Ask a Vail Sports Doc column: Dealing with ‘swimmer’s shoulder’

The Vail Valley has a surprising number of competitive swimmers and plenty of others that swim recreationally.

Swimming is unique as the shoulder and upper body supply 90 percent of the propulsive force and given the extreme training regimens of many elite swimmers, injury is not uncommon. Shoulder injuries are the most common injury that swimmers experience.

“Swimmer’s shoulder” is a term that refers to a variety of shoulder injuries seen in swimmers, such as impingment syndrome, labral tears of the shoulder, ligamentous laxity and scapular dysfunction.

Competitive swimmers train primarily by swimming the freestyle stroke. In this stroke, force is generated mainly by the pectoralis major and latissimus dorsi. Hypertrophy of these muscles is the reason Michael Phelps has that V shaped upper body. Given the thousands of yards competitive swimmers put in per week, muscle fatigue and overuse with secondary compensatory biomechanical changes in one’s stroke plays a large role in swimmers getting injured.

Subacromial impingement is synonymous with rotator cuff tendonitis. Pain from this is felt primarily at the point of hand entry into the water as this is when the subacromial space is narrowed, as the arm bone (humerus) is fully abducted and internally rotated. Thus, the rotator cuff tendons can contact the underside of the acromion and when this happens repetitively, the rotator cuff tendons get inflamed and cause pain in this position. Inflammation of the supraspinatus tendon (the rotator cuff tendon on the top of the humerus) is the leading cause of shoulder pain in swimmers.

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In some swimmers, more often young females, there is hyperlaxity of the shoulder joint. If the ligaments of the shoulder joint are loose, either from just being young and “loose jointed” or from excessive training and gradual stretching of the shoulder ligaments, then the ball (humeral head) can slide back and forth excessively in the shoulder socket (glenoid). Over time and with continued training, this can lead to tearing of the glenoid labrum. I tell patients that the glenoid labrum is like a rubber gasket that surrounds our shoulder sockets with all the ligaments of the shoulder inserting into this gasket. This gasket can tear away from the socket and cause pain in swimmers.

Shoulder range of motion is accomplished by both the ball moving in our shoulder socket and also the scapula moving on our chest wall. Competitive swimmers can develop so called scapular dyskinesia. In this, the biomechanics of the scapula moving on the thorax are abnormal. Typically, there is protraction of the scapula in swimmers. This, in turn, places increased stress on the ligaments in the front of the shoulder joint. Moreover, the muscles that would normally stabilize one’s scapula fatigue and the larger shoulder muscles (the pectoralis and serratus) overpower the scapular stabilizing muscles and cause deformity and pain.

Medical care

The treatment of the swimmer’s shoulder usually consists of ice, stretching (especially of the posterior capsule), NSAID’s and focused physical therapy. An athlete should reduce the yardage they swim to below the point of pain. The swimmer’s stroke should be analyzed by a coach to try to elucidate any compensatory mechanisms that may have been adapted by the athlete.

Scapular strengthening exercises are very important after a period of resting these muscles as is strengthening the external rotators of the shoulder to counter the overdeveloped internal rotators. Occasionally, I would consider a steroid injection if a swimmer is at the end of their season and has one last, big swimming meet coming up. Surgical treatment is rarely needed in injured swimmers unless they tear their labrum or rotator cuff tendons.

Dr. Rick Cunningham is a knee and shoulder sports medicine specialist with Vail-Summit Orthopaedics and a physician for the U.S. Ski Team. Do you have a sports medicine question you’d like him to answer in this column? Visit his website at http://www.vailknee.com to submit your topic idea. For more information about Vail-Summit Orthopaedics, visit http://www.vsortho.com.