I would like to review a little bit about shoulder injuries in swimmers. I am an orthopedic surgeon and practice in New York City. I specialize in Sports Medicine, my name is Scott Rodeo. I am currently the chairman of the USA Swimming Sports Medicine Committee. I thought I would give you a little overview of shoulder pain starting with the shoulder function and talking about what causes shoulder pain. Then, I’ll try to spend a little time on treatment and prevention. This will then lead into our last talk, Rick Eagleston’s talk about rehabilitation for swimmers with shoulder problems. I thought I would start with this quote because I think it is a great quote from Doc Councilman which really sets the stage and describes where a lot of these overuse injuries come from.
Anyway, if you think it is clear to us and we all know shoulder problems in swimmers are quite common. The incidents reported are anywhere from 40-70%. If you do some simple calculations you can add up the incredible number of arm rotations that occurs over the course of a training season. This is a typical overuse type of injury, not a whole lot different from what you will see in throwers, in tennis players, or any type of repetitive overhead type of activity. It is the high training volumes that really leads to these overuse types of injuries.
So, in this talk, I would like to briefly go over the mechanics of the swim stroke, how it relates to shoulder pain, and how certain positions can cause shoulder problems. We will talk about shoulder muscle function and then the role of muscle fatigue and joint laxity in shoulder pain in swimmers and then finish with a little bit on treatment and prevention. So, just as a point of departure, the typical factors that you should think about are causative factors in swimmers shoulder lie in probably three broad areas:
- Muscle fatigue and muscle overload
- Shoulder laxity or instability
- The impingement positions that occur during the swimming stroke
I would like to start with the last factor and talk a little about the mechanics of the swimming stroke. You will hear a lot about impingement. What is shoulder impingement? What is it that occurs? There are two types of impingement and these are probably the final common pathways that cause a lot of shoulder pain. The cause may be muscular, it may be musculofatigue, it may be instability, it can be a lot of different things, but a lot of the pain that we see does, in fact, come from impingement. Impingement can be from the rotator cuff or bursa on the overlying acromion so that would be the superficial aspect, if you will, of the rotator cuff. Another site of impingement more recently recognized is the deep surface of the rotator cuff, the articular surface which can contact the glenoid. The socket or both are potential sites of impingement.
If you think about the mechanics of the swimming stroke, certain stroke positions can certainly put a swimmer in the position for impingement. Quite simply, the overhead position where the arm is internally rotated is a classic impingement position and happens to be one of the tests we will often do in the office to reproduce impingement. It is a little provocative maneuver. Well, that is what happens, obviously, in a swimming stroke. A lot of the positions of the arm at the entry phase are sort of in that position. Again, the classic position for impingement is a forward elevation with the arm a little internally rotated, exactly what you find happening during swimming. Some of the impingement positions that occur during the swimming stroke are found in three different areas, at the pull-through, at entry as the arm comes in, and the hyperextension with the arm back in this position. At the glenohumeral joint, this actually forces the humeral head anteriorly or toward the front, actually anterosuperiorly can lead to impingement. So, this extension or even hyper extended position at the finish of the stroke is another impingement position. Jim just mentioned to you one that you can try. It is an earlier exit and that would be the reason and then during the recovery, again it is the elevation or overhead activity that causes this condition. These are all positions that can cause glenohumeral impingement.
I will now discuss the mechanics of the shoulder and how it relates to muscle function thus helping us set the stage to understand how shoulder pain occurs. Shoulder function requires a very highly coordinated synchronous pattern of muscular activity and muscle firing. There are no fewer than twenty muscles around the shoulder joint that control the shoulder. You know, the shoulder is a ball and a socket. At the socket side, your scapula is just suspended on the chest wall by muscle. So, muscle function is critical for maintaining normal shoulder mechanics. There are forced couples of muscles in the front and the back to balance the humeral head. Think of it like a golf ball on a tee, there are muscles in the front and the back that needs to fire appropriately to balance the humeral head. Again, the shoulder is an inherently unstable joint and these muscle forces really help provide stability. Muscle’s forces are even more important in the setting of concomitant instability or laxity. We will talk about that in a little bit here. This just show how there is a force coupling between the internal and the external rotators, essentially the muscles in the front of the shoulder and the muscles in the back of the shoulder.
This is some EMG work which is basically electromyelography to document or measure muscle activity throughout the swimming stroke. The infraspinatus muscle, on the bottom, is an external rotator and the subscapularis is an internal rotator. You see the internal rotators are used much more and that is consistent with the swimming stroke. There is a lot of internal rotation and in general, the internal rotators are stronger than the external rotators, normally, but there can be some imbalances that occur during swimming which relates to shoulder problems.
Most likely, the primary factor in shoulder problems in swimmers is muscle fatigue. Again, its back to overload and an overuse type of mechanism. This over-training leads to fatigue of not just the rotator cuff, but perhaps more importantly, all of the muscles around your shoulder blade. The scapular muscles and, in particular, the two areas that have been really identified is the serratus anterior and the subscapularis. Those two muscles in particular are affected, although that is probably because they have been the best studied. There are other muscles that clearly have to compensate and will also fatigue. That fatigue then affects shoulder mechanics. The result of muscle fatigue is imbalance and again, you will lose this force couple I showed you a minute ago, the importance of these normally, of this force couple to control the shoulder. Once the muscles fatigue and do not function normally, you lose that force couple. Just as importantly, the rotator cuff’s function is to keep the humeral head down, to keep the joint centered. A dysfunctional fatigued rotator cuff will allow some upward migration of the humeral head which will directly increase impingement. But again, these altered mechanics is what will lead to the eventual impingement.
Here are some specific abnormalities that have been demonstrated in shoulders of swimmers, again using EMG to measure muscle activity. These studies really document the fact that there is muscle fatigue and alterations in muscle function in swimmers.
This picture here demonstrates, this is looking just at one muscle, the serratus anterior during butterfly swimming. The solid line represents normal swimmers with normal shoulders. The line on the bottom, the dotted line, represents swimmers with shoulder pain. You can see the real difference in serratus anterior muscle function and muscle activity in swimmers with painful shoulders. This muscle had fatigued out so it really affects shoulder mechanics. Again, the subscapularis and serratus anterior are the two that are felt to be very vulnerable to fatigue. It makes sense because they are active throughout the whole swimming stroke. To summarize that whole pathway again, this fatigue leads to eventual muscle dysfunction. This is the rotator cuff which results in loss of the synchronous muscle furrowing patterns thus leading to abnormalities, also in joint position sense, the joint proprioception. The therapists in the room I am sure are familiar with that. All that will combine to lead to abnormal kinematics or abnormal motion of the shoulder resulting in the impingement and the causes of pain.
This picture of the swimmer in the water shows the arm during the recovery phase. But I wanted to use this picture to point out the importance of the scapular muscles. You can see how in this position the humeral head is here. Now, the scapula, your shoulder blade, is here. Where my pointer is now is part of the scapula, the acromion, and here is the humeral head. In this position, there is impingement and so you can see that the scapular muscles are critical for controlling the scapula. In particular, this just shows the serratus anterior here. So if these muscles, not just the serratus, there are a number of other ones not demonstrated here, but if all the muscles that control the scapula are not working normally, you have abnormal scapular mechanics. That will very much affect your swimming stroke and eventually lead to fatigue of these muscles, abnormalities in the stroke, and eventual pain. The abnormalities can be quite subtle. There are muscle fatigues during the course of a practice, a set, a week, a month. You can have very subtle alterations in the stroke which will slowly start to cause dysfunction and cause pain.
Not leaving out the other important muscles that we know are very critical, even in shoulder and upper extremity function, the so-called core muscles. These are the lower back, abdominals, and pelvic muscles. I think there is a lot of recognition in recent years of the importance of these muscles and their role in assisting normal arm function. In fact, fatigue of these muscles can certainly contribute to shoulder pain by also affecting scapular kinematics. It will affect the whole position and action of the shoulder blade and also, it affects the body position in the water. So, weakness in that area is critical. In fact, most rehab programs start with the abdominal, low back, and pelvic muscles. Rehab programs actually work on the shoulder muscles last. This is really similar to what other therapists or trainers do to take care of other throwers, if there are therapists and trainers in the room. It’s the same type of principles you use in taking care of a thrower or a tennis player or for that matter, anyone doing these repetitive overhead activities.
Some other specific abnormalities that have been documented in swimmers:
An imbalance between the internal and the external rotators, the front of the shoulder with the back of the shoulder. Again, often we’ll find the internal rotators are stronger, the muscles in the front of the shoulder. There is relative weakness in the back of the shoulder, a weakness of the posterior rotator cuff, as mentioned, the serratus anterior, as well as the lower trapezius.
The lower trapezius on the back is a critical muscle controlling the scapula. Weakness and fatigue of the trapezius also occurs. The rhomboid muscles, the rhomboid, another kind of funny muscle in the back, really are critical in controlling the scapula. When the serratus anterior fatigues, the rhomboid tries to compensate. The problem is it can’t. It naturally serves as an antagonist or opposite function to the serratus anterior. So again, a lot of it does go back to the serratus and that is the muscle that is problematic with throwers and other overhead athletes. But if it is dysfunctional, the serratus anterior, these other muscles, the trapezius and rhomboids will try to compensate, but they can’t replace the function of the serratus anterior. We then see tightness in the front. Again, you have got weakness in the back, you have overdeveloped front muscles, internal rotators, tightness of the pectoralis minor has been demonstrated and these factors are going to be important in designing your rehab programs.
Posture, Jim just mentioned that a moment ago. posture abnormalities are also something to think about and look at in your swimmers. Again, these abnormalities can be kind of subtle. This posture with sort of a rounded shoulder, you know, with a forward head, again exhibit a weakness of the muscles in the back, a tightness of the muscles in the front. This posture leads eventually to more elongation of the muscles in the back and that can lead to weakness. It can also be associated with differences, more abnormalities in the position of the scapula, but again the overall, the final common pathway being subacromial impingement and thus, pain.
Let’s shift gears a little bit now, from my talk about muscle and muscle fatigue. How about shoulder stability? That certainly is an issue in swimmers shoulder. As mentioned, the shoulder is an inherently unstable joint. Think of it as a golf ball on a tee. Shoulder stability is really governed by two parameters:
The static stabilizers
The dynamic system.
The static stabilizer is essentially the capsular ligaments which are depicted here while the dynamic stabilizers we just discussed are the muscles. A year old needs a combination of both. Muscle forces will be even more important if the static structures, the ligaments are loose. So, in a patient with a loose joint or laxity, the capsular structures aren’t doing their job well so the muscles are asked to do more. The rotator cuff muscle in particular is asked to work harder to control the laxity and can certainly relate to, again, overuse and fatigue. Increased laxity is often seen in swimmers. Some of that may be congenital while some it may even be acquired from the type of training and/or type of activities they do. Generalized ligamentus laxity, so called loose jointed, will be seen in swimmers and it is probably adaptive to a certain degree. Athletes that have increased flexibility are typically more successful, but again, there is a fine line between laxity which is physiologic and may be good and instability which is pathologic. There is a real gray line that will depend on what the athlete is doing. Backstrokers may actually have an acquired laxity. I will show you a slide in a moment that demonstrates a kind of stretch of the anterior capsule. So, some of this capsular laxity and eventual instability may in fact be acquired rather than just congenital. More than likely, though, it is probably a mix. Laxity has been demonstrated to correlate with shoulder pain in some well done studies. Bill McMaster in the past had done some things. Again, it is instability that eventually leads to secondary impingement. So again, the instability or the impingement rather, is the final common pathway.
This just shows the position in backstroke with the arm back in this position. It’s really abducted. You have some rotation in a vector force; it really starts to push the humeral head anteriorly. Athletes with anterior instability can have a real problem. Some of them have been known to dislocate right in this position. That is a typical position when the arm hits the wall, they will dislocate their shoulder. Some world class backstrokers in the past have had that problem. A disposition in this repetitive activity may lead to acquired laxity as well. I just wanted to show one case as an example or springboard for Rick’s discussion on rehab. This is a case of instability, but this is very, very atypical. I mean this type of x-ray appearance because instability typically is rather subtle. You don’t see an x-ray like this, where the ball comes out of the socket. But just to show you, actually a young swimmer, its very uncommon, but she had that type of laxity and there are different treatments for her condition.
This is a different case, but just to show Rick; Rick is going to think about thermocapsulorrhaphy. I thought I would mention it because I am sure that you have heard a lot about it. It is basically heat to shrink the capsular ligaments. I don’t want to spend too much time on the surgical management at all, but just to mention that this is something that is out there. It has been used quite a bit. I think it has a role, but a very limited role. In fact, most of us are kind of getting away from using this too much. The basic principle behind this is that heat will shrink the collagenous fibrous tissue. So using heat to shrink the ligaments, shrink the capsule. This is kind of a before and after and it doesn’t project well with these lights here, but you certainly see changes in the capsule. There is demonstrable shortening of the tissue. The problem is that tissue changes over time and there is a lot we don’t know about it’s response to heat, a lot we don’t know about how those would do over time, it is an option. You saw that it was used in this patient after having had a capsular shift and that last one to stabilize the shoulder. Just a note on surgery, surgery is an option; however, it really should be a last resort. It is uncommonly used and should uncommonly be recommended. When it is used, it should really be used at the end of your treatment and we will talk a little bit about that more.
Just to mention before we move on, other things can cause shoulder pain. Most of it, as discussed, is caused by muscular fatigue and/or probably a secondary impingement. There are other things, especially as you get into your older athlete, your masters group. A lot of different things can happen such as degenerative conditions, labile pathology, and a cervical spine. So if you are taking care of an athlete with persistent pain that doesn’t seem to respond to treatment as you would think it should, it should be evaluated. There are other things that occur. Tumors occur on the shoulder. They are not common, they are distinctly uncommon, but they are out there. Just don’t assume that everything is caused by muscular overuse. Jim mentioned some of these different alterations. These alterations you will see may be compensatory while some may be causing the pain. Some may be the primary cause of pain while others may be an adaptation the athlete makes in an effort to diminish pain. A dropped elbow is very commonly seen and certainly has been related to shoulder discomfort. Athletes might do this in an effort to avoid the internal rotation a position that bothers them. They make a subtle compensation. As the muscles fatigue and they start having pain, you will see athletes drop their elbow. With a wider hand entry the athlete may do this in an effort to avoid that impingement position, getting the arm out here. Jim mentioned an early catch, in the same way, its not coming way out in here, but with a little wider hand entry. It’s where we exit the hand during pulling. You are avoiding that hyperextension position. It comes way back here and pushes the humeral head out toward the front. This increases body roll and also may allow less of this hyperextension. But again, it can be very hard, I think, to know if these alterations are causing the pain or if they are of a compensatory nature. As a physician or even a trainer seeing the patient in the office, you need to be very careful in making recommendations about stroke mechanics without seeing that athlete swim and/or talking to the coach. These things are out there, but we need a lot more information to really understand what types of alterations are occurring.
Let’s shift gears a little bit and talk about treatment. These are just some general considerations for treatment. We will start off with training modifications, pretty intuitive. You can alter the intensity of training, the duration of training, the frequency of training, just as you do with any overuse type of injury, rest by having the athlete change their stroke, maybe eliminate the hand paddles, or just do more kicking sets. Initially, they don’t need to shut down entirely. I will give you a suggestion of what you might do initially. It’s just a start, a so-called active rest. Change what they are doing. Identify the inciting factor and change it. Vertical kicking can be used, avoid the kickboard position up here for that is the position of impingement, try some vertical kicking. Fins may help by helping you maintain body position with a decrease in shoulder stress. Reverse paddles will have a lot less stress on the shoulder. A pull buoy may actually help by changing the position of the shoulder in the water and decreasing drag. Try it; try it carefully, while carefully assessing the athlete’s response. Some people actually find that a pull buoy, despite the change in the position and decreasing drag, helps the shoulder. When you are starting training, a proper warm-up is critical. Ice, ultrasound, stim are different types of modalities your therapist can do. Non-steroidal medications, a note here: they should be used in a limited fashion for a limited period of time and they should not be used as a painkiller that will allow you to train through or with pain, may be recommended. The athletes who do, and you see them, are often the older athletes and some of the other groups of athletes I take care of. Some pro athletes abuse them and different issues have come up, be careful about NSAID’s, they may work, but it doesn’t solve the problem. You can stop your dry land upper extremity work, doing more of the lower extremity work. Identify correct stroke abnormalities. Just as importantly, think about other non-swimming type of activities that your athlete may be doing such as carrying a backpack or doing other sports at school. This may not all be from swimming. It probably manifests itself during swimming, but they can be doing a lot of other things outside of swimming which plays a primary role in causing the problem.
Lastly, proper nutrition is actually very importance for muscle recovery. Protein, zinc, adequate calories, those all help the athlete recover. Again, we are talking about an overuse type of injury here, so these are all important factors.
Some stroke corrections might be in order. Again, you may see or you may think about what we have talked about, less internal rotation and wider hand entry. There are other things we have talked about, but again, more importantly, a physician or trainer should not suggest stroke correction without consulting the coach and talking to the athlete. They should also see the athlete swim. I think when you see these athletes in the office, which includes most of us, you need to be very wary and very careful in trying to make distinct recommendations about the stroke. Those are some places to start with your treatments as coaches.
Now, for the next step, when do you need to call the physician? Here is a recommended progression and algorithm you can go through. Again, you start with training modifications and relative rest as was just discussed. Do that for three days. Go ahead and keep the athlete in the water, perhaps doing some kicking, you cut out the paddles and things like that. Then have them resume gradually. If there is no pain, have them progress gradually. Gradually is really the critical issue here. If they have recurrent pain when they try to resume more shoulder type work, I suggest you take them out of the water entirely for three days. You need to shut them down for three days, such as you would do with a baseball pitcher. If you again resume the workout and pain recurs at that point, then you could suggest that the athlete be evaluated by a physician. Other factors to consider which prompts an evaluation by a physician could occur while talking to your athlete. If they experience pain which persists outside of swimming, a pain that lasts during school, during the day, and/or lasts throughout the night, suggest seeing a physician. Look for other similar conditions, such as pain during every day activities. If they describe a sense of the shoulder feeling loose, perhaps it slips; perhaps it slides, or generally feels instable and causes pain, suggest they see a physician. It is pretty uncommon, for the athlete to say, “My shoulder comes out of the socket, it moves.”
But, some will. Some will have a distinct sense of their shoulder moving, slipping. It’s probably an athlete who has a greater degree of instability. Things like that should trigger you to act. If they say, “I feel something clicking in my shoulder.”
Joints commonly click; a click in the knee is common, a click in the shoulder is pretty common, a click per se is not a big deal. If, however, it hurts when it clicks, that is when it is different and when they need to be evaluated by a physician. Lastly, recurrent periods of missed training over several seasons could signal the need to see a physician. If this has been a recurrent problem season after season, you want to think about having it evaluated by a physician.
If the athlete is seen by a physician, he should be seen by someone who is knowledgeable with the problems of the overhead athlete. Have them see a Sports Medicine Physician who takes care of athletes who do overhead activities such as tennis, throwing, swimming, or whatever it is. X-rays should probably be done at this point. Not every athlete needs to be evaluated by a physician, but if it gets to that point, radiographs should probably be carried out. Again, different types of things can be present so it can be a good screening tool. You need a careful examination to rule-out instability. Testing beyond that, like an MRI, is very uncommonly required and certainly not to be expected or requested in the initial evaluation. They can be helpful over time, if it looks like it is not getting better in the typical fashion. In general, the MRI is not going to be of real help. The physician would normally recommend a well-designed physical therapy program. This really should be an individualized type of program. You need to assess each individual and each athlete as an individual. Injections should be used very sparingly. It is not something that is used for diagnostic purposes. Typically injected are Lidocaine or novocaine, two numbing medicine, in the shoulder. Cortisone injections should be used uncommonly, as a last resort. Maybe your older athletes have used it and use it on occasion. Diagnostic injections are often used in the shoulder and that can be very helpful for distinguishing the source of pain, but as a treatment, modality injections should be really used sparingly. Again, as mentioned, surgery should always be used as a last resort.
Athlete education is critical. Have your athlete be part of the process here, as well as the parents and the coaches. Communication between the physician, the coaches, the parents, and the athlete is really an important part of sports medicine anywhere. Make sure the athlete is really on board, that they understand the problem. Athlete education should be half of your time as a physician, making sure they understand their problem. In that way, the athlete can play an integral part of making themselves get better. They will be much more compliant with the whole routine.
Lastly, we will discuss a little about prevention and rehab, and also, a little bit about some muscle exercises which Rick will show you. To start out, do not forget nutrition. This can be a factor that is often overlooked. You need adequate protein; adequate iron, adequate calories to recover from training, especially in your female athletes, your athletes that you may suspect have nutritional deficiency. You need to think about these types of things, in particular athletes Charlene has talked a little bit about, with amenorrhea. If the athlete has a history of stress fractures, it is often one of the elements of malnutrition. This is especially true in our younger athlete. Those are the types of things to be aware of; for if you don’t ask, the athlete is unlikely to volunteer information such as this.
Before we move into all these, we can easily focus on the shoulder. Take a step back. Think about these other things. A rehab program really needs to be a comprehensive program to develop strength endurance, muscle balance and muscle flexibility.
The following is as much for prevention, to develop the type of program with your athletes to prevent these types of problems.
As mentioned, a lot of this is similar to a program we went through. We had a group that got together a couple of months ago and came up with a group of exercises, both for strengthening and for flexibility. It is on the website. I will show a couple of these pictures that will give you a sense of the more important exercises involving the three areas you are going to work on. These are things we talked about: the rotator cuff, the scapular muscles, and the core muscles which include the abdominal muscles, the low back muscles, and the pelvic muscles.
You will need a knowledgeable trainer or a therapist, someone who has some experience with swimmers or interest in swimmers. They need to assess each athlete individually so the athlete can have an individualized prescription program. The athlete may have a certain weakness. They may have a really weak trapezius or a tight pectoralis minor or whatever it is. Someone who can help identify the specific abnormality will help you to be much more successful, if you can drag your rehab program that way.
An important point if you are doing these exercises, don’t do them right before your swimming training! The problem with that is you will fatigue the muscles that you are trying to train. So, a couple of hours before or after practice, or another time would be best. About stretching, start with flexibility work, stretching some muscles is important. In particular, the pec muscles in the front, posterior shoulder capsule, some of the posterior rotator cuff muscles can become tight and weak. The latissimus can become tight so stretch there, although you generally do not need to stretch the front of the shoulder, the anterior shoulder. This stretch some are doing, they got a picture here, is generally not needed. Swimmers generally have enough laxity and perhaps even too much. So, in general, you need to be careful with your stretching. This one here, in the upper left, you will see swimmers often doing stretches the front of the shoulder. It is probably not required in a majority of swimmers. There are some other things such as stretching the pec muscles in the front. This is where your therapist can work with you on a good program and then finish up on strengthening so again.
The muscle groups that we have talked about which are the critical ones you will want to focus on for strengthening are the serratus, the rhomboid, and the trapezius. Again, notice that these are all muscles around the scapula or your shoulder blade. There is not so much focusing just on the rotator cuff because this will be backed up by the scapular muscles. In strengthening the rotator cuff, you want a as a goal for your rotation, a ratio of about 65%, that is, the ratio between the external rotator to the internal rotator. As mentioned, the internal rotators, those muscles in the front are typically stronger. Often times they are a lot stronger than the external rotators so this is a number we aim for in throwers and most overhead athletes. It is a ratio of about 2/3. Those are the things your therapist can do. It includes PNF work or proprioceptive neuromuscular facilitation. These are very useful for facilitating the agonists and antagonists muscle contractions.
Again, we go back to the whole idea that shoulder function really requires a highly coordinated muscle firing pattern. So, here are some specific exercises, these pictures were taken from a program you can see on the USA Swimming website. In general, these exercises should be done at very low weight and high repetitions. The goals you should seek are to exercise for two minutes, an extensive two minutes, doing three sets of these with maybe 30 seconds between sets. In this way, you are exercising to fatigue. Even if they can’t, for they initially may not be able to finish two minutes, that is fine. Once they are able to maintain the two minutes, you can start increasing the resistance. Just use some device such as the therabands, while again working the external rotators. This shows a very typical rotator cuff muscle exercise with the supraspinatus, another rotator cuff muscle that is kind of critical. The supraspinatus is one of the primary elevators to the shoulder. Simply lifting this plane here and fulcrum is like holding a full can. This shows some of these exercises, again. There are more descriptions on the website. But simply put, the goal here would be three sets of two minutes each while taking 30 seconds between sets. What it says down here you can’t read. It says the athlete progresses to no more than 5 pounds. Again, use a low weight with higher repetitions trying to fatigue these muscles. Other exercises for the scapular muscles as well as the rotator cuff might be a medicine ball on the wall. Toss the ball for a couple of minutes and you really fatigue the athletes’ muscles because it requires their scapular muscle to stabilize the shoulder blades. Rowing, simply rowing, you can do it using a machine or you can do it using therabands or stretch cords is another exercise the athlete might do. In doing these exercises it is important to work on scapular retraction, as the muscle fatigues, the arms tend to do this and the shoulder hunches forward. The athlete needs to think about squeezing their shoulder blades together. You will be surprised how easily some people fatigue in doing these exercises, but, then again, those are people who really need the work. This so called hitch-hiker exercise is another exercise for the scapular muscles. You are again working all the muscles back in here which stabilize the shoulder blades. These are your lower trapezius, the rhomboids and all the muscles around there. These are so called push-ups at the wall. It’s another scapular muscle strengthening exercise. You can start this by simply doing it against a wall, as it is shown here. The good part is when you go from here to here and you are really pushing out to engage the scapular muscle. The athletes can start this in the standing position, as shown here and advance to doing it on their knees. Eventually they will come to a normal push up position. The abdominal muscles, we talked about the core, the lower back, and the abdomen is critical here. If you want to call it the dead bug, it is basically lying flat; you want to keep their back flat while moving their legs. Eventually they can do their legs and arms together. Try it, it is good exercise and you will fatigue easily. Okay, you want to keep your back flat on the floor, start with legs only then do the arms as well. These are your low back and abdomen abdominal exercises. In this position, you alternate, here demonstrating the left arm and right leg movement, then, you reverse it and use your right arm and left leg. This would be hard because the back needs to be kept flat. You really need to have someone watching your body position. It is very easy to have muscle substitution patterns; mirrors are good since the athlete can see themselves. However, a trainer or a therapist who really knows these exercises would be best. It is very easy for the athlete to fatigue and change positions. This can result in substituting other muscles groups of which you did not want to focus on. Not doing the exercise correctly, especially when first learning the exercise may be harmful. Finally, we have here some stretching, hamstring stretching, upper trapezius using exercises that can help stretch the trapezius, a couple of more here for the upper trapezius, a muscle that commonly becomes fatigued. A probable a source of pain quite commonly found is a pain around the neck and upper shoulders, so these stretching exercises can be very valuable.
To finish up, what is the future direction? I think that there are more questions than answers because there are a lot of areas that need further information. We need to learn about the real basics of shoulder pain in swimmers, what causes shoulder discomfort, how dysfunction muscle relates. I think we need to understand the relationship between shoulder pain and specific characteristics such as posture and shoulder laxity, scapular motion and some of the things we talked about here. Some of the other things we need to consider involve the rib cage. You can imagine your whole rib cage along with your clavicle. There has been much less data available in these areas. Those all are a real part of the whole upper extremity kinetic change. Again, looking at the lower back and pelvis, how do abnormalities in those areas relate to the shoulder pain? We have very little information about that right now. Jim has mentioned a little about that and lastly to identify the stroke mechanics which lead to impingement and pain. I think we need to explore the relationship between stroke abnormality such as a dropped elbow and the scapular-shoulder mechanics. We need to develop objective measures of muscle fatigue. Again, we are talking about muscular fatigue, so we need to know just how to measure it? Well, we don’t really have a great way to do it other than lactic acid monitoring right now. I think we can use that as well as other instruments to get a better way to objectify and quantify muscle fatigue before we can really start to understand this better. Perhaps in the future, we will have methods to identify early overload or maybe blood tests and things like that. Using those future methods, we might be able to really identify these problems prior to their becoming a bigger problem.
Rick Eagelson will now take over to delve deeper into rehab methods.
I am Rick Eagleston and I am a physical therapist and athletic trainer. I have worked with Stanford University for about 18 or 19 years as a consultant and been in private practice for about 25. I am a former swimmer and continue as a masters swimmer. So, this subject provokes my interest. I am going to talk a little bit about rehabilitation following a surgical procedure which is called a thermocapsulorrhaphy. It is an arthroscopic procedure. Scott alluded to it earlier. The procedure basically shrink wraps the capsule and following the procedure we need to follow certain guidelines in order to not only rehabilitate the athlete in the clinic, but also return him to the water. The best solution to a shoulder problem is prevention, not to get to that stage where you will need an operation. So, a good rehabilitation program and a good preventative program prior to even the consideration of the surgical intervention, I think are really essential. If you haven’t given your athlete a good chance with conservative management, you have done the athlete a disservice. Most of the shoulder problems can be rehabilitated without a surgical correction. We may need some doctor’s help, medications, injections, and a lot of clever ideas, but most can be treated very successfully without getting to the point of surgery.
First, I am going to talk about what we look for in the clinic. You need a little background before I talk about how to get an athlete back into the water. Your biggest question for me, by the way, is how soon can I get my athlete back? I will try to tell you that. In the clinic, what we are looking for during the first two weeks is your basic anti-inflammatory measures. What we are trying to do is get the athlete over the inflammation and the trauma of the surgery itself. Lots of ices, lots of electrical stimulation, maybe some soft tissue massage, a little pump massage are all designed to try to relieve the swelling and the postoperative complications. We can do wrist and elbow range of motion.
The patient is usually in a protective sling from somewhere between ten days and three weeks. During that time, if you don’t work on the elbow and the wrist, it will tend to get stiff and you will end up with additional complications. You will then be treating three things instead of one.
From two to four weeks, we continue with the elbow and the wrist progressive rehabilitation program. PRE (Progressive Resistance Exercise) can be started very early. It’s funny how little things like using a rice bucket to try to mill the rice with your hand and doing a variety of exercises keep the strength in the forearm, wrist and elbow. Scapular stabilization exercises are begun. These are isometric exercises for the shoulder blades. If there is one thing that you should take from this series of lectures back to your programs at home, it is that scapular work is probably the foundation of all the rehabilitation or preventive efforts that you are going to do with shoulders. You have got to make the back really, really strong which is usually neglected. In the United States and other countries you tend to look at yourself in the mirror and you are looking at the front side. The emphasis over the years on bench pressing and doing militaries and things are all anterior dominant exercises. You have got to change your thinking. Work on the scapula and the other stuff will take care of itself.
We are looking for during those first two weeks, achieving abduction which is coming away from the body in a horizontal pattern at about 90 degrees or flexion to 90 degrees. We hold that to at least three weeks okay? If the patient is gaining motion too rapidly we don’t continue the motion program. We stop encouraging motion at those parameters. Why? We want thermal shrinking to take hold. We are looking for some healing to be done, some revascularization and so forth. External rotation is to 45 degrees, okay? Only to 45 degrees and that is probably the sum total of our goals for the three to four week period. From four to eight weeks we have the go ahead to begin a more aggressive range of motion. We progress the range of motion to the point where we have 90 degrees of external rotation at 90 degrees of abduction, the motion used to say, “Hi, how are you?” We stop short of the true end range because we found that over a period of time that capsule and the tightening of the shoulder will continue to loosen up with normal activity. So once I get to my parameters, I don’t go any further than that.
Beyond eight weeks, we continue the strength and endurance training. We refine scapulohumeral coordination. There is a pattern between the way your scapula moves and the way your glenohumeral joint or your shoulder joint moves. We try to re-establish that pattern. We will do that PNF (proprioceptive neuromuscular facilitation) work. We will do it through a lot of work with mirrors in the clinic so that the patient can actually visualize where his joint and his arm are in space. We will begin a conversion to a self-directed gym program. We teach him exercises that he can do on his own, okay? And we define how that individual is going to get to the highest level of function and what kind of time table they are looking for. Now, as I develop a self-directed gym program I tend to find that work with free weights, with surgical tubing, with a variety of things that allow you a certain amount of freedom through your patterns are the ones that work best for the swimmers. They are not pattern motions so much as they are free motions and this teaches a coordination of muscle effort through a variable plane of motion. If you are in machines all the time, you tend to learn that one pattern of motion and it does not translate to what you need to do in other areas.
With that, here is how we get them back in the water. The good news is that you don’t need to keep an athlete out of the water for a long period of time. Typically, I will have my athletes back in the water in ten days to two weeks. Now, that doesn’t mean that they are swimming. That means that they are doing vertical kicking, that they are doing some aerobic work in the water, or they are continuing their feel of the water. However, you will have to make sure that the incisions are clean, dry and well healed. Don’t put them back in when they still have their sutures in, but once they are capable of getting that shoulder immersed you can get them back in a protective position.
So during those first two weeks, we will do aerobics on dry land as tolerated. We will keep the patient in protective postures. We will do some home ice application following any activity and ice application in the clinic. I think that you will find that if there is one tool that you can use during the entire process of rehabilitation it is ice. An active icing program is really appropriate. I typically will tell my patients three times a day at least and certainly following exercise. How long? Fifteen minutes, certainly no more than 20 minutes because you probably have your maximum benefit by 15 minutes or so. It’s done three times a day actively, without fail!
No swimming during the first two weeks because of the wound considerations, but following the two weeks, from two to four, we are in the water doing vertical kicking, with the arm in protective positions. If we still got range of motion restrictions, then follow them. It means that you can keep your arms crossed over your chest, put fins on and vertical kick with weight belts, things like that. It is all appropriate, as long as you protect that shoulder. In and out of the pool, use a ladder, do not dive in or jumping in, okay? I will allow the patient to do kicking on their side or on their back as long as that hand is to their side and again, in a protective posture. From four to six weeks we can continue the kicking progression. I think you are all familiar with how to make vertical kicking tougher and longer so you can continue to do that. As we get additional range of motion, it will allow some spilling activity along with the kicking, such as a little resistance exercise which will also tend to begin in water rehabilitation of the rotational system. At that point in time, they are probably also eligible for some running on dry land. Before that, patients postoperatively are generally sensitive to the shock and the impact of putting one foot in front of the other. Most importantly, I think you need to watch for signs of exercise induced inflammation every day and at every practice session. If you start to have a patient with a sore shoulder, signs of inflammation, reduced range of motion, pain with motions that have been relatively pain-free, you need to take a step backward. Perhaps do a little bit more icing. If the pain persists and becomes more intense, pick up the phone to call the doctor, okay? Help! Give us some pain relief! It’s his job at this point.
At six to eight weeks, we begin to do very aggressive kicking, especially vertical kicking. But at that point in time, patients are usually ready to do a fairly normal kicking routine in the water, no kick board. We will have them do the kicking on their back or on their side as long as it is comfortable and not irritating the shoulder. We will have them do some prone sculling, the breaststroke is usually available. If we have done enough pain-free range of motion, allow for a breaststroke pull with a dolphin kick particularly. I recommend fins or zoomers for this exercise. They tend to keep the feet up in the water, allow the patient to plane the water rather than plow it and it takes a little pressure off of the upper body. The dry land exercise program at this point in time will include all light upper body activities that we have installed in the gym. This includes all of the scapular stabilization exercises and by this time, isolated rotator cuff activity. Yeah, you should have the range of motion by about six weeks to accommodate that. You may not have full extension out front, but you will be able to skull in here, okay?
Eight to twelve weeks, our goals are to convert to a self-directed dry land program. That should be done three or four times a week which is a fairly intense program. By that time the patient usually requires 45 minutes or an hour to get through the entire series of exercises. We begin base training. At this point in time it is the coaches’ job to be very, very observant. We know that when a patient has a surgical procedure done on the shoulder, they lose a sense of position and space, proprioception. With the return to normal swimming activities that swimmer is going to have all sorts of tendencies to compensate and create mechanical stroke flaws. You really need to watch that swimmer and make sure they take long, easy, very pretty swims. You make sure the stroke correction is done at that point in time. You correct a flaw over and over and over again until they are performing their stroke perfectly. I would begin with a 500 yard warm-up session and then gradually advance. A general rule of thumb is that they accomplished say, the 500 yard warm-up program well without complication three times. Then you can advance them. I advance them by about 250, sometimes 500 yards, but it is a relatively slow progression, but if you think about it over a period of four weeks as we get out to that twelve week level, that patient will be out to 2,000 or 3,000 yards of slow, easy base kind of swimming. This is done really pretty. Considering that you are thinking about a patient coming back from a shoulder surgery and actually swimming in three months, okay?
Beyond twelve weeks we are gradually increasing the yardage and the intensity. We gradually decrease the use of fins. The introduction of hand paddles and pulling gear is made at this point in time. Again, take it very easy. You do not want to stress these athletes, I believe, until around six months to really ask for some intensity. I think they deserve a lot of base work, a lot of stroke correction, a lot of care. We can introduce backstroke at this point in time. We don’t introduce butterfly until at least four months down the line. It’s probably more like six months and at that point in time they are out of therapy. They should be in a full dry land program. So, that is basically the scheme of things.
What can you expect? Well at six months, you can expect them to be swimming, but under a limited basis. By the time a year comes along, the patient should be doing pretty well, perhaps not back to his former level, but swimming at a pretty good level. The first year will give you an indication of basically where they are going to land and although they are pretty good they still have a little rehab to do. That’s what we are finding in a lot of our studies. I will show you some here in a second. It shows that the first year is pretty good. The second year is even better and the patient may even do better than that on the third year, okay? So expect it to take a little while to come back to a previously established level and then move beyond, okay? As I looked at some of the early studies, the first thing that struck me was that in one early study where there was a relatively few number of athletes, the number one category of athletes were swimmers who had this kind of procedure done and then rehabilitation. Skiing and football closely followed and went down with weight lifting and surfing. Gymnastics followed, and so forth, but it struck me that swimmers were number one on the list, even in a limited study.
What happens to stability? You don’t need to know about the numbers so much or that this is a modified graph, it doesn’t make any difference. The graph on the left is preop; the graph on the right is postop. It talks about the method of measuring the stability of the shoulder. You can see that it is dramatically improved with the operation. The raw score is the combination of stability, pain, motion, function and an overall perception of how the shoulder is functioning. Again, the graphs in the blue on the left indicate the preop condition, the graphs on the right, postop. So you can see that in most all of these situations, things have improved substantially. You will notice that motion, which is the middle graph, is about the same which simply means that you have restored normal motion after the surgery. You get it back, okay? It is no longer the case that people end up with limited ranges following a carefully done surgery. Clinical outcomes? Okay? This is at a two year level. The patients were satisfied 88% of the time and dissatisfied 12% of the time. Anterior instability was corrected in 94% of the occasions. Overall, the return to athletics was about 85% which I think is pretty good. Current clinical studies are showing that with the repair of the impingement and a slap repair and the corrective surgery for the instability that we have got 62% competing at 16 months, 50% at two years and 42% at 27 months with more traditional treatment. When we use the capsulorrhaphy technique, the statistics improve substantially with 91% competing at 27 months. I think this has to do with the amount of invasion that occurs early in the surgery. Arthroscopic surgery I think is a little easier on people. I don’t necessarily believe that this procedure rehabs any more quickly than an open procedure, but I think the amount of tissue damage that occurs surrounding the area where the surgery is actually done is significantly less and patients come back a little better from that. And that is the reason that, at two years or two years plus, we are seeing such a dramatic change.
So, in conclusion, you don’t have to keep that athlete out of the water so long any more, but you do have to be careful how you bring them back. Scapular stabilization exercise is the key, both in a preventive, a preoperative, and a postoperative phase. Athletes should be carefully brought along during the period of one or two years. Stroke correction is essential. You guys have to pay a lot of attention. I think that the therapists and coach communication is important, especially when you folks need to have some advice as to whether a patient is ready for particular maneuvers in the water.
So, with that, any questions?
Yes, you are talking about if we have shoulder pain and problems in an athlete just prior to an important competition. How do we manage that? Yeah, before the taper and during the taper, as intensity increases and the amount of work decreases, we still find that there are shoulder problems and I think that the best thing you could do during that point of time is try to manage the problem with a good ice program. Perhaps some anti-inflammatories, but I am not big on keeping the patients on anti-inflammatories for a long period of time. I think what you need to do is break the inflammatory cycle and if that requires a little bit of extra rest, a modification in the swimmers program in the pool, a lot more icing (five or six times a day), you know, some careful management usually takes care of that problem. There are a variety of physical therapy techniques that also provide you with some help, including ultrasound and electrical stimulation or soft tissue massage. You may find some range of motion imbalances. A very common cause of shoulder pain in athletes and in the normal population is a subtle change in range of motion. So you ought to watch out for that as well.
Yes, the first question regarding warm-up. I think that in these postoperative phases, if you want to put an athlete in a warm shower for a little while and let the water pour down, if you have that available at the pool, it is fine. I can’t tell you it is going to give you a lot of help but I think more importantly, you should carefully warm that individual up. I think we are finding more and more that stretching prior to exercise is not necessarily a preventive mechanism and it is not necessarily helpful in terms of reducing pain or inflammation. The stretching is probably more important after you are warmed up and after you have had your exercise routine done. So you know, I would say, just be careful about warming that individual up and start out with things that are easily accomplished. Try to move to more difficult kinds of warm-up activities as they become appropriate for the athlete. In terms of good stretching, I would refer you to our website. The website is really pretty good. What we tried to do with it is give coaches and lay people within the swimming community some sense of exercises they could do without a heck of a lot of equipment because equipment is not always available. So we designed a program that can be challenging both in terms of range of motion and in terms of strength development, but is inexpensive and convenient to accomplish.
Yeah? I think the digit finger really helps us clinicians and when you come into the clinic to see Scott Rodeo or a person like myself, often times I will say point to where it hurts and it gives you some sense as to where the pathology might lie. So, yeah, the digit works great but I don’t think that for the lay person, it tells you exactly what is going on. It can be impingement; it can be simply a bursitis or an inflammatory kind of process. It can be pathological in nature, there are a whole variety of things that go on within the shoulder and go on and on and on, believe me. The differential diagnosis is not so simple. You really need a good clinician, a good orthopedist who is Sports Medicine savvy to weed through the maze that the shoulder really is and to define what the one or two primary diagnoses are. But I think, again, if you follow Dr. Rodeo’s advice and tried to react to a problem systematically and if that problem is not resolving over a period of a week or ten days or it remains a persistent problem, then that gives you the clue as to whether they really need to get to the doctor or not.
Yes, yes we do and we are developing it all the time. And again, it is on the website where you can go. We have tried to regionalize a list for you folks, of therapists, of chiropractors, of massage therapists. I think there are a few on there, of orthopedists, of primary care people, yes, okay. Believe me, it is a real consideration for us in the Sports Medicine sector of the United States Swimming and swimming in general to get this information out and develop it more fully. We have got the shoulder package on board. That was a new thing this year. There are already plans for doing a spine and doing a knee program as well and whatever else that may be necessary. It is eventually going to get on there and as soon as we can all reach consensus, get things worked out, it is going to be there and believe me it is a very, very high priority.
Yes, they are designed primarily to try to give your bicep tendon or your biceps mechanism a little mechanical advantage and what I can tell you about it, sometimes they work, sometimes they don’t. I mean, it is an experiment worth running because they are inexpensive, but I found that people who treat the shoulder with ice and with a little TLC probably do just as well without having the band as with it on.