Maintaining Shoulder Health by Dr. Steve Kalandiak (2009)


INTRODUCTION: This is Dr. Steve Kalandiak from the University of Miami. He is a shoulder doctor. He is here to talk about maintaining healthy shoulders and I just feel that this would be a talk that probably many, many more people out there would like to hear, need to hear, and would want to hear him speak. We are very fortunate to have him come up and share his wealth with all of us at the clinic, so please welcome him.

DR. KALANDIAK: This talk is about your swimmers and is about the hyper-mobile shoulder which is both a swimmer’s blessing and also a swimmer’s curse. I want to thank Google and Yahoo for providing me with most of the images for the talk. Scott Rodeo is a Sports Surgeon at the Hospital of Special Surgery in New York and George Edelman is a physical therapist in Delaware. A lot of the exercise stuff and a lot of the prevention stuff I am going to talk about comes from talks that they have posted to the USA Swimming website and so that if you want to come and get that from me after, that’s fine. It is pretty easy to find on the USA Swimming website, you just type shoulder into their little search line and it is about the 4th hit. There is a series of articles about the swimmer’s shoulders there. So, as background, elite competitive swimmers put their shoulders through millions of stroke cycles over the course of their careers. I did a little bit of math; Michael Phelps, at least online, swims about 80,000 meters a week. That is 20 laps per 1,000 in a long course pool times the 80 a week, times 50 weeks a year, although I do not think he actually takes two weeks off. If you figure he takes 13 or 14 stroke cycles per lap,( you can look online and still watch him win a Gold Medal and set a World Record in the 200 Free in Beijing before those fancy suits came out), with his 15 meter underwater kick where he only takes 13 complete strokes to do 50 meters of freestyle, 35 meters of freestyle actually is pretty astonishing, but even with that incredible distance per stroke, which is about a million stroke cycles a year which is pretty astonishing. The problem with all those stroke cycles is that the same hyper-mobile joint that lets elite swimmers compete at the level they do also predisposes them to overuse injuries. Proper mechanics, appropriate therapy, rest and rehab are not just essential for fast swimming, but are also important for maintaining shoulder health.

What I want to talk about is the structure and the inner workings of the shoulder and the injuries that swimmers are likely to suffer and the prevention and treatment of these problems. Bill McMasters, an Orthopedic Surgeon has written a lot about swimmer’s shoulders and in 1993 he and John Troup did a survey of 12 ½ thousand US swimmers from age group up through Olympic level athletes. The prevalence of interfering shoulder pain at that point in time was anywhere from 10% for the age group swimmers to 25% for the National Team. The likelihood went up with increased time in the sport, up to and over 50% and as high as 80% in some studies have their training interrupted at some point in their careers by shoulder pain. Recently, some guys in the Orthopedic Department at the University of Iowa looked at 5 years of swimming and diving there. They had 94 swimmers and a 71% injury rate; about half of those resulted in missed time. The shoulder and the upper arm was the most frequently injured. Actually, the neck and the back were the most frequently injured. When the swimmers were cross-training, like doing weights or other sports, and they had a greatly increased number and risk of injuries in the freshmen, which would lead you to the conclusion that you should give particular attention to swimmers making the transition to a higher level of training. This would be more so with a guy who went from about 3 ½ to 4,000 yards a day in high school, up to probably 6-8,000 in college. I was one of those 37% that missed training time because my shoulders were not used to it. I do not want to kill you all with anatomy. I just want to go over the important parts so you will have some framework for understanding the injuries that we talk about later.

There are four joints in the shoulder. There is the A-C joint where the clavicle or collar bone connects to the acromion, which is the top of the shoulder blade. There is the glenohumeral, the ball and socket joint between the shoulder blade, the upper part of the humerus and the 4th joint is not really a joint, but it is very important and is the joint between the scapula and the rib cage. Actually, having a shoulder blade that is stable on your chest is a very, very important part of the mechanics of swimming.

The scapula is this flat bone jacketed by muscles and is really the platform that your arm works from. It is attached to your chest by all these. Your neck and your spine are attached by all these muscles. There are muscles that go from your torso to your arm and also from your scapula to your arm, so the important thing to remember here is that there are a ton of muscle attachments on the scapula and that just speaks to its importance in the shoulder. Two problems: the first is there is no bony stability in the shoulder. It is not really like a little ball in a deep socket. It is a lot more like a golf ball sitting on a tee. You have to have ligaments which are sort of static stabilizers, as we call them, that hold the ball on the socket rather than the capsule of the joint, which has these thickenings like here, here and here. Those are the ligaments that hold the shoulder together. One other ligament that is important for this talk is this C-A ligament that goes from the Coracoid, which is a bump on the scapula, to the acromion. The second problem is that in swimmers, ligaments are lax. This little curly looking thing is collagen which is a very, very complex protein that is twisted into fibrils that form fibers that combine together to form entire ligaments. It is not this kind of collagen which is probably what you see and hear about on a day to day basis. The important thing about the collagen your swimmers have is that it is really stretchy and it makes their joints really loose. They may look like this or even like this. If you are from Philadelphia like me, you have to put mustard on your swimmers. What I want to do is, work from the inside of the shoulder out, so if you look at the inside of the shoulder, like here, here is the socket that is called the glenoid. Around it is, a sort of bumper of soft tissue where the capsule and the cartilage and the covering of the bone all come together. That is called the labrum and is a really important structure for making the shoulder stable. Part of the bicep attaches right to the top of it and then the capsule here is what forms the ligaments of the shoulder, so that is the important part of that drawing.

Now, if you look at a slice through the shoulder you have this capsule that is one of the things that stretches out a lot in swimmers. You have the rotator cuff that has one of its tendons that people used to talk about with impingement in swimmers and other overhead athletes. The idea is that the tendons get pinched under the edge of the acromion. You are more likely to see real true rotator cuff problems if you coach masters because rotator cuff problems really are more of a degenerative thing that occurs with age. With loose jointed swimmers you actually see problems more in the joint proper rather than up here under the top of the shoulder blade. You certainly will hear a lot about the rotator cuff, it is a set of four muscles that sort of hug the ball onto the socket. There is one big one in front called the subscapularis that internally rotates your shoulder, and then there is one on top that is kind of a stabilizing force and two on the back, the infraspinatus and the Teres minor. They are the ones that rotate your shoulder out and they are actually the only muscles that rotate your shoulder out. You have a pec and a lat that are incredibly strong internal rotators, but only these two little guys rotate the shoulder out. This is the same view from above and this is here to show you the concept of impingement. If you look down on the shoulder you have these tendons coming out from under this ligament and the idea when people talk about impingement is that when you lift the arm up, these tendons get pinched under this ligament here. You have scapular stabilizers which are the muscles that hold the scapula to the chest wall. This is a view from the back and the important ones are the rhomboids and the levator. The trapezius holds the scapula to the body, but probably moves the scapula more than it steadies it. These are the stabilizers in the back. In the back, you have the latissimus which primarily pulls the arm down to your side and it also rotates it in. There is the deltoid in the back and then from the front you have the deltoid again. You have the pec which pulls your arm in and pulls it down from an elevated position. This is a very important muscle; the serratus pulls the scapula tight to your ribs. When we talk about injury prevention later it is good to know that this is a very important muscle.

The other reason we went through all the anatomy is to talk about the anatomic causes of shoulder pains. There is impingement and a newer thing called internal impingement. If you hear about impingement, what people are talking about is the rotator cuff and the bursa that lies over the top of it getting pinched or impinged by the acromion, and that CA ligament we saw before. If you are bringing your arm straight up it is more kind of the top of the shoulder blade, if you are bringing it way across, which is something you do not want to see your swimmers do, you will see beginning swimmers or people learning as adults will cross way over their midline. In doing this, you are more hitting the tendons on that CA ligament and you can feel it in your own shoulder. There is bone that is part of the shoulder blade called the coracoid, and (when you hear about impingement), this is what they are talking about. If you have swimmers with shoulder pain and they go see their primary care doctor to get an MRI. If they come back with a report that says that they have impingement, let me say this, teenagers do not get impingement, 20 year olds do not get impingement and 30 year olds do not get impingement.

If anybody is recommending an operation for impingement in anybody, probably up to the age of 30, they need to at least get another opinion. There is this newer concept called internal impingement and what this actually is, is more of an instability problem. You have these loose jointed people and they get their arm up in the air and then from this position (like in a thrower), they are internally rotating really hard and in a swimmer they are pulling down really hard. What happens is, instead of rotating smoothly in the joint, the ball sort of slides forward and down on the socket and that drags the tendons of the rotator cuff against the top back of the labrum. You have a socket and a ball that is supposed to be either rotating down or rotating in if you are pulling like a swimmer or throwing, but instead (when these really strong muscles fire), it is getting pulled sort of sideways across the socket. Question: Could that be like that sort of pain when you have your kickboard like this and you have a sharp pain in your arm? Answer: That is kind of a tough one. Let me show you two more things and then answer that question. There are two other things that you can get. A slap tear is a tear of the superior labrum when it is peeled off from anterior to posterior, front to back. That is sort of a detachment that can come from trauma, but can also come from overuse like a pitcher repeatedly cocking a throw or a swimmer recovering her arm back here over and over and over again. The last thing that happens is swimmers’ instability. They have what we call multi-directional laxity. They are loose-jointed and we call it laxity when they are just all noodley. It becomes instability when it generates symptoms like the repeated sort of off-center motion where you can tear this here, which is probably more a result of trauma and the ligaments tearing off the socket down at the bottom. It can happen as a degenerative thing like someone doing a million cycles a year as well.

Now to get back to your thing; the causes of shoulder pain in swimmers, in a loose-jointed person really, it is probably not just one thing and yes, 20 year olds can get true impingement. It is just not something I would operate on. So, if you have your swimmer out on a kickboard, and if you are doing a long kicking set and have got your arms really, really extended here with your body sinking and the kick board is pushing your arms up; you can see where those tendons would get pushed up and sort of pinched underneath the edge of the shoulder blade. If they are tight and up there, it may pinch the tendon if they are really loose jointed and are up in that position, the ball may sort of slide down in the socket a little bit and they could get that kind of superior labral problem. That was a good question. You know, if you stick an arthroscope in a painful shoulder, most likely in an elite swimmer, you will see more than one thing wrong. When I was a Med student at UCLA, before Title IX when they still had a men’s swimming team, a great idea that went astray when they enacted it, a guy that was doing a Sports Medicine Fellowship there took the entire men’s swim team and did MRI’s on their shoulders just to see what MRI’s of elite swimmer’s shoulders looked like. The whole team had one normal MRI, even though half of the guys did not have any symptoms and there were guys who were fine and you looked at their MRI and you would think, oh my God, this guy needs surgery. Knowing what a normal swimmer’s shoulder looks like is important if you have got a swimmer who has got shoulder pain that is interfering with his ability to swim. You are going to have these MRI’s that are not normal, but the important thing is you know what is causing the problem because sometimes it could be a movement pattern like a shoulder blade movement pattern that is not normal or not appropriate for what they are doing. Because of that they may have ligament problems that actually are NOT causing them that much trouble but may be something else that needs to be fixed. Guys in Denmark did arthroscopy on 20 elite level swimmers with shoulder pain and so over half of them had problems with the labrum, the little bumper around the edge of the socket, but still 30% had this impingement thing, the tendons getting pinched under the shoulder blade. With surgery and rehabilitation, only half of them got back to their pre-injury competition level, although maybe even fewer would have gotten back without surgery. It is with a variety of things that the success rate of arthroscopic procedures and returning these folks to sports was not that great. Scapular dyskinesias, abnormal shoulder blade movement patterns, were found to be very common in this group of people. So how do they get hurt? Well, yardage and intensity is one way. It is doing repetitive micro-trauma, a million cycles a year, if every stroke is a teeny tiny trauma, then a million times a year can add up to cumulative damage. There are people who I think are pretty respected guys, talking about incorrect stretching actually being something that could potentially worsen problems with the shoulder. You can get muscle imbalances like really strong pecs and lats, but no strength in the muscles that pull your shoulder blade back and rotate your shoulder out. If you think about what your swimmers do to train dry land; they do swim bench, they do bench press, they do pull downs, and they do all this lat and pec stuff because those are the muscles that pull you through the water. They really don’t attend to the little muscles that balance the shoulders out at all. My daughter finaled at JO’s and that is pretty good I guess, but she walks around like this because she has like these big pecs and lats and if she never does anything for the muscles that draw her shoulders back, she is going to have problems. Lots and lots of swimmers look like that and that kind of imbalance and tightness in the front of your shoulder, without strength or endurance in the back can be a cause of the problems, and then there are flaws in technique.

There is not really a lot to say about training yardage or training intensity except that you do need to look out for swimmers going from one level to another because that is a point where they just haven’t built up the endurance to do this stuff yet. Floyd Landis, the Tour de France bike rider, the year before he won and got booted for testosterone. Somebody talked to him about being over-trained and being fatigued from being over-trained and his answer was “there is no such thing as over-training, it just means that you have under-trained to that point in time. You have not built up the endurance to do something”. Michael Phelps swam 6, 7 or 8 months, up to the World Championships in Rome rather than two years and was relatively under-trained. Lance Armstrong has been riding probably 10 or 11 months for his comeback in the Tour de France this summer and he feels like he needs another year before he is in shape. If you are taking somebody to the next level, you really need to expect that it is going to take them probably a season or a year to adapt to a higher level of training. You need to be careful because if you press on past the point where their technique falls apart, if their mechanics are collapsing, then you are reinforcing bad stroke habits and you are putting their shoulders at risk, so go slow. If you want to increase their training, only increase one thing a week or every two weeks. Go up on their distance, but not the intensity or the density, but do not take everything up at once. Remember that elite athletes need months or years to get to their full level of fitness. That is it for training.

This concept of repetitive micro-trauma is how the swimmers get this acquired laxity where they are loose-jointed to begin with – like this lady here who is getting her arm pulled out of her socket by some guy pulling down on her elbow. When you take that baseline loose ligament shoulder that swimmers have and start stretching it a little bit, half a million times a year, or even a quarter of a million times a year, can actually make you worse instead of better. We get an unbalanced shoulder that fatigues and starts slipping out of place. That is when things start to get stretched out and poor mechanics can worsen this, and technique breakdown can worsen this also. So, why do we stretch? It is kind of traditional. We are sort of like, the big kids stretch so the little kids stretch. We think it prevents injuries, but there is actually very little proof of that. There are some papers that say it works and there are some papers that say it doesn’t, but on balance, it is certainly not a proven injury preventer in all situations. Stretching does relieve muscle soreness and there probably is a role for it to loosen tight muscle groups and correct an unbalanced joint. Question: On your last point on micro-trauma and acquired laxity – is there a pattern or is there a certain proper stroke technique that your 2 million or so strokes are not going to create those issues? ANSWER: I think so. We will try to get at that a little bit later, but one thing that people talk about that if you are in here, you make your catch in your start to cut through. The whole science of swimming is really like, this is how it works and then you actually look at the best swimmers in the world and what we think is often wrong like back before there was a butterfly, when like Johnny Weissmuller and Duke Kahanamoku were swimming. Anyway, they taught people to push straight back to go straight forward. Then Doc Councilman took a camera underwater and it turned out all the best swimmers in the world swam well. That didn’t really make sense so you know they were doing something right. They figured out this sort of next level of using your hand like a propeller to hold onto the water while you pull your body past. If you were a Thorpe or Phelps who have different sort of strokes and you look for what they all do the same, and what those guys all do the same is that they come in and they make their catch and they get their hand down and their elbow up and when they come through, their body sort of snaps over and they are always keeping their shoulder open.

People talk about scapular plane swimming now. That is, your arm being in the plane of your shoulder blade and is a very comfortable, mutual relaxed, safe position. If you start breaking down and you are pulling, put your shoulder blades forward so you are sort of stacked like this. Backstroke is one of the things that probably generates the most anterior hassle problem. It can even happen in butterfly from the recovery to here. You are stretching the front of your shoulder a lot more in a pattern where your shoulder blade is forward, but your elbow is back is one that is going to stretch the front of your shoulder too much. When you are coming from this position through to here, you want your shoulder blade and your arm lined up in the same plane. The rotation of your torso is what kind of gives you room to bring that through and keep that lined up in a way that doesn’t generate problems. It is like pushing the water straight back to go straight forward. It makes sense to us right now. I mean there are some reasons to do this, but if you look at these stretches and this is what these guys are saying. Scott Rodeo, who is the National Team Physician for USA Swimming is one guy, so it is a bright guy saying this. If you look at these stretches and these are all things that stretch the capsule, the anterior capsule, the inferior capsule, and the posterior capsule. Those are the structures that people have that cross over and have too much laxity; they have gone beyond being beneficial to creating problems. Those are the structures that become problematic.

They are talking about a door frame stretch where you come up and sort of step through. It goes more to the muscle than to the capsule or a stretch for your lats – where you are on a bar leaning through or on the ground lying like this. You are sort of letting your arm stretch out and in doing that, you will feel it more in your lats. It is not quite as powerful to the joint as you know. Really pulling it back to stretch your triceps is actually an interesting one to me because my neck used to always feel like I needed to do this, except I never did. The muscles that kind of elevate and retract your scapula get really tight and if you are training a lot, these are the ones that they are talking about doing because the muscles can get sort of unbalanced. Your pecs and your lats get really strong and they get tight. It is hard have good mechanics on the back of your shoulder. You have the adductors that are things that sort of bring your limps to your body. People talk about your pecs bringing your arm forward or your lats bringing it back, actually their most powerful movement is to bring the arm down to pull yourself when you are swimming. Those are very, very big and strong and they can really overwhelm the small muscles on the back of your shoulder and because they are so much stronger, they do not fatigue as rapidly as the smaller muscles that support the shoulder blade like your serratus, which is the muscle that stabilizes your shoulder blade to your side, and your subscapularis, which is one that fatigues quickly. If those muscles get over-powered, your scapula won’t move in a smooth manner so that can potentially contribute to this sort of acquired capsular laxity things because the movement patterns are not appropriate. The Rotator cuff is little, it fatigues faster than the bigger muscle groups. This is another thing that can cause this sort of instability where your big muscles are still good to go, but the little muscles can’t control your shoulder blade any more, so the link between your torso and your arm is sort of gone. This slide is an example of scapular dyskinesias. When the arm is pulling down, the scapula is sort of smooth to the chest wall and here on the other side they are pulling down and their shoulder blade kind of kicks out. This is called winging. The shoulder blade sort of kicks up off their back because the muscles that hold it down to the chest wall are not strong. A flaw in the technique is rolling our body a lot more; like I don’t think anybody ever told me to roll my body. They did 25 years ago, but nobody talked about body roll the way we talk about it now. You don’t want to have your arm across the midline. You don’t want to pull with an elbow that is too straight. You don’t want to keep training if you are so tired that your mechanics are falling apart.

Unilateral breathing, I don’t know. Jason Lezak looked pretty good when he split that 0:46 flat at the end of the 400 free relay in the Olympics and he only breathed to one side. Phelps uses paddles all the time and he has got great shoulders so, proper mechanics is obviously important. With breathing, and with paddles, there are defenders I think that would say exactly what you said. Comment: I have used paddles that have caused problems and the same sized paddle of a different manufacturer and a different shape, did not. Right. Comment: I think sometimes the shape of the paddle has something to do with it. Yeah, I think you are probably right. It probably has to do with the swimmer, the size of the paddle, their individual technique and the shape, because they feel different. Comment: I mean as a team we went through an entire style of paddles a couple of years back and had a huge number of sore shoulders. We didn’t change the training regimen at all. We just changed our paddle shape and went back to the paddles we had used previously and it went away. That is a good point. A lot of this stuff is specific to the situation and what you mentioned with Jason, I don’t know how Phelps breathes in practice, but I think a lot of the folks who say you should breathe on both sides to balance your stroke are people who are fanatical about it. They will flip out on their swimmer if they do not breathe every third stroke in a race and then there are other people who say in a race to do what feels right. You need more air you breathe every other stroke. Comment: I wonder how much of a hassle it would do to you with developing balance when you are developing a swimmer and making sure that you are symmetrical when you swim and then as you get older and that physiology is set and it is not going to change that much? The unilateral / bilateral breathing is really interesting to me because I think you are right about needing air. Breathing every stroke that whole hundred is probably what gave him that extra little burst to pass Alain Bernard in the last 15 meters. He had not built up the lactate that Bernard had maybe, but if you look at Lezak, Phelps or Katie Hoff, they have this kind of loping freestyle. They are very kind of one-sided, and I find it hard to believe that Phelps has ever breathed to both sides, not that he couldn’t if he wanted to. It’s just the way his freestyle is, it does not seem to cause problems for him. I think that the things that people sort of agree on, the things that are probably more accepted now, poor body roll is bad and a very flat freestyle doesn’t give you room to clear your arm, and I think one of the mistakes we make when we are talking to our swimmers is we talk about high elbows during the recovery. We don’t really mean we want their elbows high, like I don’t care if my swimmer’s elbow is high. That is just a proxy for a high shoulder on their recovery and it is one of these things where all the best swimmers in the world have high elbows, so we tell our swimmers: high elbow, high elbow, and high elbow. Then, you watch some little kid, you tell them high elbow and he pulls his arm up his side like this without turning the shoulders to open the front of the shoulder up and it is no wonder that we generate anterior shoulder pain.

If your body doesn’t roll, then a high elbow will cause shoulder problems. I have no interest in the FINIS forearm paddle except that this is a great picture to me, not of a high elbow, but a great body roll and you can see that with this great body roll, the arm is right in the plane of the shoulder blade. If you tried to go high elbow here, your shoulder would be just forced way back and you can see here and this is a great illustration of how hard it is to recover your arm through if you are not rolling. How easy is it to get your arm through with a high elbow if you have rotated your hip? It is amazing; I had stopped swimming after college and I kind of went back to it a couple of times and people were talking more about rolling your shoulders and I did try to roll my shoulders. One of my residents swam for Princeton and my daughter is starting to swim more, so one Saturday, we said let’s all go to the pool. My resident was talking to my daughter and she told her that when you put your arm in, take the point bone on your hip and make it face the bottom of the pool. I had never thought of it that way and I thought I’d try that and I immediately felt like a measurable difference in my stroke. I think you are very keyed into something, the upper hip, right, but it makes a huge difference to what this does. Obviously, crossing the midline is bad. It throws you all out of whack. This is another thing that people get all bent out of shape over. There is more talk about what part of your hand should go in the water first. Do you think Alain Bernard or Eamon Sullivan think about how their hand goes in the water? Or Stefan Nystrand? Or Janet Evans? It really doesn’t matter if you go in small finger first. When you are here and everything is relaxed, this is just window dressing; this is just your forearm attention. It is not your shoulder here, when it is going in; when it matters is after you have come out, that is when you need to realize that when we are trying to figure out correct mechanics we need to think about all the stuff the smart guys say and if they agree on something it must be right. So you have got little finger first guys and thumb first guys and fingertip first guys, but they all agree when you go to make your catch, straight to the bottom of the pool and then obviously, the problem is not how you enter, it’s how you make your catch. It is if you keep that when you go forward because that is a very unnatural position, so you go from entering here; that is where I think you need to get what you were showing. There are an awful lot of World Record Holders that do it wrong then. Comment: All my stroke mechanics are done constantly, I get in the water with all my swimmers and unless they are doing a certain technique, I don’t have them train. Right, I am not disagreeing with you, I think the thing that we all agree on, regardless of what people say about this is when you make that catch it has got to be right there. The fingertip is down to get the good pressure like you said because that pressure on your hand is the right thing. I don’t know if you guys are early vertical forearm folks and that pressure on your hand is what gets you up to get the pressure on your whole forearm. I think everybody agrees on that. Arm tree straight during the pull is more of an old school error. Comment: It has become a new school error! Well, I know. One of the guys I watched yesterday was Chello Filo(sp?) and I am looking at him and thinking that damn he swims wrong, so does Eamon Sullivan. Bernard’s pull does not look very good and I think the reason is that they are sprinters and you can have the same muscle acting in a greater distance which applies more force, but I don’t think you could do that stroke for more than a hundred. The point of this is not so much that it is bad for speed, but that it is bad for structure. Comment: I have tried that quite recently for my self. My guys were in the water and tried to do a normal sprint and compared to the other sprinter, straight-armed, it does have a lot of costs and you feel it. Yeah. –– You feel it really a lot if you have to have this part and for the back muscles really to be strong for that. So, pressing on; when mechanics fail, if your swimmers are breaking down, you need to switch their stroke, you need to change to a drill. You need to kick instead because if their stroke is falling apart, and they continue to swim, you are just reinforcing their bad technique and you are putting their joints at risk and you’re potentially contributing to them developing laxity if they are really in a high yardage program. Mary T. Meagher may have been able to do 1,000 fly or 10,000 fly or whatever it was she could do. Her hips floated higher than anybody else’s I have ever seen in the past 20 years, but I do not think Christine Magnuson ever does more than a hundred fly at a time. Comment: Obviously, if you do too much fly, you can damage your technique. Mark Spitz you know, if you read Doc’s book, was really kind of lazy. Mary T. Meagher could do it. You know – she didn’t break down, but she is the exception and not the rule.

I think we did talk about breathing and the paddles a little bit, so treatment should primarily be non-surgical. 1st, 2nd and 3rd visits to the doctor remember; You can always operate on somebody, you can never “un-operate” on them. You can have a pretty bad labral injury and win an Olympic Gold Medal just by doing therapy, and actually, if you keep at it, you can do the same thing 4 years later. Do not swim through the pain! You can swim with it, if it’s not too bad and you can do different strokes. You can drop your intensity or your yardage and then build back up. If it is really bad, you’ll want to minimize their swimming. You can work on aerobic fitness, you can work on their core and you will want to look at their technique and see if you can figure out why they are in pain. Saying, “I swam through pain, so you should do it too,” is NOT the way to go!

If there is really a problem, and if there is a really, really good therapist in your area, a good physio, it would be good to have them evaluate it and get them on an exercise program that is going to hopefully prevent problems. If you want surgery, I can give you my phone number, but basically you want to repair or re-attach torn stuff if you can. In some cases you might want to tighten some stretched tissue; that is probably still sometimes an open operation. We tried shrinking capsules with magic heat wands and it did not work. I am proud to say that I never shrank anybody’s capsule, I always thought that it was bullshit. If you have got a Masters swimmer with a tear that cannot be repaired, and they cannot work their problem out with therapy, you can just smooth rough areas, but the rehab for surgery is long. You know, it takes a year to really come back to an elite level. Prevention is the best cure. Shoulder and muscle development is important, but probably not too much. You want to be able to touch your ear at least.

The USA Swimming website has these excellent articles so go to USA Swimming, there is a little search bar on the right, you type in shoulder and it is in the first five hits and they have 3 really good papers on the stretching stuff that I went over briefly. There is a sort of committee program on a good dry land program, to prevent problems in the uninjured shoulder. This is for after practice or a few hours before or a couple of times a week. You don’t want to do it right before to fatigue the muscles.

Rotator cuff, scapular stabilizers, core and stretching, I will just go through these fast. If you all have questions you can ask them. Rotator Cuff: all of these exercises are low resistance, high rep, not fast rep, and controlled. Do a couple of minutes on a minute break, but if you lose your form, you stop. These are surgical tubing. That is a loop of surgical tubing right there and it is actually a Thera-Band. Thera-Band light, and you want to have something real light when you start doing it. It should feel really easy because you are going to do it for 2 minutes. External rotators: pinch your shoulder blades back and start here. Hold out for a second and then let it go. Hold out for another second and let it go. Scaption: this is your biomechanics question; you know the plane of your shoulder blade is not here, the plane of your shoulder blade is here and is about 30 degrees forward of the plane of your body. If you take 10 pound weights and try and lift it up here. 10 pounds is way heavier than you would use for this exercise, this is barely an arm weight exercise, but take a 10 pound weight or even a 5 pound weight and lift it up here, you will find that it is really uncomfortable. Lift it up here and it is kind of uncomfortable. But, lift it in the plane of your shoulder blades, and you actually feel that that is the place that your shoulder wants to be. A ball on a wall works your scapular protractors, the muscles that push your shoulder blade forward, although I think you want to hold back for this and work more on the rotator cuff.

The muscles that stabilize your shoulder blade; you are all familiar with Rose, this is lying down on your belly and just kind of coming up a couple of inches and holding it. In all of these exercises you are kind of pinching your shoulder blades together at your spine and a push-up plus which is a push-up and then push through it, like push your shoulder blades forward on your chest wall. You are arching your back, but intact. It is this little extra bit forward that really works that serratus. We talked about how that stabilizes your shoulder blade to your chest wall. This article is a few years old but CORE workouts are so popular now. You can go to Yahoo and type core and you will get about ten million exercise programs. When you want to work your abs, you want to do stuff that works your obliques but you also want to work your lower back.

This is a good one because I think we ignore the low back a lot. It is relative to abs now that we are doing all this core stuff. Some people call this Bird Dog and some call it Quadra-ped. Your back should be flat. Your belly should be tight and your low back should be tight. One way to think about it is that you are trying to suck your belly in and get into a pair of jeans that are too tight. That is the position you want to be in when you are doing these exercises. You lift the opposite leg and opposite arm.

Stretching: hamstrings, upper back, this is stuff we kind of ignore. You can strengthen your upper back with these YTWL stretches and these are actually good to do on a ball. A ball is great for stretching. It is really good for core stuff and you can do a lot of stuff for your back on the exercise ball and I think that is probably the thing that it is good for that but hard to get anywhere else. I mean, you can lie over that thing in the gym and do reverse sit-ups, but that just feels so uncomfortable. All the stuff on the ball is lower resistance and higher rep and very good for stabilizing the back side of your core. Hyper mobile joints let’s swimmers compete, but they also predispose them to injuries. Control your increase in training. Make sure your swimmers have good mechanics. Get them some preventative exercises and do not try to fight through problems. Recognize them, rest and figure out why it is happening, because fixing that is how you are going to get your swimmer back in competition long-term.

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