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.
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.
What is Dry Needling?
Dry Needling is a specialised form of treatment that we use for reducing your pain and inflammation. Your trigger points are targeted with acupuncture needles to treat your pain, muscle tension, injury, and dysfunction. Dry Needling treatment is highly effective and you will often feel immediate pain relief as your muscles relax.
Common injuries treated with Dry Needling
Headaches & Migraine
Carpal Tunnel Syndrome
Hip & Knee Pain
How does Dry Needling work?
Needles are usually used to target painful trigger points in muscles. The penetration of the needle causes a micro-trauma that increases blood flow and alters the chemical balance in the muscle, assisting with muscle relaxation and healing.
The stimulation of pain receptors also causes the body to release opioids (e.g. endorphins). These are natural pain relievers in your brain. Their release provides further pain relief to you.
Your muscle may respond with a twitch response to the needle stimulation. This is a highly effective form of dry needling treatment and you often feel immediate benefits from this form of release. Your muscle releases tension and lengthens. Substance p, a pain chemical in your body, as well as inflammatory chemicals are eliminated around your trigger point. Flushing out these nasty chemicals can provide a longer lasting pain relief.
How is Dry Needling different to Acupuncture?
Acupuncture generally refers to the traditional Chinese medicine which is based on stimulating the flow of Chi (energy) through the meridians of the body, whereas Dry Needling is based on anatomical and neurophysiological principles. While the dry needles are the same and many of the ideas behind acupuncture are still applicable, the principles behind the use of Needling are very different.
Often people may use the term acupuncture when referring to Dry Needling so if you have had acupuncture in the past it could have been Dry Needles.
Is Dry Needling Physiotherapy safe?
Dry Needling Physio is very safe. There are certain factors that may make you unsuitable for Needling or that require extra care to be taken (e.g. Diabetes) but your Physio will consider these. All dry needles are sterile and used once before being disposed of safely in a sharps container.
Will Dry Needling Hurt?
One of the great advantages of Dry Needles over deep tissue massage for muscle release is that there is generally less pain both during and after treatment.
Most people don’t feel the insertion of the dry needle. When the needle penetrates the trigger point, you may feel an initial twitch or deep ache that quickly settles to become a light dull ache, warmth, heaviness or nothing at all. This is far better than the constant feeling associated with a firm massage that would be required to achieve an equal effect.
After Dry Needling Physio treatment there is often no or little soreness. Sometimes you may feel slightly tight, sore or an ache for a short time (up to 1-2 days). This again is invariably much less that than felt after massage and soft tissues techniques.
What is it?
Hip bursitis is a fairly common condition, and involves inflammation of the bursae around the hip joint. The bursa are small fluid-filled sacs, and are present to reduce the friction between tendons and the bone and ensure that everything is able to move smoothly. However they can become inflamed and painful with overuse, trauma and incorrect muscle use or weakness. There are many, however the bursitis we most commonly see is the Trochanteric Hip Bursitis. The trochanteric bursa cushions the outside of the hip against the gluteal muscles (especially gluteal maximus) and the Iliotibial Band (ITB). It is the most commonly injured as these are muscles very commonly used and therefore give the bursa a lot of work!
What are the causes?
As mentioned earlier, there are a few key causes of bursitis:
Overuse (or muscles around the area) and repetitive stress – eg. With frequent running, jumping, squatting
Trauma – e.g. a fall directly onto the outside of the hip (where there isn’t much padding)
Incorrect muscle use and muscle patterns, causing altered biomechanics of the lower limb – this can also include weakness of the core muscles
Weakness in the deeper gluteal muscles (Gluteus Medius and Minimus), and tightness in the Iliotibial Band (a band that runs down the outside of the thigh). As a result of the weakness in the deeper gluteal muscles, the gluteus maximus (biggest gluteal muscle) is forced to work more than it should, and so places more pressure in the bursa, which over time causes irritation and inflammation, and pain.
Interestingly, there are recent studies to suggest that hip bursitis does not often occur on its own, and that there is commonly some element of Gluteal pathology – especially tendinopathy of the Gluteus Medius (the main stabilising glute muscle). This may be the causative reason for weakness in this area, however it is not known yet as to which comes first – the bursitis, or the tendinopathy.
What are the signs and symptoms?
Commonly, sufferers will have a sharp pain on the side of their hip (worst directly over the bony outer part of the hip, and often tender to touch). This pain may extend down towards the knee, or even upwards towards the lower back. In fact, as the lower back, hip and knee are so closely linked, it is not uncommon to see problems in all areas along with hip bursitis, including pain, stiffness and restricted movement of these areas.
Sometimes there will also be a visible swelling over the outside of the hip, or even just the feeling of swelling.
There is often difficulty lying down on the side (due to the direct pressure), or even on the unaffected side (due to the stretch). This may cause trouble with sleeping.
Walking is also aggravating, especially first thing in the morning, or after a busy day. A limp may be present. There may also be pain with sitting cross-legged, or rising out of a chair after sitting for a while.
What are the treatment options?
There are several options when it comes to improving pain and keeping the bursitis away.
Physiotherapy – this is highly successful for treating trochanteric bursitis. Initially, treatment will involve techniques to reduce the pain and swelling (eg. Ultrasound, ice, gentle massage, acupuncture, taping). Following this, your physiotherapist will aim to return full range of motion of the affected hip (and also lower back, knee if affected), correct any muscle imbalances around the hip and restore full function of the stabilising hip and core muscles, and work to eliminate any excess tightness that may be contributing to the problem. Due to the nature of trochanteric bursitis, and the danger of it recurring, a long-term program may be required.
Ice – due to the inflammatory nature of trochanteric bursitis. Ice for 15 minutes at least once per day, and also after aggravating activities
Cortisone Injections – this involves injecting a corticosteroid (anti-inflammatory) along with a local anaesthetic into the bursa in order to settle the inflammation and stimulate healing. A guided injection (usually via ultrasound) is preferred as it will assist with needle placement. Cortisone injections can be very helpful, however repeat injections have been shown affect tendon health detrimentally – it would be wise to discuss side effects with your GP.
What can I do to help?
If sleeping is a problem, it can be improved in the short term with a pillow between the legs, to level out the hips when laying on the unaffected side.
Driving can be aided by sitting slightly higher (so your hips are not as bent). This may involve lifting the seat (in newer cars), or simply sitting on a pillow. Do make sure you can still reach the pedals & drive safely however!
There are several helpful exercises that will assist in recovery and strengthening. These will ideally be performed after the initial healing phase is completed (that is, when the pain and swelling have diminished). These exercises should be performed within your comfort levels, without causing pain.
Seated gluteal stretch
Sit on edge of chair, cross one foot over the other knee, SIT UP TALL, and lean forwards
There should be a comfortable stretch in the buttocks, or even down the side/back of the leg
Hold 20 seconds, repeat 3 times each leg
Lying gluteal stretch (Single knee to chest)
Lying on your back, slowly bring one knee up towards the opposite shoulder as far as comfortable.
You should feel a gentle, comfortable stretch in your lower back, or buttocks
Hold for 10 seconds, repeat 5 times
Start on your back with knees bent (no pillow is best)
Slowly roll pelvis/hips off floor, followed by one vertebrae at a time
Aim to lower down, one vertebrae at a time
Try 10 repetitions
Prone Knee Bend
Start by lying on your tummy, feel the front of your hips on the floor.
Bend one knee to 90 degrees and then slowly lift thigh off floor (the front of your hips should stay firmly on the floor)
Once lifted, straighten your leg in the air, then slowly lower your straight leg
Repeat 10 times each leg
Start lying on your side with knees bent slightly. Make sure your shoulders, hips and feet are in a straight line.
Keep your feet together, back still and gently open your knees apart.
Repeat 10+ times on each leg, or until fatigue
* This exercise is especially helpful as it targets the Gluteus Medius
As above, make sure your body is aligned well.
This time, lift your feet up, keep your lower knee on the floor and lift your knees apart.
Repeat 10+ times on each leg, or until fatigue