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.
Headaches are experienced by most of the population at some point in their lives. For most they are minor and fleeting, and for others they pose an ongoing problem, having complex underlying causes. Types of headaches vary greatly and determining their root cause can be difficult. Having a greater understanding of how these types of head pain are categorised, can at least provide a starting point for minimising the impact headaches have on daily life.
One thing that is certain for all headaches, is that the pain is not felt from the brain. The brain receives pain signals from the nervous system, yet it is one organ of the body that does not have pain receptors. Rather it is the interactions between blood vessels and surrounding nerves in the structures in the head, neck or elsewhere, that send pain signals to the brain, which make a headache felt.
These pain sensations come in a variety of styles, so classifying types of headache is important in determining the appropriate treatment. There are two main categories of headaches, those being primary and secondary. The most common headaches are primary where the headache is the cause of the pain, as opposed to a secondary headache where there is an underlying medical condition.
Infection such as meningitis or a brain bleed due to trauma are examples life threatening secondary headaches. They can also derive from less severe conditions, for example medication overuse and issues relating to the structures of the head, such as the sinus region. Conditions of the head, neck, and even the the stomach or intestines, that are inflammation, trauma, illness or disease related, may also cause headaches.
As one of the most common ailments we experience, the symptoms and pain experienced will vary greatly. Although types of headaches are classified into groups, this is only a rough guide. There is much crossover regarding symptoms between one category and another, which makes headaches difficult to diagnose. This is where some deductive reasoning comes into play in differentiating one type of headache from another, especially considering there are over two hundred documented types of headaches.
Main types of headache
Tension, migraine or cluster are the main types of primary headaches. Migranes can be very debilitating, and often are accompanied by other symptoms such as nausea, vomiting and are often only felt on one side of the head. They can also be accompanied by an aura, which is a visual disturbance such as seeing sparkles or dots. There may also be feelings of anxiety, sensitivity to light or sensations that effect the limbs or stomach.
Unlike a migraine where these sensations can forewarn the onset of a headache, the cluster comes on suddenly, yet departs as quickly as it arrived. As they are one of the most painful headaches, it is fortunate that they are not as common. The name for this type of headache derives from them appearing as a cluster of short but intense pain, that occur in cycles over a period of a few weeks or months.
These characteristics help differentiate between a migraine, cluster and the most common of all headaches, which relates to tension. A tension headache is less severe and often caused by muscle contraction in the head and neck region. It presents as a tightness or pressure across the forehead, like a tight strap, with pain described as a dull ache. A sensitivity to loud noises, muscles aches on the side or back of the head, or even tenderness when touching the scalp, neck or shoulders, can be other indicators of this type of headache.
Developing tension headaches can be due to stress, anxiety or strain on the muscles over a long period of time, such as staring at a computer screen, especially one that has not been ergonomically positioned. Sitting for extended periods, lack of sleep, poor eating habits or chronic stress can all contribute to tension headaches.
So neck strain is one of many sources of a primary type tension headache. Yet the neck can also be the source of referred pain from a type of secondary headache, known as cervicogenic headaches, with ‘cervicogenic’ meaning originating from the neck. This upper most section of the spinal cord, known medically as the cervical spine, also involves the connected muscle, tendon and nerve structures that surround the neck and head region.
As cervicogenic headaches can refer pain to the head rather than being felt in the neck, it can sometimes times be hard to differentiate them from other types of secondary headaches. The names of these secondary headaches are prolific, but often have descriptors preceding the word ‘headache’ that indicate the root cause, for example ‘caffeine’, ‘pregnancy’ or ‘medication overuse’. For other types of secondary headaches, determining less obvious causes is something that can be assisted with the help of both the patient, and the health professionals involved.
Head pain and deductive reasoning
Sometimes the headaches we experience can be explained by a simple cause and effect. Overindulging in wine, staring at a screen for too long or lacking hydration are all self apparent causes for a basic headache. Then in hindsight, avoiding these triggers can then be the best prevention.
Some causes though will require a little more detective work, and a diary can be very helpful for when the headache is evaluated in a consultation. This record should contain a history of the headaches, with a date, a start and finish time, along with any other symptoms that accompany the pain, such as a fever, an upset stomach or the location of muscular aches. A description of the type of pain, such as ‘throbbing’ or ‘sharp’ can be added, as well as the pain severity on a scale of one to ten, ten being to the point of being incapacitated.
Further detail can be added to the diary such as foods or liquids consumed, including medication or supplements being taken. Quality of sleep, physical or emotional stressors at home or work, daily activities and conversely time spent at a desk inactive, are also important in pinpointing any potential triggers.
Even with these records, primary headaches are more difficult to tackle compared to secondary headaches, as determining the root cause of migraines and cluster headaches is often unclear. However when a headache is due to tension or referred pain from bone or soft tissue of the neck, physiotherapy treatment can offer some assistance.
Headaches relating to physiotherapy
Determining whether a headache is originating from the neck region, may or may not be obvious as symptoms for each type of headache overlap. For example a tension headache and a cervicogenic headache can both be accompanied by pain in the scalp, neck and shoulders.
How a headache differs may help in its diagnosis as to which type of headache is being experienced. For example a cervicogenic headache may be felt at the back of the head, the top of the skull, forehead, temple or behind the eye, as opposed to a tension headache where a band like pressure is felt across the forehead, back or sides of the head.
Unlike a tension headache a direct connection with the neck may not be experienced with a cervicogenic headache, instead there may be feelings of dizziness, nausea or poor concentration. Either of these headaches could start or be increased in severity by head movement or a prolonged posture, and a reduced range of motion of the neck may also be an indicator.
The underlying cause of a cervicogenic headache can either be a problem with the vertebrae immediately below the skull or the soft tissues of the neck. It could also be due to a strain or injury, and even long term conditions such as degenerative disc disease of the neck’s vertebrae.
To make matters more complex, what appears to be a cervicogenic headache, may in fact be occipital neuralgia. This is when the nerves that run from the top of the spinal cord and up through the scalp, become inflamed or damaged. Regardless of the type of headache, a physical examination provides a starting point from which further investigation may involve X-rays, scans and imaging to provide a clearer view of the neck’s structures. If nerve pain is experienced as part of the headache, a nerve block injection may be organised where appropriate, to help diagnose the cause and treat the condition.
Treatment of neck related headaches
Any neck treatment is a delicate matter because of the complexity of its structure. The vertebrae of spine at this point are smaller than those lower down the back, and so support of the head relies on a complex layering of muscles. Muscles closest to the spine are shorter, typically connecting one bone of the spine to another, while further away from the spine, muscles are generally broader and longer, spanning more joints and connecting more parts of the body. As such any of these can be injured as can the connective tissues, such as ligaments and tendons. Further to this the cartilage that assists in the smooth action of the neck can degenerate, as can the joints through arthritis which can lead to headaches and neck pain.
The complex interaction of nerves and bone joints at the junction of the upper spine and skull provides multiple points of potential injury as well. Nerve compression can cause inflammation and pain, whilst the upper spinal vertebrae are susceptible to compression and movement injuries such as bone spurs or a bulged disc, that can in turn impinge nerves. Thankfully nerve pain from the spine can be mapped, as general areas of the skin are mostly supplied by a specific nerve, that can be traced back to its root in a spinal segment. For example the second and third vertebrae of the cervical spine cover the areas or ‘dermatomes’ on the back half of the head. So head pain felt in these areas may provide an indicator to damage within the second or third vertebrae.
With physiotherapy, an assessment can help differentiate which type of headache is being experienced, and where appropriate, treatment can be very effective in managing headaches of a neck related origin. A physiotherapist can assess the joints of your neck, associated muscle and nerve structures, to identify any abnormalities. Along with the diary, any previous trauma to the neck region, such as whiplash, can also be taken into consideration.
Depending on the specific presentation and symptoms of neck related headaches, physiotherapy management may include joint or soft tissue mobilisation and exercise. Joint mobilisation can be used to help unlock or loosen stiff vertebrae, whilst dry needling, massage and the prescription of strengthening exercises can address tight or weak muscles, and restore stability to the neck area. A physiotherapist can also look at posture and general ergonomic improvements, as these can have a significant impact on headache development and its recurrence.
Ongoing management can involve postural advice and correction, which could include an ergonomic assessment or general advice regarding the setup of your work place. To compliment the hands on therapy and exercise prescription provided by a physiotherapist, stress and tension management may also include assistance in seeking out relaxation techniques or taking up classes such as yoga, that incorporate meditation.
Short term Flare ups
For short term flare ups a hot or cold pack can be used until your next appointment. The use of over the counter pain medication should be in moderation, for example less than three days a week, and preferably after advice from your physiotherapist or doctor. Too much medication can cause what is known as a ‘rebound headache’. This is where medication is taken to cope with the head pain, that reappears after an analgesic or painkiller used for a headache, wears off. So paradoxically the headache is the result of withdrawal from the very drug, that is supposed to stop the head pain.
Ultimately treatment for a headache should lead to self management through understanding of the stressors that initiate a headache. Broader lifestyle changes such as a balanced diet, regular sleep and exercise can also have a positive influence of the recurrence, duration and intensity of a headache, be that neck related or otherwise.
What is Sciatica?
Sciatica is the name given to pain, numbness or weakness in the areas that are supplied by the sciatic nerve. These areas include hip, buttock, thigh, calf and foot. The sciatic nerve is the longest nerve in the body and when compressed, irritated or inflamed can be debilitating.
When does it occur?
Sciatica is often brought on by restrictions within the spine affecting the sciatic nerve and causing referred pain. Restrictions in the pelvis could cause a tightening in the gluteal muscles putting pressure directly on the sciatic nerve.
Sciatica can also be caused by more serious issues which is why it is important to consult a physiotherapist if you notice any referred pain in the leg. It may not always be a biomechanical or disc related issue that causes sciatica which is why its important it is diagnosed correctly.
Sciatica is most commonly preceded by a few weeks of back pain before the leg pain becomes worse than the back pain. In severe cases, it can damage nerves and leg reflexes and cause muscle atrophy of the lower leg most noticeably in the calf.
Often people wait until the pain is unbearable to consult with a physiotherapist. It is important to consult a professional when the pain initially begins as sciatica can cause long-term damage which means longer treatment and longer recovery times.
Sciatica can have numerous sources thus there are a number of Physiotherapy treatments, none of which involve drugs or surgery. Techniques we use include manual therapies (MT) including muscle energy technique (MET), core rehabilitation (CR), dry needling, soft tissue techniques (STT), trigger point therapy (TPT) and home exercise regime (HEP).
Consult one of our Physiotherapists to review your complete medical history and perform a thorough physical examination to determine the cause of your sciatica.
Treatment Protocols have changed significantly when it comes to sports Injuries even though the injuries themselves have remained unchanged in medical textbooks for many years.
Most of the advances in treatment have come about from research lead by exercise physiologists and specialists who monitor and test our elite athletes and of course lets not forget the sharp learning curve provided by good old fashion trial and error.
It wasn’t that long ago a patient booked for knee surgery would be in a cast and asked to rest as much as possible. Medical specialist began to realise that the cast would accelerate atrophy (muscle wasting) of the leg muscles making postoperative recovery a long and unnecessary drawn out.
Nowadays the complete opposite occurs. Instead of resting and immobilising the injured segment, the patient is given a carefully considered treatment plan combined with prescribed rehabilitation exercises, pre and post-operatively.
There are a number of important factors to be considered before any treatment or rehabilitation program is given to minimise aggravation of the healing structures. A poor and inexperienced approach could set back recovery significantly, or worse, contribute to further damage to the recovering tissues.
Our physiotherapists have years of experience treating injuries. They have seen just about every combination of sports injury and treat many elite athletes.
Treating any injury whether it is sports related, work related or just plain bad luck does not change the rehab rules. Each injury is categorised in different phases with goals and criteria to progress through each different phase.
All our rehabilitation exercises are based on best current practices that are evidence-based. Our Physiotherapists clearly set out what type of exercises are appropriate for the current injury level, how many reps, at what intensity and how many times in the day these exercises should be completed.
Combine this approach with his proven treatment protocols gives our patients the best results.
In nearly all cases, treatment is accompanied by a customised exercise rehab program to accelerate recovery and enhance positive long lasting results.