Physical Therapy for Swimmer’s Shoulder
Swimming is a sport that primarily utilizes the upper body for propulsive force with 90% of the driving force provided by the torque generated from the shoulder. Swimmer’s shoulder is the most common swimming-related shoulder injury, often caused by overuse due to the repetitive overhead motion of the swim stroke that irritates and inflames the rotator cuff muscles and tendons, leading to pain and limited shoulder mobility. Physical therapy is one of the most effective treatments for swimmer’s shoulder, utilizing a targeted manual therapy, stretching, and strength and conditioning exercise program to restore shoulder function, mobility, and strength and a safe return to competitive swimming.
Understanding Shoulder Anatomy
The shoulder complex is designed to achieve the greatest range of motion of any joint in the body. The excessive mobility of the shoulder at the glenohumeral and scapulothoracic joint is balanced by the stability of the acromioclavicular (AC) and sternoclavicular joints.
There is a complex ligament system at the glenohumeral joint that contributes to primary stability as well as a musculotendon system that serves as a secondary stabilizer to the shoulder. This allows the shoulder to withstand large external forces, while providing enough mobility for the upper extremity to accomplish complex movement patterns.
What is Swimmer’s Shoulder?
The shoulder muscles are the main part of the body that propel the swimmer through the water. Swimming is a sport that primarily utilizes the upper body for propulsive force with 90% of the driving force provided by the torque generated from the shoulder. Elite swimmers log 60,000 to 80,000 meters per week, which is equivalent to 30,000 strokes per arm. The swim stroke requires the shoulder to move in range-of-motion extremes while tremendous muscular force is exerted on the shoulder joint structures.
Swimmer’s shoulder is the most common swimming-related shoulder injury, often caused by overuse due to the repetitive overhead motion of the swim stroke that irritates and inflames the rotator cuff muscles and tendons, leading to pain and limited shoulder mobility. Swimmer’s shoulder can result from shoulder impingement, rotator cuff tendinitis, shoulder labrum injuries, pinched nerves, or shoulder muscle strains as well.
Common causes of swimmer’s shoulder include:
Overuse: The repetitive overhead motion of the freestyle, butterfly, back stroke, and breaststroke place significant stress on the swimmer’s shoulder. If the swimmer overtrains or does not allow for sufficient recovery time, this can cause inflammation and irritation in the shoulder joint complex, muscles, and tendons. The repetitive shoulder revolutions can fatigue the serratus anterior and subscapularis muscles as they are most active during the pull-through phase of the stroke, which can place stress on the rest of the shoulder complex.
Laxity and multi-direction instability: Laxity of the static stabilizer muscles of the shoulder joint is very common among competitive swimmers, which can stress the rotator cuff muscles and cause shoulder dysfunction. Muscular imbalances can also contribute to laxity and instability in the joint.
Improper swim stroke technique: Faulty stroke mechanics, such as having the hand cross the mid-line during the pull-through phase of the freestyle stroke, can contribute to excessive body roll which can then lead to shoulder impingement.
Impingement: Shoulder impingement can result in swimmers due to muscle fatigue and laxity, particularly of the glenohumeral joint that then impinges on the rotator cuff tendons.
Scapular dyskinesia: When the serratus anterior and subscapularis muscles are fatigued, there is unopposed action of the pectoralis major that strains the anterior glenohumeral joint. This causes abnormal scapular movements, leading to secondary impingement and causing labral tears and shoulder pain.
Symptoms of swimmer’s shoulder include:
Pain when reaching arms overhead or behind the back
Weakness in the shoulder
Decreased range of motion in the shoulder
Shoulder stiffness
Swelling or tenderness in the shoulder
Pain that radiates from shoulder to neck or down the arm
Physical Therapy for Swimmer’s Shoulder
Physical therapy is one of the most effective treatments for swimmer’s shoulder, utilizing a targeted manual therapy, stretching, and strength and conditioning exercise program to restore shoulder function, mobility, and strength and a safe return to competitive swimming.
The physical therapist first conducts a thorough assessment, analyzing stroke technique; shoulder joint flexibility, strength, joint stability, and muscular imbalances; breathing techniques; and postural deviations. From there, the therapist designs a customized exercise and manual therapy program for the swimmer to address their specific impairments, alleviate pain, and restore shoulder function and mobility.
Physical therapy for swimmer’s shoulder can include:
Pain management using ice and heat as well as rest from aggravating activities to reduce inflammation in the shoulder.
Manual therapy: soft tissue and joint mobilizations to improve range of motion in the shoulder and restore the shoulder joint’s full mobility. The therapist may specifically conduct posterior capsule mobilizations as tightness in this area often accompanies anterior shoulder laxity and contributes to swimmer’s shoulder.
Targeted stretching of tight muscles in the shoulder joint, upper chest, and upper back that may be restricting normal shoulder movement.
Targeted strengthening exercises:
Range of motion exercises involving gentle stretching and mobility exercises to improve flexibility and restore normal shoulder function.
Rotator cuff strengthening involves external and internal rotation, abduction, and retraction exercises to help strengthen the rotator cuff muscles and restore muscular balance.
Scapular strengthening involves targeted exercises to strengthen the middle and lower trapezius, serratus anterior, and rhomboid muscles.
Core strengthening to ensure a strong foundation for movement in the abdominal and lower back muscles, allowing for a fluid transfer of power from the lower body to the upper body and shoulder.
Postural education to ensure proper posture to reduce stress on the shoulder and allow the shoulder to rest in proper position.
Sport-specific functional training focused on ensuring correct swim stroke technique to reduce excessive stress on the shoulder. A gradual return to sport program may be implemented with the swim coach, starting with low-intensity short-duration sessions, and gradually increasing in duration and intensity as the swimmer can tolerate.
