A shoulder injury can be a significant barrier to both training and competition, particularly for swimmers. Due to the repetitive nature of swimming strokes and high demands placed on the shoulder, this is an area often susceptible to injury and overuse. Swimming requires many different shoulder motions, which are then combined and performed simultaneously to carry out one particular stroke. Having a thorough understanding of the biomechanical makeup of swimming strokes (most commonly freestyle), as well as the early warning signs of injury, is necessary to ensure the likelihood of shoulder injury is reduced.
‘Swimmer’s Shoulder’ is a musculoskeletal injury, often caused by overuse and repetitive stress resulting in pain felt deep within the front shoulder joint itself. It is a result of inflammation and irritation of the tendons passing through the shoulder joint capsule and subacromial space (area beneath the collarbone at the front of your shoulder). As the cause of swimmers shoulder is often mechanical and movement based, increasing pain is generally felt the longer the shoulder is in use. Swimmer’s shoulder may also be attributable to poor posture, lack of joint mobility and flexibility, inadequate muscle control (neuromuscular control) as well as errors in training or unrealistic training loads.
The shoulder is an inherently unstable joint. This ‘ball-and-socket’ type of joint is comprised of a large ball, which sits within a relatively shallow socket. While this allows for greater shoulder range of movement, the anatomy of this joint means its structural stability is somewhat limited. Given this, many structures act upon the shoulder to reinforce both strength and stability, and often it is these areas in which we must focus our attention for prevention and management of shoulder injuries. Increased stress may also be placed on the shoulder due to movement deficiencies in surrounding areas of the body. Stiffness and hypomobility of the neck and mid-back commonly result in a higher workload of the shoulders meaning overuse is more likely.
Poor postures often place the shoulder in rolled forward and elevated position, which can add additional stress and reduce the sub-acromial space. Such postural adaptations include forward chin poke, rounded shoulders and increased curvature of the spine. Often, this arises from tightness in muscles and tissues in the front of the shoulders, and lengthening and weakness in those at the back. This muscle imbalance may cause the shoulders to drift forward and up, resulting in decreased joint and subacromial space leaving little space for the affected tendons to sit. Altered postures can be managed through gentle stretching and tissue release of tight anterior muscles, and activation and strengthening of those weakened to place the shoulder in less compromising positions.
The rotator cuff is the shoulder’s primary movement mechanism and a highly important stabiliser of the shoulder joint. It consists of a collection of muscles that all act upon the shoulder to allow different movements and provide strength and stability throughout its range of motion. These muscles not only perform large movements that we can visually see, but also pivot and spin the humerus (arm bone) within the joint capsule to ensure adequate joint and subacromial space is upheld. This group of muscles, among others, also controls the movement of the scapula (shoulder blade). It is important that both the scapula and humerus bones move in smooth sequence to allow sufficient joint and subacromial space to be upheld. If the rotator cuff is not allowing this to occur, either due to weakness, fatigue, or poor muscular control, high swimming loads may also result in overuse and onset of shoulder injury.
So, now to the part you’re probably most concerned about. How might my training predispose me to a swimmer’s shoulder? What modifications should I make if I am experiencing shoulder pain? As I mentioned previously, generally swimmers shoulder will present with progressive pain throughout the length of each swimming session. This is enough to suggest that some training modifications need to be made and further investigation of the shoulder may be necessary. A thorough assessment of the athlete should be performed including technique and movement analysis, insight into training demands as well as any extrinsic factors that may contribute to excessive loads. Generally, this assessment should consider overuse, misuse and abuse.
Overuse refers to loads placed on the shoulder that exceed its ability to be able to recover from and/or withstand. This may be due to an imbalance between muscle strength or due to an unrealistic training load. In the beginning stages of training, swimming loads should start conservatively and be gradually increased in realistic increments. Often, starting or returning to training following a break, and completing high load sessions without adequate recovery can cause joint overuse. As training loads are gradually increased the body has a greater capacity to adapt to new loads and withstand these loads in future training and competition.
Niggles: Starting to feel a pinch? It might be the start of something more concerning.
Misuse suggests swimming with incorrect or improper technique and placing higher than normal stress on structures within the shoulder. Arms or hands crossing the midline of the body upon water entry, or altered degrees of body roll during freestyle are common mechanical faults that can increase the stress on the shoulder. These faults, among others, have the potential to place the shoulder in compromising positions which may reduce the subacromial space and impinge on the tissues within this space.
Abuse is placing higher than necessary resistance on certain structures, and often certain types of equipment may cause this. Hand paddles are a commonly used training tool and highly useful in their own right. When using hand paddles the resistance placed on the shoulder is much higher than normal due to larger amounts of water being moved. Utilising equipment such as hand paddles should be done so with specific purpose, but prolonging the use of such equipment may lead to shoulder abuse due to high resistance loads.
In summary, swimmer’s shoulder generally presents because of intrinsic factors related to posture and joint hypomobility, as well as extrinsic factors related to high training loads, swimming technique and equipment overuse. Early detection of swimmer’s shoulder generally means a fast and full recovery can be achieved, but an understanding of all contributing factors is ideal for prevention of such injuries. In the early stages of swimmer’s shoulder, likely contributing factors should be identified to allow an effective rehabilitation plan to be implemented. Generally, stretching of tight and shortened tissues, joint mobilisation, appropriate activity and training modifications as well as exercises for retraining of neuro-muscular control are appropriate to maximise return to full training and competition. Coaches and athletes may also wish to implement simple pre season screening as an effective preventative and early detection tool.