Notes on shoulder pain by larry weisenthal

Notes on Shoulder Pain by Larry Weisenthal

In a recent usenet article a poster wrote:

It's sort of a burning pain in the joint that feels terrible when I begin swimming,
eases a bit with warm up and continues (tolerably) through the swim. I feel it in
between sessions as well -- but only if I lift my arms above my head. The poster
is describing a common impingement type of injury. This is the most common
cause of shoulder pain in swimming. The human body wasn't designed to work
with the arms above the head (as they are in swimming).

I received an email from a swimming coach describing a similar problem. His
question and my answer may be of interest to coaches working with talented
teenage swimmers with shoulder pain. Here is that letter:

At present I have a 16 year old girl who is starting to develop shoulder pain.
Unfortunately she is, perhaps, the most talented of all my swimmers. I think she
has the potential to be quite a good distance swimmer. Her freestyle pull is
near textbook perfect. She maintains the highest elbow at catch and pullthrough
of any swimmer I have seen (this may actually be exacerbating the problem). I
may be panicking too early, however, having gone through my own shoulder
problems as well as sharing the heartache and frustration another swimmer
felt through her injury/recovery; I want to be sure [my swimmer] is looked after
early. The pain has come and gone before. There does seem to be some
correlation between yardage increases and pain. The last few weeks we have
been covering a little more work (peak of about 10K a day this week). We have
been doing a little more fly as well which in the past has lead to her shoulder
pain flaring up.

Below is a summary of when and where she feels pain:
· Right shoulder only (she does breathe to both sides, however she definitely
favors the Left side)
· Freestyle -- pain at catch and at end of pull-through
· Fly -- pain during recovery
· Back -- not too bad, however, sometimes pain at end of recovery and start of pull
· Breast -- pain at start of pull-through (not too bad though)
· Sometimes upon picking a heavy object up or by pushing herself up off the ground
she feels like she is 'pulling freestyle', i.e. the pain.

The pain is a dull ache and lasts all day. It is not sore to touch. Physiotherapists
suggested to her that there was weakness in the stabilisers of the scapula. She
does have quite a hunched over posture. She is a slender girl. Basically just from
looking at her I get the feeling she is a prime candidate for shoulder problems.

Any advice or help would be greatly appreciated.
My answer follows. Ninety percent of these problems are from impingement. The
symptoms you describe are consistent with this. This can be reduced by some simple
stroke modifications (see below).

Two causes (besides technique):

1. Bad bone anatomy. Big or downsloping or spurred acromion (bone you feel when
you clap yourself on the shoulder) or else thickened coracoacromial ligament (runs
from the lateral tip of the acromion to a little boney knob in the front of the scapula to
which the short head biceps tendon attaches). Diagnose this with an MRI (14 y.o. girls
can have poorly ossified acromial head, which can be difficult to see on plain x-ray).

2. Lax/hypermobile joint. Humerus held up against scapula by ligaments called the
joint capsule. Most good swimmers are very flexible (because their joint capsules are
loose). Have her hold her arm straight ahead while standing up.elbow down, palm up.
Look at the angle between the (upper) arm and forearm. Is it 180 degrees? Then she's
probably NOT hypermobile. Is it greater than 180 degrees? Then she very well may be
hypermobile. Problem with hypermobility is that the head of the humerus can migrate
upwards, smashing the superior rotator cuff (supraspinatus) tendon against the "roof"
of the shoulder (acromion and coracoacromial ligament). This is worse during the
stroke.usually worst right at the very start of catch and pull-through. This is because
when downward/rearward pressure is applied, the head of the humerus is forced
upward.

Oftentimes, swimmers have both problem # 1 AND problem #2.

Tests for #1 type impingement (in addition to MRI to define anatomy):

Neer Test Raise arm overhead, pointing straight up. Rotate hand so palm is outward.
Examiner then presses against palm, forcing hand over the top of the head. Does this
hurt? If so, it is a positive test. Note that this is a position commonly advocated for
swimmers. Swimmer on the side, hand reached straight forward, palm down. Is there
any wonder that swimming causes shoulder problems when some swimmers are taught
to swim by performing a Neer test on them selves with each stroke?

Hawkins test Arms at side. Lift elbow up to the side, so that (upper) arm is at shoulder
level, parallel to ground, Finger tips pointing straight down. Now, rotate thumb
backwards, while securing wrist to keep fingers pointing straight down, while examiner
forcefully pushes shoulder forward. Pain?? Positive test. Note that this position can be
achieved also during the swimming stroke, with certain types of high elbow recoveries.
Or think a butterfly recovery, with elbows slightly bent and thumbs down and slightly
backward facing, with pinkies and back of hand leading. Does your kid recover fly with
thumbs down? Have her recover thumbs forward, palm of hand parallel to water.
Coaches like thumbs down, back of hand foward, because it is slightly easier to clear
the water this way. But about 35% of elite flyers do recover palms down, thumb leading,
so it is NOT incompatible with fast fly swimming. While your kid is actually having pain
(not just trying to prevent pain), she might even tilt her thumbs slightly upward during
recovery, to completely avoid internal rotation. Internal rotation is bad because it rotates
the vulnerable supraspinatus tendon right underneath the most narrow part of the
acromion and coracoacromial ligament (where there is the least space and where the
tendon gets squeezed the most).

Also, it is essential to rule out that the pain is being caused by epiphysitis. This is similar
to a lower body (leg) problem called Osgood-Schlatter's syndrome. This is a VERY
COMMON problem in 14 year old land athletes (soccer, basketball, running). The lower
patellar tendon attaches to the top of the tibia right over a growth plate (epiphysis).
Traction of the tendon against the growth plate can hurt like heck. Cure is aging enough
so that the growth plate closes. The same thing can happen in the shoulder, where the
acromial epiphysis can get inflamed from repetitive motion. This is very easy to
diagnose. Put two fingers on the top of the acromion, right near the ("drop off") end of
the top of the shoulder bone. Press firmly on the top of the bone with two fingers and
see if you can force her to the ground, not with pressure, but by eliciting pain. If this
doesn't happen (i.e. you can't force her down with pain), then you have ruled out
epiphysitis as a cause. If you CAN force her down, then she has epiphysitis and the
following material is not applicable. Consult a physician for treatments.

Presuming the problem is impingement syndrome (and not epiphysitis), here's what to
do.

1. Kicking only until she is having no more pain. My daughter's team had a 15 y.o. girl
with a nearly identical problem who kicked for about 12 weeks straight last winter, but
10 weeks after resuming full stroke swimming, swam a 4:47 400 IM LCM. Will it take 4
or 8 or 12 weeks? I don't know. But definitely do this; your swimmer is only 14 and a
stitch in time saves nine.

2. Posterior rotator cuff strengthening (to strengthen active stabilizers, i.e. the rotator
cuff tself.to keep the head of the humerus down where it belongs and not migrate
upward. Particularly important if the "elbow bend test" (see above) diagnoses
hypermobility.

3. Stroke modification. Rule number 1: Avoid/minimize internal rotation of the
hand/forearm/(upper) arm complex. Internal rotation is counter-clockwise on right and
clockwise on left. Rule number 2: See rule number 1! Rule number 3: Don't apply any
downward/backward forces at the catch until the forearm has descended well into the
high elbow position. The problem with paddles is that there is a tendency to begin the
pull much oo early, as it takes longer for the hand to drop to the catch position while
wearing a paddle. The problem with a too early pull is that the head of the humerus is
forced upward. Rule number 4: Don't have a big, strong push back to "finish the stroke."
This produces a "wring-out" effect, crimping off the small arteriole which supplies blood
to the supraspinatus tendon. Don't worry. Your great Aussie coaching colleague Carew
teaches an early exit. Perkins doesn't finish the stroke but swims with an early exit. So
does Fanzi Van Almsick, WR holder in the 200 free.

How to avoid internal rotation?

1. Something I call the "Birmingham feather" (named after Paul Birmingham, the
Australian swim coach who invented the maneuver, during his tenure coaching the
Golden West Swim Club in Huntington Beach, CA). Think rowing. After the end of the
stroke, what does a competitive rower do? He "feathers" the oar so that the flat part of
the blade is parallel to the surface of the water. This is what Coach Birmingham taught
my daughter to do. She still does it. So does my other daughter. So do I. As long as we
remember to do this, none of us has any shoulder pain at all. In an article by Yanai and
Hay at the University of Iowa published last year, they found that the number one cause
of impingement was delayed external rotation (delayed Birmingham feathering) during
recovery.

2. Don't swim with a locked elbow forward reach unless you are Ian Thorpe and have a
great kick. Pieter van den Hoogenband never completely straightens his left elbow, and
he's the fastest freestyle swimmer (100/200) in history. A female distance swimmer
shouldn't ever swim with a locked elbow stroke unless she is Astrid Strauss on steroids
with an unbelievable kick racing Janet Evans in the '88 Olympics. Otherwise, swim like
Brooke Bennett or Diana Munz. Shorter stroke; faster turnover; no Neer test, no internal
rotation during recovery and entry. Early exit to avoid supraspinatus artery wring out.
Locked elbow stroke only makes sense in the context of a great kick (e.g. US distance
ace Erik Vendt). Otherwise, in a weak kicker (e.g. most female distance swimmers or
swimmers such as Claudia Poll and Lindsay Benko), the more rapid turnover is needed
to conserve momentum, which is rapidly lost with locked elbow stroke in the absence of
a good kick. Locked elbow stroke recapitulates the orthopedic Neer impingement test
and will be more likely to produce shoulder (rotator cuff) injury.

3. Basically, you want to have thumb ahead of pinky during recovery and entry. At the
moment of catch and pull, it's probably more efficient to have some internal rotation, but
80% of all impingement occurs at recovery and entry, and only 20% during pull-through.
However, if the swimmer is still having pain, then even keeping the thumb slightly
forward (toward the direction that the swimmer is moving in or toward the approaching
wall) of the pinky during pull through will eliminate internal rotation at all times, and
minimize impingement as well. To allow for an effective angle of attack, the entry should
be a little wider than usual, so that the initial part of the pull resembles the initial part of
the butterfly pull (where the hand typically enters wider than in freestyle and the start of
the pull is an inward diagonal).

4. Swim fly by recovering with palms down, thumbs forward (see above).

5. Swim back with thumb out, pinky in.but when do you rotate the wrist? Many
backstrokers rotate immediately, to lead with the pinky as the hand moves out of the
water and over the head. This is internal rotation (bad). You want to keep the thumb
forward, pointing to the direction of travel until just before entry, when you feather the
hand to enter pinky first.

6. Breast.your swimmer is getting pain I presume at the time she rotates her thumbs
inward to begin the (high elbow) pull. Internal rotation again. Hard to describe how to
modify this without seeing her swim in person. Maybe just a slight reduction in internal
rotation (i.e. thumbs not so much inward) is all it will take to give her some relief.

Generally, avoid internal rotation where ever possible. E.g. if doing a hand lead kicking
drill on the side, keep the palm of the hand up, rather than down. While reaching for the
wall, do so with thumb up. While raising her hand in class, do so with thumb back, palm
in, etc.

Finally, an aside on breathing:

You say that she favors left sided breathing. Is she right handed? Right handers should
NEVER develop dominant left sided breathing. Never, never, never. This is one of the
cardinal sins in freestyle swimming. All swimmers are asymmetric. Even elite
swimmers. This was documented at the International Center for Aquatics Research in
Colorado Springs. Described in Maglischo's book, Swimming Even Faster. Put any
swimmer in the middle of the ocean without visual clues and he will swim in circles. Just
like everyone would row in circles. So you want to strengthen the left sided pull (if you
are right handed). Otherwise, you are creating a lot of drag as you constantly re-aim to
stay on the black line and not veer against the lane line. This is what van den
Hoogenband's "loping" stroke achieves. But everyone "lopes" a bit just by breathing.
You end up getting more body side forces assisting the pull of the non-breathing side
arm, as the body rotates back from breathing. Thus, a left sided/ right handed breather
is ACCENTUATING the right/left strength assymetry, rather than reducing it. The bonus
is that there is often less impingement on the breathing side. Easier to maintain external
rotation during recovery and entry and avoid internal rotation. If your swimmer is right
handed, she should be a primary right side breather. This will even out force vectors
between right and left and should reduce impingement to her right (sore) side in the
bargain.

Source: http://njst.usswim.net/NJST%20Parents/Notes%20on%20Shoulder%20Pain.pdf