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.
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.
Some common spinal injuries and conditions we treat:
Acute lower back (lumbar) pain due to spinal disc and/or facet joint injuries
Chronic low back (lumbar) pain
Sciatica – referred pain and symptoms into the lower limb
Pelvic dysfunction syndromes . Often diagnosed in patients who feel ‘out’.
Childbirth related instability and acute pain syndromes of the lower back and pelvis.
Spondylolisthesis (forward slip of one vertebrae on the vertebrae directly below it)
Spondylosis (disc space narrowing combined with degenerative changes in the facet joints common with age)
Acute neck pain due to facet joint and/or spinal disc injury
Chronic neck pain
Brachialgia-referred pain and symptoms into the arm, ‘pinched nerve’ pain and/or pins and needles/numbness (known as paraesthesia)
Mid-back (thoracic) and rib (costovertebral joint) pain (which, in some cases, refer pain around the chest wall)
Acute/chronic (myofascial) trigger point conditions. (These are tender and hypersensitive coin sized zones within the muscle tissue that can cause local pain and tightness and can also refer to distant sites.)
Muscle and joint stiffness
Causes of Spinal Pain
Acute and chronic spinal pain is experienced due to the stimulation, via mechanical or chemical irritation, of small nerve endings, nerve root or spinal cord sheaths, nerve cords, complex pain mechanisms in the central nervous system or a combination of the above.
Acute Spinal Pain
This can involve findings of bulging disc, disc protrusion or disc prolapse/rupture. Disc problems are very common in the lower back (lumbar spine). They are often associated with episodes of bending, bend with twist or prolonged sitting /driving which distorts the rim of the disc causing acute pain. In addition it can produce pressure on the spinal nerves in the lower back which produce symptoms known as sciatica. This is felt as pain, pins and needles sensation, numbness and/or weakness in the leg(s). In the neck (cervical spine), disc injuries can cause debilitating pain into the neck and commonly severe pain into the arm called brachialgia due to compression of the spinal nerves in the neck. This is commonly referred to as ‘pinched nerve’.
These joints are small joints which flank the disc on either side and behind the spinal discs. They are like a finger joint in their structure and when injured swell and inflame and cause acute pain and restriction of movement. They can be sprained in an injury or activities involving twisting, arching and reaching upward movements. In the neck they can become overstrained by an awkward night’s sleep leading to a condition known as ‘Acute Wry Neck’. They can cause local pain and also refer pain to neighbouring and even distant sites.
The joints of the pelvis can suffer acute injuries through high force trauma such as motor vehicle/bicycle accidents, contact sports, slips and falls on to the ground/floor, landing from a height, or when the female pelvis is vulnerable before and after childbirth. Injury and acute instability syndromes can occur which involve the sacroiliac and pubic joints. Lumbo-pelvic dysfunction conditions are common in the sporting population. Muscle imbalance, asymmetrical posture and structural alignment, as well as poor activation and stabilising strength (core control) can create syndromes such as chronic back pain, Osteitis Pubis (OP), recurrent hamstring strains, and contribute to a range of soft tissue injuries/conditions in the lower body.
This refers to the soft tissue layer involving the muscles, tendons and fascial tissues. This can be injured acutely and cause local pain at the site of injury but can also be responsible for ache and pain at distant sites. Myofascial pain is often associated with damage to deeper joint structures, namely disc and facet joints as either a primary (injured tissue) and/or secondary (protective spasm) component of the acute injury.
“Tension headaches” are often talked about and we see a lot of patients with these headaches. In our diagnosis of these conditions, about eighty five percent of all headaches arise from the neck, or cervical spine, which refers pain into the head through the nerves which go to both areas. Neck problems cause head pain because some of the nerves which come from the spinal cord have branches which go to the upper neck joints and other branches which spread over the back of the head, with still others going to the front of the head. When one area is sore the brain interprets the pain as coming from all the areas the nerve branches go to.
CAUSES OF TENSION HEADACHES
Patients who have “Tension Headaches” or “stress headaches’’, are often very busy and have work related problems, a tough boss, urgent deadlines, problems with managing work flow and they often have trouble sleeping because of work problems and their worries. This causes the patient to be mentally and emotionally stressed and their relationships at work and with their families suffer.
They develop a headache which they cannot shake and they feel helpless, tired, tense, anxious and in pain. We have seen many cases where the headaches have continued for weeks and frequently kept recurring, sometimes over many years.
It is important to understand that a Tension Headache is due to “physical tension” in the tissues, often from a poor working position and the damage it has caused, not the other mental “tensions” listed above. Once full neck movement has been restored with treatment, the tissues have healed and the postural strains have been removed, patients often cope better with the other aspects of their lives. This is where Physiotherapy can help by breaking the vicious “Physical Tension” cycle. It is better to think of these as “structural headaches”.
Our neck is made of seven vertebrae stacked one above another. They support the head and they are joined together at the front by discs and at the back by facet joints. When we bend forward, the vertebra above tilts and slides forward, compressing the disc and stretching the facet joints which join the back of the vertebrae. When we bend backward, the disc compression is reduced at the front and the facet joints are compressed at the back. The junction of the first vertebra and the head does not have a disc and the joints there are particularly susceptible to leaning forward which causes the weight of the head to strain the joints, ligaments and muscles as gravity causes a shearing force as the head slides downward.
The neck muscles are often blamed as the cause of pain but this is rarely the whole story. Muscle pain often develops as the muscles contract to prevent further damage, as they protect the primary underlying structures. This pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture, etc, there is temporary relief but the pain will always comes back as the muscles resume their protective bracing. The most common sources of primary pain are the facet joints and their ligaments in the upper neck and the discs in the lower levels of the neck.
A facet joint strain is much like an ankle sprain, strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged.
In the upper neck, facet joint strains typically occur during excessive bending or twisting movements and may follow trauma such as a car accident causing whiplash but generally, Tension Headaches occur with prolonged forces such as slouching, keying and reading.
There is often a previous history of pain coming and going as the damaged area became inflamed, was treated and settled for a while but as the underlying problem still remained, the pain flared up repeatedly every time it was strained. This type of injury, although often chronic, responds very well to specific Physiotherapy treatment.
There are many other sources of headaches and neck pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will advise you should a more serious condition be suspected.
SYMPTOMS OF TENSION HEADACHES
Symptoms of “Tension Headaches” arising in the neck, are always affected by movement of the head and neck. This is important to understand. Symptoms are sometimes severe and may be sudden in onset but also may be mild and of gradual onset. There are other serious conditions which can produce headaches. If you have severe headache symptoms which are not affected by movement and a recent history of fever or nausea, you must consult a doctor urgently.
Facet joints, discs, muscles and other structures are affected by our neck positions and movements and when damaged, will respond very well to Physiotherapy treatment.
DIAGNOSIS OF TENSION HEADACHES
“Tension Headaches” often appear complex and require a full understanding of the history and a comprehensive physical examination. It is important for your Physiotherapist to establish a specific and accurate diagnosis to direct the choice of treatment. In some cases, the pain may arise from several tissues and these coexisting pathologies are treated individually as each is identified. Where the Physiotherapist requires further information or management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.
TENSION HEADACHE RELIEF
Some of these cases will temporarily respond to a general non-specific treatment such as bed rest, ice and anti-inflammatories, however Musculoskeletal Physiotherapists have developed diagnostic skills and treatment techniques, targeted to stopping “Tension Headaches”. We will identify the reasons for the development of the pain and advise strategies to promote healing and to prevent further damage.
Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education.
When normal function has been achieved, the inflammation and pain has settled and the structures have healed, using your new strategies will reduce the possibility of the headaches ever recurring. We use this approach to reduce or stop chronic pain. While we have the choice to manipulate or “click” joints, those with ongoing pain will seldom benefit from repeated “adjustment”. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost as the tissues tighten up again. Potentially dangerous “adjustments” of this type have little long term benefit and can lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safe and appropriate treatment for you.
PROGNOSIS OF TENSION HEADACHES
Physiotherapy for “Tension Headaches” can provide outstanding results but it is a process, not magic. The damage which produces “Tension Headaches” takes time to develop and time to repair and heal. You will understand there are often several interacting factors to deal with and your compliance is necessary.