Up to 90% of swimmers will experience shoulder pain at some point in their swimming careers. Andrew Hamilton looks at injury rehab recommendations and, in particular, the need for an appropriate return to a swimming program in the pool.
Syrian refugee and Olympic swimmer Yusra Mardini is pictured during a training session in 2018.
Although swimming is a relatively low-risk sport for injury, shoulder pain is surprisingly common in swimmers. Various studies show that over a career lifetime, between 40% and 91% of swimmers will suffer a swimming-related shoulder injury(1,2,3,4). However, when you consider that elite swimmers may be racking up over 10km in the pool each day and that the arms are the prime generators of forward thrust, we should perhaps not be surprised. High-volume training can lead to muscle fatigue of the rotator cuff, upper back, and pectoral muscles, which in turn may result in microtrauma due to the decrease of dynamic stabilization of the humeral head(5,6).
To appreciate the vulnerability of a swimmer’s shoulder to injury, it helps to understand the biomechanics of the stroke cycle. Since freestyle is the most commonly used stroke (for example, the stroke of choice in related sports such as triathlon), we will focus on this style. The freestyle stroke consists of four distinct phases (see figures 1-4).
In freestyle swimming, each of these phases has the potential to increase the risk of shoulder injury when executed incorrectly. Some of the common errors are as follows:
In more general terms, it’s important to appreciate that the shoulder is an inherently unstable joint and that a correct balance of muscle forces is critical for maintaining stability, proper motion, and painless function. Since the bulk of the propulsive force in swimming is generated by adduction and internal rotation of the upper arm involving contraction of the pectoralis major and the latissimus dorsi, high training volumes tend to favor increased adduction and internal rotation strength, which can lead to imbalance and reduced glenohumeral stability(7,8). It’s also worth noting that female swimmers, on average, have shorter arm strokes than those of their male colleagues and are, from a biomechanical perspective, at a greater risk of suffering an overuse injury, due to the requirement for more arm revolutions per lap(2).
Studies suggest that an endurance training and strengthening program for the shoulder and periscapular muscles, with emphasis placed on the serratus anterior, rhomboids, lower trapezius, and subscapularis, may help prevent injuries and speed recovery when injury does occur(9,10). There’s also evidence that abdominal and scapular muscle strengthening performed in dry-land training can yield benefits; in particular, the goal of core and abdominal strengthening is to develop increased control of the pelvis by avoiding excessive anterior pelvic tilt and lumbar lordosis(11,12).
When shoulder injury does occur, clinical evaluation and diagnosis is recommended, along with complete or relative rest and the judicious use of dry-land rehab exercises. During periods of relative rest, ice may be used, and short courses (up to 1 week) of non-steroidal anti-inflammatory medication may be beneficial. Injection of corticosteroid into the subacromial bursa, however, is a more controversial option and should be limited to swimmers with constant pain. It’s difficult to determine the optimum duration of relative rest, but in all cases, the resumption of training should be gradual and closely monitored. If the pain persists, a three-day period of absolute rest is recommended, and the swimmer should then be reassessed before resuming training in the water. If pain persists upon the resumption of training, an evaluation by a physician is indicated(13).
Muscle group | Examples of training exercises |
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Primary rotator cuff muscles (performed in standing position, scapulae maintained in retraction) |
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Scapular muscles |
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Abdominal and lower back muscles |
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The use of equipment
The use of swimming aids to develop strength and power is commonplace in the competitive environment. However, when returning to the pool after a shoulder injury, some aids are contraindicated:
- Kickboards — used to focus on kicking only. These are most commonly used with arms extended in front of the body, which increases loading on the shoulder and therefore best avoided in all cases of injury;
- Pull buoys — used to focus on arm stroke only. The pull buoy is placed between upper legs to prevent kicking while providing buoyancy to the lower body. Because the workload performed by the upper body is increased, pull buoys may be contraindicated in cases of shoulder tendinitis/tendinosis;
- Paddles — coming in a variety of sizes, paddles are worn on the hands to increase surface area of the hand, which slows down the pull and increases the ‘feel’ of the water while building strength. The increased loading with paddles make them unsuitable in all cases of shoulder pain and injury, especially where stroke technique is less than perfect.
Much has been written about pain management and dry land rehab training following a shoulder injury. However, the successful return to pain-free swimming training in the water presents a major challenge. All too often, symptoms improve or resolve after rest and dry-land training, only to recur once the swimmer is back in the pool. The particular hurdles that need to be overcome at this stage are ironing any stroke imperfections while building up swimming training volume gradually and without overload.
There are two key criteria that need to be achieved before a swimmer can begin a return swimming program: firstly, the swimmer should be nearly pain-free in the shoulder complex and be able to achieve full active extension and external rotation of the glenohumeral joint. Secondly, the strength of the rotator cuff and scapular stabilizing muscles should be scored at 5/5 when tested using traditional manual muscle testing(14,15).
Dry-land training performed regularly is generally very effective at getting the swimmer to this point. However, it is important for physiotherapists to appreciate that simply handing the swimmer back to the coach without any further support or advice risks further setbacks as the predisposing factors to injury may still be present. A preferred approach is collaboration with the coach to ensure the subsequent training is both measured and appropriate.
In a recently published paper on this topic, Spigelman et al. suggests a two-phase approach(16):
What’s important to bear in mind is that the goal of a return to swimming program is to gradually return the swimmer to practice; focusing on the swimmer’s specialty stroke or distance is not important at this time. Only when the swimmer can swim reasonable training volumes with correct technique and without pain should event-specific training be considered.
It follows from the above that good communication is required, both between the swimmer and coach and between the coach and physiotherapist. The coach needs to communicate with the swimmer the importance of providing constant feedback about how their shoulder is responding to the increasing training load. It should be stressed that any symptoms of pain or discomfort need to be reported immediately so the coach can pause the training if necessary and evaluate the situation. A useful tool in this respect is the ‘Swimming Soreness Rules,’ which can help the swimmer recognize pain, and the coach/physio adjust the swimming portion of shoulder rehabilitation in the swimmer’s program(16).
The ‘Swimming Soreness Rules’
- So long as no soreness manifests, increase the total swimming distance by 200-300m per day;
- If the shoulder is sore during the warm-up but the soreness has gone within the first 500-800m of training, repeat a similar workout from the previous day. If the shoulder becomes sore during this workout, cease the workout and take two days off. When returning to the pool, decrease the distance of the session by 300m compared to the last pain-free workout;
- If the shoulder is sore for more than one hour after swimming, or the next day, take one day off and repeat the most recent swimming workout;
- If the shoulder is sore during the warm-up and the soreness hasn’t gone within the first 500-800m of training, stop immediately and take two days off. When returning to the pool, decrease the distance of the session by 300m compared to the last pain-free workout;
- If soreness occurs repeatedly despite this graduated return to training, a further evaluation should be made by the physiotherapist.
A detailed description of suitable drills and swimming workouts for the swimmer returning to the pool is beyond the scope of this article and will, of course, depend on the swimmer in question, their event, stage of development, etc. However, the general criteria for progression from Phase one to Phase two, and from Phase two to resuming event-specific training can be given (see table 2). It must be emphasized that the swimmer and coach both need to understand that progression should only be very gradual. Any increases in pain, soreness, or discomfort need to be recognized by the swimmer and coach as potential warning signs to decrease or even suspend training while re-evaluation takes place.
Phase 1 | Phase 2 onwards | Return to Swimming | |||
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Typical total distance (meters) | 1000-1500 | 1500-2200 | 2200-3000 | 2800-3900 | 3500-4700+ |
Typical warmup distance (meters) |
300-400 | 600-700 | 700-900 | 900-1100 | 1000-1200 |
Drills | Stroke technique using drills (300-500m) | Stroke technique using drills (400-600m) | Stroke technique using drills (600-700m). Incorporate drills at the beginning and end of practice |
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Incorporate a drill set of 1000-1200m at the end of the workout |
Intervals | None | None | One set at 70% effort. | Gradually increase the number of intervals while maintaining correct stroke technique (500-1000m maximum) | Gradually increase interval pace to that of pre-injury pace while maintaining stroke technique (800-1300m) |
Paddle use | No paddles | No paddles | No paddles | No paddles | No paddles |
Kickboard use | No kickboard | No kickboard | No kickboard | Kickboard if comfortable | Kickboard if comfortable |
Criteria to progress |
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(Swimmer rejoins team)
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Overuse injuries to the shoulder are all too common in competitive swimmers, especially where training volumes are high, and stroke technique is less than perfect. Evaluation by the clinician, rest, and appropriate dry-land strengthening exercises are important in the first phase of any recovery program. However, the process of rehab shouldn’t stop there.
The first few weeks in the pool as part of a return to swimming program are vitally important for a full recovery, and this is a time when cooperation between the clinician and the swimmer’s coach can be extremely useful. During the return to swimming program, any increase in workload should only be very gradual, with an emphasis on correcting any stroke errors rather than rushing the swimmer back to full-race fitness. A key part of this process is constant monitoring of and feedback from the swimmer so that the coach and physio can make any adjustments to the program as needed.
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