is a complex joint, and as swimming placed it under load, an appreciation of its function and limitations can help keep the body injury free. This is especially true for those who swim very regularly or have poor stroke technique, as they are most at risk.
Shoulder mobility as a strength and a weakness
Compared to other joints in the body, the shoulders and hips have an unparalleled range of motion. This is due both of them having ball and socket joints capable of a 360 degree conical movement. However, stability for each of these joints differs. The hip joint fits snugly like a ball in a glove, as the rounded head of the thigh bone, fits into the deep, cup shaped socket of the pelvis. Unlike the hip, the shoulder has a small flat socket about half the size of the ball, along with several other bones, plus a collection of muscles and tendons that support this wide range of motion. Although one of the largest and most complex joints in the body, its unique structure is also a weakness, as the shoulder accounts for up to 20% of all athletic injuries and is the most commonly dislocated joint in the body.
This balance between shoulder mobility and stability is put to the test during sports that require overhead motion. Racket sports such as tennis, or throwing sports like volleyball require two or three patterns of overhead movement. Swimming however, requires multiple overhead movement patterns and a steady conical 360 degree motion of the humerus, the bone of the upper arm. This bone fits into a socket of the scapula, more commonly known as the shoulder blade, which has a cuff of cartilage called the labrum. This ring of rubbery tissue helps keep the ball like head of the humerus in place.
As the humerus fits loosely into the shoulder joint compared to the hip, a collection of muscles and tendons known as the rotator cuff, provide support for raising and rotating the arm. To further aid fluid motion there is a small sac of fluid called a bursa that protects and cushions the rotator cuff tendons. It lies between the rotator cuff and the roof of the shoulder blade, which has two bony projections, the coracoid process and the acromion, which is above the bursa and attaches to the clavicle. Otherwise known as the collar bone, the clavicle, makes up one of three bones of the shoulder, the other two being the previously mentioned humerus and scapula. These three bones are connected to the shoulder by four joints, one being the ball and socket joint of the humerus and scapula, one for where the scapula meets the ribs at the back, and two for the clavicle which joins the scapula at one end and the chest bone at the other.
All of these structures have the potential to be injured, and as such swimmer’s shoulder can derive from a variety of sources. An appreciation of the forces at work upon the body during swimming, can provide a greater understanding of the root cause of swimmer’s shoulder.
The sources of swimmer’s shoulder
Good swimming technique requires a greater range of motion and flexibility of the shoulder compared to other sports and plays a major role in the upper body’s ability to provide locomotion. This placing of the shoulder under load, is further increased since swimming is performed in a fluid medium. As opposed to air, water creates greater resistance and forces upon the structures of the shoulder.
In one study, two thirds of the elite swimmers reported shoulder pain. In some cases swimmer’s shoulder can involve irritation to the tendons of the rotator cuff muscles, but it can also be due a range of painful shoulder overuse injuries such as impingement. This is where the shoulder blade’s bony point that joins with the collar bone, rubs on the rotor cuff and bursa. This can then lead to inflammation of the bursa, known as bursitis, or tendonitis.
The four tendons that make up the rotator cuff and one of the bicep tendons are most commonly affected by tendonitis, once again as a result of wear. Like with any other joint in the body, the ligaments, tendons, and muscles around the shoulder can tear or become loose. This can lead to instability in the shoulder and the chance of greater injury, such as a tear to the the ring of cartilage that holds the humerus in place, or dislocation. Also these areas can be affected by chronic conditions such as osteoarthritis.
The repeated overhead motion of the arm in swimming and pressures placed upon the shoulder joints in water, mean that immediate care of a newly acquired injury and preventative measures are essential. Seeking physiotherapy treatment can identify the exact area of injury, alleviate pain and then planning can be put into place to regain stability, strength and flexibility. For example a gym program with some simple strength and flexibility exercises can be easily prescribed. Through future self management of the swimmer’s shoulder condition there lies the opportunity to proactively train the body so as to minimise the risk of injury.
Managing shoulder health
First of all as with any inflammation injury, the PRICE principle should be applied to the shoulder. This is achieved by protecting the injured area, resting the shoulder, applying ice for 15-20 minutes every two to three hours, compression with a bandage and elevation of the arm above the level of the heart.
Once the area has recovered due to rest or treatment by a physiotherapist, and a strengthening plan has been devised for the injured area and surrounding structures, then it is time to venture back into the water. At this point advice from your physiotherapist, doctor should be taken and the help of a qualified swimming professional or experienced swimmer could ease the transition back to the pool.
After all investigating and understanding proper swimming stroke technique, could prevent a relapse of injury and aid in the rehabilitation of an recovered shoulder. It is also important to know the limits that a recovering shoulder can take, being sure to train conservatively so as to avoid tired muscles. This is also true for those who are injury free, as training at a limit within the body’s fitness level will maintain stability of the shoulder and aid correct function.
Prevention through correct technique
Swimmer’s shoulder can develop with all styles of swimming, with freestyle, backstroke and butterfly seen to be the most responsible for injury, as the arms circle overhead. Although the most gentle looking, breast stroke still places pressure on other parts of the body, and like the other styles, requires good technique to avoid injury. So an option could be to vary the types of swim stroke performed, as this can provide rest and recovery to muscles, joints and tendons that would otherwise be overworked. Refining the technique and building the strength of each swimming stroke style can also avoid other swimming conditions that effect the knees, neck and lower back.
In general terms there are four areas of swimming technique that can aid protection against shoulder injury. As with land based activities, good posture is essential, so keeping the shoulders back and the chest forward will help. Next is developing symmetrical body rotation, that is encouraged by a balanced left and right breathing pattern. This allows for better support to the rotator cuff and generates more power by engaging the muscles of the back and core.
Regarding the best practice for stroke technique, hand placement as the arm enters the water and the shape of the arm when pulling through the water, are also essential in injury avoidance. It is best to have a flat hand as it enters the water at the start of a stroke. This is fingertips first, rather than thumb whereby the arm is rotated outwards. Lastly as the hand then catches the water and pulls through, the elbow should be high so that the water is pushed back, rather than down when the elbow is dropped or the arm is very straight.
Falls cause 2/3rds of deaths due to unintentional injury in the elderly, which is the 5th leading cause of death of people over 65 years of age.
A fall by an elderly person can be defined as “a situation in which the older adult falls to the ground or is found lying on the ground” or “any unintended contact with a supporting surface, such as a chair, counter or wall”. (Shumway-Cook & Woollacott 2017)
We have your health in mind, and the prevention of such an adverse event, in our best interest and priority. We have decided to write a blog post to provide you with information to help minimise your risk of falling and increase your chances to lead a fit and healthy aging process.
The following list presents risk factors that are relevant to individual factors that increase the chance of falling:
History of falling
Walk with a limp
Poor balance (feel wobbly when walking)
Use of a walking aid (e.g. walking stick or frame)
Poor cognition (e.g. memory/ ability to problem solve)
Age greater than 80 years old
Are any of the symptoms listed above relevant to you?
It is difficult to attribute ageing as the sole reason for the development of the traits listed above, as older adults of the same age can demonstrate physical function ranging from physically elite to entirely dependent on others for all activities of daily living. However, there are some common trends of declining function to do with the neuromuscular system which occur in older adults, and although age may not be the main cause for these changes in the systems of postural control, it is likely, increasing age has a detrimental effect.
The aspects of the systems of postural control potentially detrimentally affected by age include:
Range of motion
Static balance (ability to remain stable when you are not moving)
Dynamic balance (ability to remain stable with movement)
Reactive balance control (ability to sequence movement, time muscle activation and adapt to changing tasks and environmental demands
Anticipatory balance control (the ability to stabilise the body before performing a movement)
Sensation (the ability to detect change in the external environment through vision, hearing, touch, ability to sense vibration, and proprioception, or the ability to sense where your body is in space)
It is also necessary to comment on the loss of bone density associated with increased age (>50 years old). A loss of bone density increases your risk of fracture when falling and is something everyone can and should actively work to minimise.
Our Physiotherapists are pleased to guide you and minimise your risk of falling. Therefore, we have developed a very simple home exercise program for all readers, using equipment all should have access to, to enable you to take action to reduce your risk of developing risk factors of falling and consequently your overall risk of falling, immediately!!:
Sit to stand (to increase muscle strength)
Sitting upright in a chair
Lean forward with hands on chair
Push through arms and heels keeping back straight
Squeeze your buttocks to stand as tall as possible
Repeat 15 squats
Perform 3 x daily
Thoracic extension (to increase range of motion)
Sitting on a chair which has a high back
Place a rolled towel horizontally behind your shoulder blades
Place both hands behind your neck and interlock your fingers
Touch elbows together
Bend backward to a comfortable position and hold for 30seconds
Perform 3 x daily
SLS (to increase static postural control)
Standing next to a stable object
Place one hand on the stable object
Lift one leg off of the floor to form a L-shape
If you are confident and safe, take your hand off of the chair
Hold for 30 seconds
Repeat on the opposite leg
Perform 3 x daily
SLS – Eyes closed (to enhance sensation especially proprioception)
As above, however once stable, close your eyes and hold for 30 seconds
Tandem stance (to increase static postural control)
Standing next to a stable object
Place one hand on the stable object
Place one foot directly in front of the other, so that your toes of the back foot are touching the heel of the front foot, forming in a straight line
If you are confident and safe, take your hand off of the chair
Hold for 30 seconds
Repeat with the opposite leg in front
Perform 3 x daily
Tandem walking (to increase dynamic postural control)
Continue to get into the position as above, however, continue walking – like you are walking on a tightrope! (We recommend alongside the kitchen bench for safety precautions)
30 minutes of walking daily (to increase bone density, dynamic postural control anticipatory balance and importantly cardiovascular fitness – or heart and lung health!!)
This program is very basic and does not cover all of the aspects of postural control. Please make an appointment with one of our physiotherapists to extend your exercise program, so that we can make it more tailored to your needs and more interesting. We will use modern, exciting equipment and more fun movements!!
Finally, the following listed items are external factors that also increase one’s likelihood of falling. They are known as secondary factors and are easily controlled:
Clutter in the home
Please take a moment to consider how you can minimise your risk of falling through controlling these listed items, for example placing non-slip mats in the shower, reducing clutter in frequently used walkways, having a bedside lamp to use when going to the bathroom in the middle of the night.
We hope you have found this blog helpful and please do call us for any questions or comments.
Chapter 9 Shumway-Cook, A & Woollacott MH 2017, ‘Aging and Postural Control’, in M Nobel (ed.)Motor Control: Translating Research into Clinical Practice, 5th edition, Wolters Kluwer, Philadelphia, pp. 206- 228.
Does running accelerate the development of osteoarthritis?
There are so many misconceptions about running and how bad it can be for your joints. You may have heard many friends and family members comment on this and they may have even tried to convince you to stop running and go swimming instead. Here is what the scientific research tells us so far:
Osteoarthritis (OA) is a musculoskeletal condition that involves degeneration of the joints and impact during weightbearing exercise such as running and may contribute to joint loads. There is very little evidence however, that running causes OA in the knees or hips. One study reported in 1985 by Sohn and Micheli compared incidence of hip and knee pain and surgery over 25 years in 504 former cross-country runners. Only 0.8% of the runners needed surgery for OA in this time and the researchers concluded that moderate running (25.4 miles/week on average) was not associated with increased incidence of OA.
In another smaller study of 35 older runners and 38 controls with a mean age of 63 years, researchers looked at progression of OA over 5 years in the hands, lumbar spine and knees (Lane et al. 1993) . They used questionnaires and x-rays as measurement tools. In a span of 5 years, both groups had some participants who developed OA- but found that running did not increase the rate of OA in the knees. They reported that the 12% risk of developing knee OA in their group could be attributed to aging and not to running. In 2008, a group of researchers reported results from a longitudinal study in which 45 long distance runners and 53 non-runners were followed for 21 years. Assessment of their knee X-Rays, revealed that runners did not have a higher risk of developing OA than the non-running control group. They did note however, that the subjects with worse OA on x-ray also had higher BMI (Body Mass Index) and some early arthritic change in their knees at the outset of the study.
Is it better to walk than to run?
It is a common belief that it must be better to walk than to run to protect your joints. In a recent study comparing the effects of running and walking on the development of OA and hip replacement risk, the incidence of hip OA was 2.6% in the running group, compared with 4.7% in the walking group (Williams et al 2013). The percentage of walkers who eventually required a hip replacement was 0.7%, while in the running group, it was lower at 0.3%. Although the incidence is small, the authors suggest the chance of runners developing OA of the hip is less than walkers.
In the same study, Williams and colleagues reinforced that running actually helped keep middle-age weight gain down. As excess weight may correlate with increased risk of developing OA, running may reduce the risks of OA. The relationship between bodyweight and knee OA has been well-established in scientific studies, so running for fitness and keeping your weight under control is much less likely to wear out your knees than being inactive and carrying excess weight.
Is there a limit?
Recent studies have shown that we should be doing 30 minutes of moderate exercise daily to prevent cardiovascular disease and diabetes. But with running, researchers still have not established the exact dosage of runners that has optimal health effects. Hansen and colleagues’ review of the evidence to date reported that the current literature is inconclusive about the possible relationship about running volume and development of OA but suggested that physiotherapists can help runners by correcting gait abnormalities, treating injuries appropriately and encouraging them to keep the BMI down.
We still do not know how much is “too much” for our joints. However, we do know that with age, we expect degenerative changes to occur in the joints whether we run or not. Osteoarthritis is just as common as getting grey hair. The important thing is that we keep the joints as happy and healthy as possible.
How do you start running?
If you are not a runner and would like to start running, walking would be a good way to start and then work your way up to short running intervals and then longer intervals as you improve your fitness and allow time for your body to adapt. Therefore, running in general is not bad for the joints. It does not seem to increase our risk of developing OA in the hips and knees. But the way you run, the way you train and how fast you change your running frequency and distance may play a role in future injuries of the joints.
Physiotherapy For Back Pain
Back problems are the third most common reasons for taking time off work behind the common headaches and colds and are also the second most common reason people go and see their GP. It is believed that approximately 8 in 10 people in western countries suffer from some form of back pain at least occasionally.
Back pain or back ache is a symptom that can arise from many causes including arthritis, muscle and ligament strains, disc lesions, osteoporosis, sciatica and stress. Many cases of upper and low back pain and sore backs in general are caused by stresses on the muscles and ligaments that support the spine. Back pain affects patients of in the neck (cervical spine), mid back (thoracic spine) and lower back (lumbar spine).
At Saanich Physio we deal with a high volume of cases of back pain/injuries and have a proven track record to providing good relief! Our staff here are specially trained in dealing with back related issues whereby digital spinal analysis, X-rays and a comprehensive physical exam are utilized to determine the exact cause of the back pain. We know that everyone is different and therefore we tailor a management program that best suits you! A ‘generic’ treatment formula simply won’t work if you want to stop your pain from coming back.
Here at Saanich Physio we also take a research based ‘holistic’ approach to one’s back problems; as such we also consider and give advice on lifestyle factors that can contribute to back pain. Majority of cases of back pain are aggravated by lifestyle factors, including lack of exercise, schoolbags, being overweight/obese, sedentary lifestyles, poor posture, stress and bad work practices. In relation to obesity – we can also provide superior quality weight loss supplements to assist in this area. We address all of the contributing factors to prevent the pain in your back from coming back for good. Many back pain ailments can be addressed easily and quickly but those with serious and chronic back pain often benefit from an ongoing maintenance program.
Physiotherapy to prevent relapses and worsening of symptoms
Simply, our Back Program is a tailored treatment program to address the exact cause of your problems and to get you back to your favourite activities fast! So if your back is holding you back from sport, occupation and other activities or you just simply have pain whilst sitting or getting in/out of your car then our Better Back Program may be the answer for you!
Our Back Program involves an initial assessment with one of our highly skilled physiotherapists. You will also receive a detailed report at the beginning and conclusion of your back therapy to show your progress and your family doctor and relevant specialists will receive a copy also so that everyone in your medical team helps you move towards being fit and painfree.