Swimmer problems PETER FOWLER, M.D., London , Ontario , Canada
In swimming,
the
major problem we see with the shoulder is impingement syndrome which occurs in the free-style and butterfly swimmers. Occasionally, we will see an apprehensionthe
type shoulder in the back stroker. We will first talk about the impingement syndrome. There couple of anatomical and biomechanical problems inherent in this syndrome. The major consideration is the vascularity of the rotator cuff, specifically to the supraspinatus and the biceps tendons. Raspin and McNabb in Toronto have shown that the supraspinatus tendon close to its insertion is wrung over rather markedly when the arm is down at the side in the adducted position and particularly in the adducted internal rotation position. Similarly, the biceps tendon in its intraarticular course has poor blood supply. Also, we find that the acromion abuts against the greater tuberosity as the forward flexed shoulder is internally rotated. Unfortunately, the way free-style and butterfly swimmers have to train, they have to do many many yards a day in order to keep up the pace; therefore, they have multiple episodes of &dquo;wringing out&dquo; the rotator cuff as the arm is brought down to the side and then abutted against the acromion as it comes around and then abutted against the coracoacromial arch as the forward flexed shoulder is internally rotated. Many of them are swimming 15,000 to 20,000 yards a day. This &dquo;abutting&dquo; occurs many times. The question about strokes is raised. Yes, there is a marked difference in shoulder problems. Breast strokers really do not have this impingement syndrome nor do back strokers. The disorder is confined to free-stylers and butterfly stroke swimmers. There is no difference between these two strokes. The butterfly stroke swimmer is basically doing the same stroke with both arms at the same time that the free-style swimmer is doing it alternately with his arms. Many factors enter into the problems for these swimmers. Certainly, a &dquo;tight-shouldered&dquo; individual has a predisposition to the problem of impingement; also, the stroke mechanics an individual uses have a lot to do with the severity of problem. The person with the higher arm recovery seems to have fewer problems. The big thing in the treatment of the swimmer’s shoulder is prevention. There is no question that exercises in the preseason prevent many of the problems to the shoulder. The training program should include both flexibility and strengthening exercises. Locally, we have a period of V2 hr for warm-up flexibility exercises before the swimmers enter the water. This practice seems to have prevented swimmer’s shoulder to a great extent. We also use a strengthening program for specific muscles, particularly the internal rotators (rotator cuff muscles). It just stands to reason that a muscle-tendon unit that has been strengthened will stand stress a little better. The proper stroke mechanics are also important in the prevention of swimmer’s shoulder. are a
After the syndrome has resolved, we like to classify it. We usually use the classification that Blazina outlined for jumper’s knee in Orthopedic Clinics of North America. Phase 1 would be the swimmer that just has some pain following his activity. Phase 2 would be the swimmer who has pain during the activity and after activity but still is able to compete at his normal level. Phase 3 would be the swimmer who has sufficient problem with the shoulder to the extent that he is unable to compete at the level to which he is accustomed. I would like to add Phase 4-the swimmer who has gone through Phase 3 and is having
pain with everyday living. The treatment depends on the phase in which we see the swimmer. In all phases, just as Dr. Jobe emphasized for the baseball thrower, initial rest is important. In swimming, we do not need to keep them out of the water but we have to keep them from doing that particular stroke which aggravates the syndrome. There are many other things that he can do, such as leg work, swimming back stroke, or breast stroke which will not irritate the situation. While they are resting, we like to see if we can stop the problem. We check to see if the swimmer is a tight-shouldered individual or if he uses improper stroke mechanics. We work on those aspects, if we can. During this time, we also work on flexibility and strengthening. We use oral anti-inflammatory agents, ice, and ultrasound. After the swimmer’s problem has started to resolve, we like to see him get back into the activity and we continue to use the modalities, particularly ice. We use ice massage 15 min before the warmup period, then encourage a long warm-up time, and gradually get the patient back to swimming. If the swimmer is in Phase 3, he is probably very much more resistent to all of this. On occasion, we will treat him with a steroid injection. We warn against excessive use of steroid, but we do sometimes use one or two injections. If we get swimmers with marked chronic problems, we entertain thoughts of suggesting another sport or surgical treatment. It should be mentioned that surgical treatment does not promise a return to high level competition. The surgical treatment would be increasing the subacromial space; this would be a resection of a portion of the coracoacromial ligament usually accompanied by a small acromioplasty. After recuperation, we gradually get him back into swimming through the same program we have outlined. We make certain that the swimmer’s shoulder is flexible and strong before he returns to
competition.
You mentioned a &dquo;tight shoulder.&dquo; What do you clinically by a tight shoulder? Dr. Fowler: Clinically, a tight shoulder is one that has poor flexibility; the person may have poor flexibility generally and specifically in the shoulder. Dr. Clancy: When you say &dquo;poor flexibility,&dquo; do you mean certain motions? What motions would you consider important? Dr.
Clancy:
mean
141
Occasionally, a person may sublux the shoulder if he has laxity and develop a rather apprehensive approach with each of the turns. We have a couple of alternatives to suggest for this syndrome. First, the swimmer can just put up with the condition. He can develop skill at a front-flip turn. It is acceptable for a back stroke swimmer to reach across and do a front flip provided he reaches across and touches the wall while he is
Dr. Fowler: All motions, in all directions, are important, particularly abduction and internal rotation. Dr. Clancy: Would the exercises be the static type and not the
ballistic type? Dr. Fowler: I think that it is important to do both types of flexibility exercises. The types we use are first of all the ballistic type. One of the better exercises that we have used through the years is swinging Indian clubs. Although this was disbanded about 20 years ago, they are coming back into vogue and, somehow, I think that since Indian clubs have not been used in the last few years, the incidence of swimmer’s shoulder has increased. We have to do the static type of flexibility exercises as well to overcome the fatigue situation that occurs with the daily swimming routine. We try some techniques which alter the swimmer’s stroke; for example, high arm recovery because we have seen that those persons with this motion tend to have fewer problems than those persons who swing the arms around. Also, if the swimmer breathes to the same side all of the time, we suggest varying the side and often this alleviates the problem. When one asks if a tight-shouldered individual is a better swimmer than a loose-shouldered individual, I cannot make an absolute comparison. In general, strength is most important (with all other variables being equal) but certainly, if we can get a strong person with a loose-type shoulder, then we have a better swimmer. The apprehension-type shoulder is the second syndrome we should talk about. This occurs frequently in the back stroke swimmer. The back stroke itself requires marked external rotation, particularly, when the swimmer goes into the turn.
Problems among the experienced athlete
still on his back. The other alternative is to correct the anterior subluxation of the shoulder through a surgical procedure. The surgeon must be careful not to limit the swimmer’s external rotation. If this motion is limited, the swimmer will probably be finished as a high-class back stroker. Dr. Clancy: Would you mention something about weight training isokinetics versus isometrics? Dr. Fowler: There is certainly a controversy surrounding the preference for isokinetics or isometics. Sometimes this depends on the facilities in which one has to practice one or the other types of exercise. Our city team uses just a straight weight training program, which is basically an isotonic one, because there is not isokinetic facility available. In our university, we have managed to cut down the incidence of swimmer’s shoulder by using the flexibility program I have described plus using the Nautilus, which is straight isotonic. Probably, the better exercise program would be an isokinetic strengthening program which would accommodate what they are doing with these programs a little bit better. What I really want to say is, isokinetics would be the better program, but anything is better than nothing, and I certainly emphasize that isotonic exercises are better than isometric exercises.
inexperienced and
DOUGLAS W. JACKSON, M.D., Long Beach , California
M any sports requiring repetitiveincreasingly popular strenuous
of the shoulder have become
overhead motion in this
country. Tennis, volleyball, racquetball, softball, handball, and gymnastics are now being enjoyed by almost every age group. The physician caring for athletes presenting with shoulder problems sees a spectrum of entities. Often the athletes are participating on a year-round basis in their chosen sport and will consider a prolonged period of rest only as a last resort in their treatment. The effects of overuse and abuse of the shoulder can be seen in youngsters with an immature skeletal system and open growth plates working out two times a day, as well as in the aging athlete with wear and tear changes competing in the Golden Masters age group, and some even into their 70s. Regardless of how well an athlete conditions or stretches out the shoulder, there are unusual events and wear and tear changes that may result in some period of disability
swimming,
142
the shoulder in those participating for a number of given sport. The problems vary among the inexperienced and the experienced athlete. Proper form will allow maximum performance to be achieved from the musculoskeletal system, but does not protect it from overuse and abuse injuries. A prevention program is an important part of training for any athlete participating in a shoulder-oriented sport. The programs described by Dr. Jobe and Dr. Fowler for the thrower and swimmer are directly applicable to all the overhead shoulder sports. Physicians involved in caring for participants in shoulder-oriented sports should counsel their patients in the importance of conditioning, warm-up, and stretching in relationship to the prevention of injuries. Much attention has been given to the importance of stretching the Achilles tendon complex (i.e., in the distance runner), but we have neglected the anterior capsule and rotator
related
to
years in
a
In swimming,
the
major problem we see with the shoulder is impingement syndrome which occurs in the free-style and butterfly swimmers. Occasionally, we will see an apprehensionthe
type shoulder in the back stroker. We will first talk about the impingement syndrome. There couple of anatomical and biomechanical problems inherent in this syndrome. The major consideration is the vascularity of the rotator cuff, specifically to the supraspinatus and the biceps tendons. Raspin and McNabb in Toronto have shown that the supraspinatus tendon close to its insertion is wrung over rather markedly when the arm is down at the side in the adducted position and particularly in the adducted internal rotation position. Similarly, the biceps tendon in its intraarticular course has poor blood supply. Also, we find that the acromion abuts against the greater tuberosity as the forward flexed shoulder is internally rotated. Unfortunately, the way free-style and butterfly swimmers have to train, they have to do many many yards a day in order to keep up the pace; therefore, they have multiple episodes of &dquo;wringing out&dquo; the rotator cuff as the arm is brought down to the side and then abutted against the acromion as it comes around and then abutted against the coracoacromial arch as the forward flexed shoulder is internally rotated. Many of them are swimming 15,000 to 20,000 yards a day. This &dquo;abutting&dquo; occurs many times. The question about strokes is raised. Yes, there is a marked difference in shoulder problems. Breast strokers really do not have this impingement syndrome nor do back strokers. The disorder is confined to free-stylers and butterfly stroke swimmers. There is no difference between these two strokes. The butterfly stroke swimmer is basically doing the same stroke with both arms at the same time that the free-style swimmer is doing it alternately with his arms. Many factors enter into the problems for these swimmers. Certainly, a &dquo;tight-shouldered&dquo; individual has a predisposition to the problem of impingement; also, the stroke mechanics an individual uses have a lot to do with the severity of problem. The person with the higher arm recovery seems to have fewer problems. The big thing in the treatment of the swimmer’s shoulder is prevention. There is no question that exercises in the preseason prevent many of the problems to the shoulder. The training program should include both flexibility and strengthening exercises. Locally, we have a period of V2 hr for warm-up flexibility exercises before the swimmers enter the water. This practice seems to have prevented swimmer’s shoulder to a great extent. We also use a strengthening program for specific muscles, particularly the internal rotators (rotator cuff muscles). It just stands to reason that a muscle-tendon unit that has been strengthened will stand stress a little better. The proper stroke mechanics are also important in the prevention of swimmer’s shoulder. are a
After the syndrome has resolved, we like to classify it. We usually use the classification that Blazina outlined for jumper’s knee in Orthopedic Clinics of North America. Phase 1 would be the swimmer that just has some pain following his activity. Phase 2 would be the swimmer who has pain during the activity and after activity but still is able to compete at his normal level. Phase 3 would be the swimmer who has sufficient problem with the shoulder to the extent that he is unable to compete at the level to which he is accustomed. I would like to add Phase 4-the swimmer who has gone through Phase 3 and is having
pain with everyday living. The treatment depends on the phase in which we see the swimmer. In all phases, just as Dr. Jobe emphasized for the baseball thrower, initial rest is important. In swimming, we do not need to keep them out of the water but we have to keep them from doing that particular stroke which aggravates the syndrome. There are many other things that he can do, such as leg work, swimming back stroke, or breast stroke which will not irritate the situation. While they are resting, we like to see if we can stop the problem. We check to see if the swimmer is a tight-shouldered individual or if he uses improper stroke mechanics. We work on those aspects, if we can. During this time, we also work on flexibility and strengthening. We use oral anti-inflammatory agents, ice, and ultrasound. After the swimmer’s problem has started to resolve, we like to see him get back into the activity and we continue to use the modalities, particularly ice. We use ice massage 15 min before the warmup period, then encourage a long warm-up time, and gradually get the patient back to swimming. If the swimmer is in Phase 3, he is probably very much more resistent to all of this. On occasion, we will treat him with a steroid injection. We warn against excessive use of steroid, but we do sometimes use one or two injections. If we get swimmers with marked chronic problems, we entertain thoughts of suggesting another sport or surgical treatment. It should be mentioned that surgical treatment does not promise a return to high level competition. The surgical treatment would be increasing the subacromial space; this would be a resection of a portion of the coracoacromial ligament usually accompanied by a small acromioplasty. After recuperation, we gradually get him back into swimming through the same program we have outlined. We make certain that the swimmer’s shoulder is flexible and strong before he returns to
competition.
You mentioned a &dquo;tight shoulder.&dquo; What do you clinically by a tight shoulder? Dr. Fowler: Clinically, a tight shoulder is one that has poor flexibility; the person may have poor flexibility generally and specifically in the shoulder. Dr. Clancy: When you say &dquo;poor flexibility,&dquo; do you mean certain motions? What motions would you consider important? Dr.
Clancy:
mean
141
Occasionally, a person may sublux the shoulder if he has laxity and develop a rather apprehensive approach with each of the turns. We have a couple of alternatives to suggest for this syndrome. First, the swimmer can just put up with the condition. He can develop skill at a front-flip turn. It is acceptable for a back stroke swimmer to reach across and do a front flip provided he reaches across and touches the wall while he is
Dr. Fowler: All motions, in all directions, are important, particularly abduction and internal rotation. Dr. Clancy: Would the exercises be the static type and not the
ballistic type? Dr. Fowler: I think that it is important to do both types of flexibility exercises. The types we use are first of all the ballistic type. One of the better exercises that we have used through the years is swinging Indian clubs. Although this was disbanded about 20 years ago, they are coming back into vogue and, somehow, I think that since Indian clubs have not been used in the last few years, the incidence of swimmer’s shoulder has increased. We have to do the static type of flexibility exercises as well to overcome the fatigue situation that occurs with the daily swimming routine. We try some techniques which alter the swimmer’s stroke; for example, high arm recovery because we have seen that those persons with this motion tend to have fewer problems than those persons who swing the arms around. Also, if the swimmer breathes to the same side all of the time, we suggest varying the side and often this alleviates the problem. When one asks if a tight-shouldered individual is a better swimmer than a loose-shouldered individual, I cannot make an absolute comparison. In general, strength is most important (with all other variables being equal) but certainly, if we can get a strong person with a loose-type shoulder, then we have a better swimmer. The apprehension-type shoulder is the second syndrome we should talk about. This occurs frequently in the back stroke swimmer. The back stroke itself requires marked external rotation, particularly, when the swimmer goes into the turn.
Problems among the experienced athlete
still on his back. The other alternative is to correct the anterior subluxation of the shoulder through a surgical procedure. The surgeon must be careful not to limit the swimmer’s external rotation. If this motion is limited, the swimmer will probably be finished as a high-class back stroker. Dr. Clancy: Would you mention something about weight training isokinetics versus isometrics? Dr. Fowler: There is certainly a controversy surrounding the preference for isokinetics or isometics. Sometimes this depends on the facilities in which one has to practice one or the other types of exercise. Our city team uses just a straight weight training program, which is basically an isotonic one, because there is not isokinetic facility available. In our university, we have managed to cut down the incidence of swimmer’s shoulder by using the flexibility program I have described plus using the Nautilus, which is straight isotonic. Probably, the better exercise program would be an isokinetic strengthening program which would accommodate what they are doing with these programs a little bit better. What I really want to say is, isokinetics would be the better program, but anything is better than nothing, and I certainly emphasize that isotonic exercises are better than isometric exercises.
inexperienced and
DOUGLAS W. JACKSON, M.D., Long Beach , California
M any sports requiring repetitiveincreasingly popular strenuous
of the shoulder have become
overhead motion in this
country. Tennis, volleyball, racquetball, softball, handball, and gymnastics are now being enjoyed by almost every age group. The physician caring for athletes presenting with shoulder problems sees a spectrum of entities. Often the athletes are participating on a year-round basis in their chosen sport and will consider a prolonged period of rest only as a last resort in their treatment. The effects of overuse and abuse of the shoulder can be seen in youngsters with an immature skeletal system and open growth plates working out two times a day, as well as in the aging athlete with wear and tear changes competing in the Golden Masters age group, and some even into their 70s. Regardless of how well an athlete conditions or stretches out the shoulder, there are unusual events and wear and tear changes that may result in some period of disability
swimming,
142
the shoulder in those participating for a number of given sport. The problems vary among the inexperienced and the experienced athlete. Proper form will allow maximum performance to be achieved from the musculoskeletal system, but does not protect it from overuse and abuse injuries. A prevention program is an important part of training for any athlete participating in a shoulder-oriented sport. The programs described by Dr. Jobe and Dr. Fowler for the thrower and swimmer are directly applicable to all the overhead shoulder sports. Physicians involved in caring for participants in shoulder-oriented sports should counsel their patients in the importance of conditioning, warm-up, and stretching in relationship to the prevention of injuries. Much attention has been given to the importance of stretching the Achilles tendon complex (i.e., in the distance runner), but we have neglected the anterior capsule and rotator
related
to
years in
a
