Shoulder Injury Prevention Program for Competitive Swimmers
Noelle Martin
Overview:
Swimming consists of four strokes: freestyle, backstroke, breaststroke, and butterfly. Freestyle is the fastest of the four strokes and commands the majority of practice time. The average competitive swimmer practices 5-7 days a week, completes 6,000 – 10,000 meters a day and 60,000-80,000 meters a week.1 With an average stroke count of 8-10 strokes per lap, each shoulder performs over 30,000 rotations a week! There are tremendous amounts of stress directed at the glenohumeral joint and shoulder girdle as about 90% of the forward propulsive force comes from the upper extremity.1 Therefore, it is no surprise that shoulder pain is the most common musculoskeletal complaint among competitive swimmers. This is termed “swimmer’s shoulder” and can be triggered by decreased muscle strength and endurance, muscle imbalances, altered scapular kinematics, incorrect stroke technique, poor posture, fatigue, subacromial impingement, and overuse.1-8 These factors increase the risk of shoulder injuries. In fact, 47% of 10-18 year olds, 66% of senior development swimmers, and 73% of elite swimmers have experienced shoulder pain and injuries that has interfered with participation.1,9 Due to this relatively high incidence, a shoulder injury prevention program should be implemented.
My interest in this topic of shoulder injury prevention derives from my personal experience as a competitive swimmer. My 16 year competitive swimming career at the national and collegiate level was filled with numerous shoulder injuries. My first and nearly career ending shoulder injury occurred at age 10. Thankfully, the remainder of my career presented with only relatively minor shoulder injuries. While learning about the shoulder in classroom and in the clinic, I was intent on understanding the cause of my previous shoulder injuries and am motivated to assist others facing similar situations. Working through these experiences always led me to consider how these injuries could have been prevented. Therefore, I decided to focus my capstone project on finding and/or creating a shoulder injury prevention program for competitive swimmers.
Literature Review:
Over this past year I have directed my efforts to find a shoulder injury prevention program for competitive swimmers. My research began in Evidence Based Practice II with my PICO question: For competitive swimmers between 10-25 years old, does a scapular strengthening program vs. no strengthening program, decrease the risk of seasonal shoulder injuries? I found a limited number of studies that investigated this issue. I organized the available literature into an Evidence Table. I was able to update the table this spring when I identified a newly published article that contributed to this clinical question.
The available evidence had multiple focal points which include correcting muscle imbalances, strengthening weak glenohumeral and scapular muscles, correcting poor posture, and stretching tight musculature. The evidence is further discussed, analyzed, and applied to clinical practice in my EBP II Paper and EBP II Paper Summary. To date, there is not an established or effective shoulder injury prevention program available to implement. This evidence is unable to definitively answer my proposed PICO question. Nevertheless, the evidence has proven useful by demonstrating interventions that lower the incidence of shoulder pain, providing strengthening exercises to utilize in a program, and identifying swimming related factors that increase the risk of shoulder injuries. In the Health & Wellness course, I utilized this evidence to begin creating a shoulder injury prevention program and developed a Health and Wellness Proposal that would be the draft of my capstone project.
Products:
I created a shoulder injury prevention program for the National Prep Teams I and II on the Winston-Salem YMCA Swim Team (TYDE). This program consists of two components: an educational session for the coaches and an exercise program for the swimmers. I gave this Shoulder Injury Prevention Program Presentation to the two National Prep Team coaches on April 3, 2014. Here are the additional PowerPoint Notes from the presentation. I provided each coach with a Handout that contained the main points from the presentation and a list of online resources for future reference. Next, I guided the coaches through the entire 16 week exercise program for the athletes. I allotted time for them to practice the exercises in Phase 1, Phase 2, and Phase 3. I also included Advanced Exercises so that the coaches can continue to progress the program. This organization of the educational session was a great way for the coaches to learn how to properly perform the exercises, clarify technique, and ask questions prior to instructing the swimmers. Following this educational session, I met with the National Prep Team swimmers to explain the purpose of the program and to initiate Phase I of the exercise program. At the program’s conclusion, the coaches completed and returned an Evaluation Form for feedback on the delivery and content of the presentation to the coaches and athletes. Here are the Results. Overall, the coaches’ expectations and need was met with this evidenced based shoulder injury prevention program. They voiced their excitement to begin implementing the program into their practice time. Since my final clinical rotation is in Winston-Salem, I offered my continued assistance to the coaches throughout the summer months to further execute this shoulder injury prevention program. I also wrote a Self Assessment of this first application of the program to further explain my experience and identify areas of improvement.
Special Thanks and Feedback:
I want to give a big thank you to my advisor, Mike Gross, and my committee members, Robin Jacobs and Miranda Martin, for their valued input and guidance throughout the capstone process. I also want to thank Karen McCulloch and Mike Lewek for their helpful discussions and direction throughout the planning period of this project.
Thank you for visiting my capstone webpage. Please feel free to provide comments below or contact me at noelle_martin@med.unc.edu regarding any aspects of my project. I am looking forward to receiving feedback and ideas on how to improve this program for future use.
References:
- Hibberd EE, Oyama S, Spang JT, Prentice W, Myers JB. Effect of a 6-week strengthening program on shoulder and scapular-stabilizer strength and scapular kinematics in division I collegiate swimmers. J Sport Rehabil. 2012;21(3):253-265.
- Niederbracht Y, Shim AL, Sloniger MA, Paternostro-Bayles M, Short TH. Effects of a shoulder injury prevention strength training program on eccentric external rotator muscle strength and glenohumeral joint imbalance in female overhead activity athletes. J Strength Cond Res. 2008;22(1):140-145. doi: 10.1519/JSC.0b013e31815f5634; 10.1519/JSC.0b013e31815f5634.
- Lynch SS, Thigpen CA, Mihalik JP, Prentice WE, Padua D. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. Br J Sports Med. 2010;44(5):376-381.https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2010618332&site=ehost-live&scope=site. doi: 10.1136/bjsm.2009.066837.
- Kluemper M, Uhl T, Hazelrigg H. Effect of stretching and strengthening shoulder muscles on forward shoulder posture in competitive swimmers. J SPORT REHABIL. 2006;15(1):58-70. https://auth-lib-unc-edu.libproxy.lib.unc.edu/ezproxy_auth.php?url=http://search.ebscohost.com.libproxy.lib.unc.edu/login.aspx?direct=true&db=c8h&AN=2009114883&site=ehost-live&scope=site.
- Van de Velde A, De Mey K, Maenhout A, Calders P, Cools AM. Scapular-muscle performance: Two training programs in adolescent swimmers. J Athl Train. 2011;46(2):160-7; discussion 168-9. doi: 10.4085/1062-6050-46.2.160; 10.4085/1062-6050-46.2.160.
- Swanik KA, Swanik CB, Lephart SM, Huxel K. The effect of functional training on the incidence of shoulder pain and strength in intercollegiate swimmers. JSportRehab. 2002;11(2):140-154
- Bak K, Magnusson SP. Shoulder strength and range of motion in symptomatic and pain-free elite swimmers. Am J Sports Med. 1997;25(4):454-459.
- Batalha NM, Raimundo AM, Tomas-Carus P, Barbosa TM, Silva AJ. Shoulder rotator cuff balance, strength, and endurance in young swimmers during a competitive season. J Strength Cond Res. 2013;27(9):2562-2568. doi: 10.1519/JSC.0b013e31827fd849; 10.1519/JSC.0b013e31827fd849.
- Heinlein SA, Cosgarea AJ. Biomechanical considerations in the competitive swimmer’s shoulder. Sports Health. 2010;2(6):519-525. doi: 10.1177/1941738110377611.
9 Responses to “Shoulder Injury Prevention Program for Competitive Swimmers”
Morven Ross
Oops! I have definitely been using paddles. However, since reading your Capstone materials I have made several adjustments to my stroke technique and implemented your strengthening program. So far I am feeling good!
Great job Noelle!
Noelle Martin
Audrey,
Thanks for your comments! You are so right about the increasing interest in swimming! It is great to see, but as you mentioned we have more people at risk for shoulder pain and injuries. I am sure many types of swimmers will enter the clinic—recreational swimmers, elite swimmers, triathletes, weekend warriors, etc. The good news is that this program can apply to many of these swimmers and that shoulder pain and injuries can be prevented! Feel free to utilize this information to help patients continue to participate in this great sport! Noelle
Noelle Martin
Gabrielle,
Thanks for visiting and commenting on my capstone page! That is so great that your dad is an avid swimmer! Yes, I think this program can apply to individuals outside of the 10-25 age group that I focused on because many of the contributors to shoulder pain and injuries still apply due to the nature of the sport. Here is a good article that discusses swimming throughout the lifespan and common impairments in older swimmers. (Tate A, Turner GN, Knab SE, Jorgensen C, Strittmatter A, Michener LA. Risk factors associated with shoulder pain and disability across the lifespan of competitive swimmers. J Athl Train. 2012;47(2):149-158.) Master swimmers have more shoulder pain, disability, and dissatisfaction compared to younger swimmers. It is suggested that older swimmers reduce swim training frequency, increase cross training, stretch the pectorals and posterior shoulder, core endurance training, and shoulder strengthening. The subjects included in this article are only females, but I still think this article still gives valuable insight. Hope it helps! Noelle
Noelle Martin
Morven,
Thanks for your comments! I identified a swimmer who had increased glenohumeral laxity. I noticed that he was hypermobile in general. I do not know if he had glenohumeral instability though. Therefore, I cannot answer your question based on this particular swimmer. However, to address your question, I did not want him to perform the sleeper stretch because 1) he could not feel a stretch in the proper position, and 2) when he was placing his shoulder in a compromised position when he tried to do the stretch. I would recommend for him to perform across the body stretch or horizontal adduction stretch instead. That way we can address possible posterior shoulder tightness without compromising the integrity of his joint. Additionally, this shoulder injury prevention program is based on the generalized findings in swimmers. It is a possibility that some swimmers will have better stability or more inherent joint laxity than others. I addressed this possibility to the coaches and was pleased to have real examples during the athlete component of the program. I think this showed the coaches to use their judgment in these situations and that this program is not a cookie cutter, fits all program, and that it can be modified based on the swimmer’s unique presentation.
Hand paddles are used to help swimmers “feel” the water better, improve the catch and pull phases of the stroke, and strengthen stroke specific muscles. However, swimmers must have the strength to pull the water with hand paddles correctly. And this is one of the major issues here. The swimmer must have correct stroke technique and the necessary strength to use hand paddles, period. There are various types and sizes of hand paddles so coaches have many options available to them. I was pleased to see that the TYDE swimmers used small paddles that aimed to correct stroke technique.
Overall, I do not recommend hand paddles for swimmers with poor stroke technique or with glenohumeral instability. I think those impairments need to be addressed first. However, as I mentioned above, certain small paddles can be used to address stroke technique, but this would occur during swim drills only. I highly discourage using larger paddles for swim sets as they will increase the surface area, require increased muscular demand, direct the shoulder anteriorly, and further worsen muscle imbalances and shoulder instability. Personally, I do not think paddles are always necessary as shoulder strength can be achieved in other ways.
On another note, I see recreational swimmers use hand paddles incorrectly all the time, which is unfortunate because they are increasing their risk of shoulder pain and injuries. Morven, I hope you are not one of these people! I hope I answered all your questions.
Thanks again for your feedback! Noelle
Noelle Martin
Austin,
Thanks for your comments. You pose some great questions! As you can see in the evidence table, the subjects in the studies are a mix of male and female, if it was reported at all. Only one study, Harrington et al article1, discussed the increased risk of shoulder injuries by gender. Based on this discussion, collegiate female swimmers are at a higher risk for shoulder injury. Some reasons can be due to generalized glenohumeral hypermobility, increased participation, and increased complaints of shoulder pain.1 But, considering the literature as a whole, I would say that the cause is multifactorial. Next, the literature does not differentiate between adolescent and collegiate level swimmers and the set risk at each level. However, the authors suggest that the sooner a shoulder injury prevention program is implemented the better the swimmers shoulder health will be. It’s hard to say which group is more at risk because there are different factors involved. For example, adolescent swimmers are still refining their technique; therefore, poor stroke mechanics is a larger issue here. Whereas with collegiate swimmers, fatigue is a greater issue due to increase training duration, intensity, and frequency. Regardless of the swimmers age, the risk for shoulder pain and injuries remains due to the repetitive nature and demand of the sport.
One of the unique aspects of swimming is that it is a year round sport and “preseason” does not really exist. At best, competitive swimmers will get a few weeks off in August. Some of the studies implemented their prevention program either during this preseason period or throughout the swim season. The consensus is that a yearlong or season long strengthening program would be best to maintain strength, muscle balance, muscle activation patterns, and scapular positioning. Because swimming alone causes muscle imbalances early in the season and are maintained throughout the entire season, the prevention program should be year round.
Thanks again for your feedback! Noelle
Reference:
1. Harrington S, Meisel C, Tate A. A cross-sectional study examining shoulder pain and disability in division I female swimmers. J Sport Rehabil. 2014;23(1):65-75. doi: 10.1123/jsr.2012-0123; 10.1123/jsr.2012-0123.
Audrey Osinski
Noelle,
It’s unfortunate you experienced an almost career-ending shoulder injury when you were younger, but man has it led to a very impressive capstone. You clearly identified the need in a shoulder injury prevention program. All of your materials and the presentation of your recommendations are fantastic. Everything flows well and is clearly described. Also, you were a great model for all of the exercises!
It seems the coaches and athletes were/are responsive to your materials and will be consulting you this summer! You sure will have a lot on your plate!
Like Morven, I am purely a recreational swimmer since it’s kinda sorta necessary to do for triathlons ☺. I think it’s important for all of us as future physical therapists (especially those of you pursuing opportunities in ortho) to be aware of these important causes and treatment of shoulder pain for swimmers. Because although some of you may not be working with elite swimmers (like you should, former rockstar Michigan athlete), all you ortho folks may be working with an every day person that competes in triathlons. The sport is growing tremendously – from around 100,000 in 1998 to over 550,000 in 2012! Imagine all of those individuals who will have all of the risk factors Noelle mentioned in the presentation (e.g., especially poor stroke technique, fatigue, most likely incorrect intensity and training volumes, etc.) I know I’m guilty of all of these, and yes, have had shoulder pain. I’d be surprised if you all didn’t treat at least one triathlete in your career.
So ultimately, your resources, Noelle, can help fellow classmates address shoulder issues for these elite and recreational athletes. I know I’ll be implementing some of these things into my exercise routines – so thanks in advance ☺
Great job!!
Audrey
Gabrielle Scronce
Hi Noelle,
Thanks for sharing this information about the background and prevention of shoulder injuries in swimmers! I just shared your post with my dad, a 65-year-old who has missed only a handful of 5:30am weekday swims at the YMCA over the past 25 years. He has had minor shoulder injuries, but he is currently experiencing increased neck pain and decreased cervical ROM. I can imagine that some shoulder and neck injuries in older swimmers, especially older and obsessive swimmers like my dad, could be avoided through implementation of your program. Do you think your program could apply to swimmers outside the age ranges described in the literature you found?
Thanks!
Gabrielle
Morven Ross
Noelle,
Great work on your capstone! As a recreational swimmer I have experienced shoulder pain, so I found your materials to be very beneficial. Your materials were easy to follow and understand. I especially enjoyed reading your health and wellness proposal. It really identified the need and how you were going to develop your Capstone project to meet that need. Great overall picture of your project.
Your exercise program was very thorough and the lay out made it easy to understand. I especially liked your handouts that included pictures and description. Those will be invaluable resources for coaches and swimmers.
In your self-assessment you mentioned that those individuals with GH instability should not perform the sleeper stretch. Are there any other stretches that they should not do? Should they do any stretches? And if so which ones would you recommend? Additionally in your presentation you mention the use of hand paddles do you feel that these poorly change mechanics or help? Specifically for individuals with instability and poor technique do you think that these individuals may actually find them helpful to increase muscular activation and prevent excessive GH and scapular mobility while swimming? Overall your materials were excellent. You clearly put a lot of work into this project and it shows.
Great work Noelle!
Best wishes,
Morven
Austin Leedy
Noelle,
I was very interested to read your Capstone since both of our projects involved overuse injuries of the shoulder only in regards to two very different patient populations! I was most interested to analyze as to whether I could find similarities between the two groups. The most significant factor of both of our prevention programs seems to be avoiding the cycle of experiencing pain due to the development of an overuse injury as a result of poor biomechanics, causing further biomechanical compensations during stroke, causing further increases in pain and injury. I was curious as to whether any of your research found differences between males vs. females? Adolescent vs. Collegiate, etc.? My research found that females experienced greater shoulder pain with researchers hypothesizing this pain has to do with increased ROM and ligament laxity; therefore, I was wondering if your researched mentioned anything similar.
I was very happy to read that your research also supported the use of a scapular strengthening program to decrease pain/injury. You mention in your PowerPoint presentation that this prevention program is good to implement during training, but did any of your research provide recommendations during the off-season of competitive swimming? Or, supplemental prevention techniques when individuals are not training?
I found your presentation and handout materials to be easy to read and to comprehend, and feel that they will be a source of valuable information for coaches and athletes in the future. Furthermore, I really liked how you split up the exercises by phases. This further clarified the progression sequence and is a great way to help a student therapist or therapist inexperienced with working with this patient population to improve understanding of the treatment program.
Awesome job, Noelle!
Austin