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.
A Running Analysis at Saanich Physio involves one of our experienced Physiotherapists observing and assessing how you run. We will watch you in real time and also video you, so that we can analyse your form in slow motion.
This kind of analysis is helpful whether you have an injury or if you want to know if you are running with optimal technique. We will explain our findings to you, with analysis of how certain movement patterns or imbalances may contribute to your injury or efficiency as a runner.
We highly recommend this no matter what level of ability you are, whether a beginner, weekend jogger or competitive athlete.
We Are Runners
We feel that in order to understand runners and running injuries, it’s helpful to be a runner yourself. Our Physiotherapists are all keen runners and between them have competed in short and mid distance track events all the way up to half marathons, full marathons and ultra-marathon distances.
We watch you run in real time, then record you and analyse your form using slow motion video. We will outline how your form compares to the ideal. We will only look to change particular elements of your form if it is impacting on your injury, efficiency or if it will help you prevent injury.
We focus on education, with a clear explanation of our findings and how they impact your body. We work with you to achieve a more efficient running technique.
Our aim is to get you back running as quickly as possible if injury is stopping you. We will provide specifically targeted exercises and a return to running program if needed. Our aim is to help you achieve a stronger form, become more efficient, and prevent injury.
Our experienced Saanich Physiotherapists will analyse your running technique and help you achieve better form to prevent injury and maximise efficiency.
Your Physiotherapist will start by discussing your running program and injury history with you.
They will then video you running. From observing you in real time and also through slow motion recording, they will explain what ideal running form is and how your technique compares.
Based on the findings from the video analysis we can give you specific and individualised cues to help improve your form. You will have a chance within the session to practice this on the treadmill and review your video footage.
A biomechanical assessment may also be performed to test your joints and muscles for flexibility and strength. From this information we will create a specific and focused treatment plan that will work to correct your imbalances and help you become a better runner.
Three Steps to Better Form
Video analysis and running assessment software
Biomechanical assessment of your strength and flexibility
Personalised video home exercise program which can be accessed on your smartphone or computer
Patellofemoral joint injury/runner’s knee
Tibialis posterior tendon injury
Iliotibial band syndrome
Hip impingement, labral injuries
Chronic strains and sprains
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.