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.
The Piriformis Muscle
Do you have pain in your buttock? Low Back Pain? Your Piriformis muscle may be the culprit.
Your Piriformis muscle is a small, deep, buttock muscle. Many of us have a tight piriformis muscle which can cause pain issues in your gluteal/buttock region as it passes right over your sciatic nerve. When your piriformis becomes tight it can compress your sciatic nerve and start creating all kinds of issues. Many of us sit at computer desks for many hours on most days. This essentially means that you sit on your sciatic nerve, gluteal muscles and piriformis muscle every day. If your nerve is calm and not irritated, that feels ok but if it is stirred up from a tight piriformis muscle your gluteal and buttock region can become extremely painful.
Symptoms of piriformis muscle syndrome
If your piriformis is irritated you may feel pain in your buttock region, pain down your leg, numbness and tingling traveling into your leg and foot, pain on sitting, standing and squatting down.
Our therapists determine if your sciatic nerve pain is originating from your piriformis muscle or from your spine. If your piriformis muscle is the culprit, you will feel like your pain originates in your buttock regions, not your spine. Another distinction between the two origins of your pain is that with a tight piriformis muscle you usually won’t have muscle weakness in the affected lower limb side whereas you if your pain originates from your spine you may get symptoms down the affected limb side.
Some men have had a sciatic nerve irritation caused or aggravated by sitting on their wallet in their back pocket. “Note– Never sit on your wallet” Piriformis muscle pain doesn’t have to be isolated to the muscle itself. You can have SIJ (sacroiliac joint) pain and wider spread gluteal muscle pain too.
Piriformis Muscle Treatment
Your physiotherapist will first identify the cause of your pain and symptoms. This may include a biomechanical assessment of certain movements involving your lower limbs and pelvis. We will then target hands-on treatment to release your tight Piriformis muscle. We will also assess and treat any tightness or symptoms around your other gluteal muscles and lower back if they are contributing to your pain issues. Treatment techniques that may be helpful include IMS Dry needling and Shockwave Therapy.
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.