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Swimmer’s Shoulder

By James N. Johnson, MD

Swimmer’s shoulder is the term most commonly used to refer to the triad of over-use injuries which affect the anterior capsule (front) of the shoulder. The three conditions which all cause similar pain are biceps tendonitis, subacromial bursitis, and rotator cuff (usually supraspinatus) tendonitis. These entities all overlap and are related. The problem develops one of three ways or a combination of the three – improper technique related to a strength/laxity imbalance, too rapidly increasing volume, or too rapidly increasing intensity.

Improper technique, most often in freestyle swimming which makes up the largest percentage of training volume, develops because the athlete that chooses swimming usually has lax (loose) joints. A loose shoulder joint causes what is commonly called dropping the elbow but is actually the front part of the shoulder joint moving anterior (forward) to the plane connecting the body to the arm, more technically called anterior subluxation. The simplest way to correct this is teaching the swimmer to roll his or her body as a unit – hips, core, and shoulders at the same time. The idea is to keep the head and spine in line and for the body to rotate on the long axis of the spine like a barbecue skewer. Bilateral breathing may help some swimmers who have asymmetric body roll. Pulling with a buoy may help in the learning process by floating the legs thus decreasing the load on the shoulders and emphasizing the importance of generating the roll from the hips and core.

Too rapidly increasing the volume or intensity of training especially in the context of improper technique exacerbates the problem. Volume in itself is not bad. Some swimmers respond physiologically to high volume training based on their cardiovascular characteristics and muscle fiber type. Also, there is a place for high intensity training for a different type of athlete. And combinations of volume and intensity in different percentages benefit different athletes. But generally a progressive training program in terms of volume and intensity will protect the athlete with improper technique from swimmer’s shoulder. So, it is important to know each athlete’s training and racing history before beginning a season. Important aspects to consider are: maximum training volume per week in career, average training volume per week over the last season, number of years training and number of practices per week over that career, and, of course, history of race times and when they occurred during each season.

If an injury does occur despite proper technique and progression, prompt and considerate treatment is required. First, athletes must be allowed to communicate that they are injured. Once an injury is identified, the first thing a coach should recommend is to get a physician with an interest in sports involved. The athlete needs to have a proper evaluation and appropriate diagnostic work-up to diagnose swimmer’s shoulder because there are less common more serious problems, which must be ruled out. After a diagnosis of swimmer’s shoulder is made, the initial treatment includes relative rest, ice, and anti-inflammatory medication. Relative rest is generally returning to the level of training at which the shoulder did not hurt. If the pain persists at this level, further reduction in training load should be considered. Ice should be applied for 20 minutes at a time at least three times daily or more often if possible(as much as 20 minutes per hour in the evening after practice and prior to sleep). And, under a physician’s supervision, a 10-14 day course of anti-inflammatory medication (being aware that stomach pain could indicate a side effect, which would require discontinuation of medication). If initial treatment is unsuccessful after a two-week trial, reevaluation by a physician and subsequent physical therapy may be indicated. Cortisone injections are recommended by some physicians, and there is a place for them; but make sure the physician knows if the athlete has had any previous injections and where the athlete is in the progression of their swimming career (someone approaching their last ever meet may be a better candidate for an injection than someone early in their career). Surgery is a late stage treatment in rare cases.

In addition to monitoring technique and progression of training, prevention should also focus on strength development of the primary scapular stabilizers in addition to the rotator cuff. The rotator cuff muscles should function only as the secondary stabilizers of the shoulder joint. The rotator cuff is designed to move the shoulder through its full range and should not bear a heavy load. Strength training should focus on the trapezius, rhomboids, serratus anterior, and latissimus dorsi muscles of the back in addition to band exercises for the rotator cuff DONE PROPERLY, (emphasizing the inner range of motion which is well described in the literature).

Swimmer’s shoulder is a common entity which all coaches should be familiar with. There are accepted modes of prevention, diagnosis, and treatment that should be followed, which can help the athlete return to competition. If the physician, coach and athlete communicate and work closely together, fast and fun and injury-free swimming will be the end result.

References

  1. “Swimmer’s Shoulder.” Lecture by Craig Ferrell, MD ACSM Annual Meeting. 3 June 2000
  2. “Swimmer’s Shoulder: Targeting Treatment.” Scott Koehler MD and David Thorson MD The Physician and Sports Medicine. Vol. 24, No 11, 39-50, Nov 96.
  3. “Swimming Injuries.” William C. McMaster MD Sports Medicine. Vol. 22, No 5, 332-36, Nov 96.
  4. “Rehabilitation of Injuries in Competitive Swimmers.” Katherine Kenal and Laura Knapp. Sports Medicine. Vol. 22, No 5, 337-47, Nov 96.
Mayo Clinic, Department of Family Medicine, Jacksonville, FL, USA Swimming Sports Medicine Society, Assistant Coach of Gustavo Borges and Beaches Aquatics Club Olympic/Olympic Trials Group.
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Exercises

by Coach Ed Fraser

Editors Note: Ed Fraser is the age group and high school coach for the USA’s two top breaststrokers of the moment, Jeremy Linn for men, and Kristy Kowal for women. Linn is currently swimming at the University of Tennessee, and Kowal at the University of Georgia. Earlier, Fraser developed breaststroke sensation Anita Nall. All from a small town in Central Pennsylvania. This man knows something about breaststroke kick. We are indebted to him for sharing his ideas with us here.

EXERCISE #1 Swimmer stands firmly on both feet with hands clasped firmly behind head &elbows pressed back behind the shoulder line. The legs are then slightly bent with the knees pointing sideways and a leap upward is made. On landing, the feet should be 18 inches apart with the knees still pointing out and the back erect. The leap is then repeated and the landing made with the feet together, the knees out and the back erect. We do a minimum of 16 repeats starting out &then in as the swimmers gain strength. I believe this one is especially good for power off the wall and increasing ankle flexibility.

EXERCISE #2 The back is kept erect. The knees are bent as far as possible with the feet turned out. When no further bend is possible, the heels are raised and bending is continued until the thighs are horizontal to the floor. The heels are then lowered to the floor, keeping as much knee bend as possible. Then, keeping heels on the floor, the legs are straightened. In 5 the heels are raised and then the starting position is resumed. NOTE: The toes are pointed out throughout the exercises. We do 4 repeats of this slowly.

EXERCISE #3 The knee is thrust (with force) forward & upward 4 times, then sideways 4 times, then backwards 4 times, then sideways again 4 times. The starting position is then resumed and the exercise is then repeated using the same leg before moving on to the other leg.

EXERCISE #4The leg is lifted about 12 inches off the floor and straightened to the side. It is then turned inward with the knee bent &thigh across the body. The thigh is then lifted as high as possible and turned sideways where the leg is again straightened and locked out. At this point the leg moves in a circular movement 4 times. NOTE: This is done 4 times without putting the foot back on the ground. Then the starting position is resumed. The exercise should be done slowly. Repeat on the other leg.

EXERCISE #5 Both heels are raised from the ground. Keeping the body erect, go to a squat position. The leg opposite from the supporting hand is then extended slowly until straight. At this point using the support leg ONLY, the body is brought to an upright position with the leg still extended in front. We repeat this 4 times on each leg. NOTE: Caution here as this exercise causes pretty good leg strain.

EXERCISE #6 Start with the body erect and the right arm held horizontally. The heels are then raised and the legs bent to a squat position with the back erect. The head is then placed on the knees and the heel is grasped with the free hand The knees are slowly straightened without the head being lifted from them. Recovery to the starting position is then carried out. We do 6 to 8 repeats very slowly on each side.

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Teaching Backstroke with Mirrors

By Michael Cody, Mountain Lakes, NJ

In an effort to teach backstroke better we resorted to using mirrors. We used mirrors to teach body roll, a still head position, bent arm pull and proper hand entry. At first we used mirrors on land. The swimmers would look at themselves in the mirror while the coach instructed them on the corrections. However, this method did not give the immediate feedback I was looking for! I could put the mirrors in the water on the pool bottom and all of the other strokes were given immediate feedback. The feedback given was limited but was still great. We videotaped our backstrokers underwater, from the balcony and from the side and ends of the pool. However, the swimmer would get out of the water, see visually what they were doing and get back in and try to make the proper stroke correction. I was still left looking for something immediate. I asked How can I use a mirror for backstrokers? I thought that if a swimmer could see themselves while they were swimming backstroke they would be able to make the corrections themselves. How can I place mirrors above the pool on the ceiling so the backstrokers can fix their strokes.

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Coaching Novice Swimmers Freestyle & Backstroke

By Pete Malone, Head Coach; Mike Lewellyn, Head Age Group Coach; and Mary Lane Kamberg, Novice and Age Group Coach.

Peter Malone earned a Bachelor's in Business Administration and Financial Management. He was awarded a Business Education Certificate from the University of Toledo, and was a licensed teacher in Ohio from 1972-1975. From 1975 to the present, Peter Malone has been the General Manager and Head Coach of the Kansas City Blazer Swim Team. He is also the Chief Aquatics Administrator at Johnson County Park and Recreation District.

From 1968-1974, Mr. Malone was the Head Coach of the Greater Toledo Aquatic Club. There he also established and managed the US Diving Program. He was also the assistant High School Coach at Toledo St. Francis DeSale, from 1968-1972. Some of his professional achievements include being the coach of Olympic Gold Medalist Janie Wagstaff in 1992. Janie won 100m and 200m backstroke, and the 400m medley relay. Janie also holds the American Record, in the 100m backstroke. In addition, Mr. Malone was the coach of Mark Dean, who was a member of the 1988 Olympic Team and the 1991 Pan American Team, where he won a Gold Medal in the 200m Butterfly.

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Training For Middle-Distance & Distance Swimming Events

By David Pyne Ph.D. Sports Physiologist Australian Institute of Sport

The middle distance (400m) and distance (800m and 1500m) events require a highly developed level of endurance fitness. Historically. Australia has produced many champion distance swimmers. This trend continues with our successes in the Mens 1500m Freestyle and the Womens 800m Freestyle events at the international level in the last few years. Despite the great work of our leading swimmers, there is some concern about the next generation of distance swimmers coming through. After the top two or three male and female distance swimmers, the standard drops away fairly quickly. The depth in these events appears to be considerably lower than in some of the form stroke and sprint events where the number of competitors in contention is comparatively much greater.

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