Swimmer's shoulder II

Swimming Technique, Jul-Sep 2000 by Wwisenthal, Larry M

What can coaches do for their athletes who have swimmer's shoulder? Reduce the time the swimmer spends in full forward flexion/abduction; and reduce or, preferably, eliminate internal rotation.

This is the second of a two-part series on swimmer's shoulder. In the Last issue (April June), Dr. WeisenthaL discussed how swimmer's shoulder originates and suggested how physicians should treat it. Here, in the second half, he explains what swim coaches can do when their swimmers are confronted with the ailment.

Short of surgery-or in addition to surgery-what can a swim coach do when their athletes are confronted with swimmer's shoulder?

First, every swimmer on the team should do dryland exercises to strengthen the posterior rotator muscles. By having a very strong rotator cuff, stability of the head of the humerus is improved. Also, banging against the supraspinatus tendon is reduced. These prophylactic rotator cuff-strengthening exercises are far more important than any other form of dryland training.

Second, the coach should make sure that unstable shoulders are not made more unstable by unsafe stretching and unsafe weight training (e.g., many medicine ball activities, which might be fine for Mike Barrowman, are not appropriate for hyperflexible adolescent girls).

Third, technique can be adjusted in a way to optimize both performance and shoulder safety.

These are the biomechanical principles:

As you progressively raise the arm up over the head, impingement increases to one maximum at about 90 degrees, followed by a lessening, followed by another maximum as the arm is raised first straight overhead ( 180 degrees), then actually pushed backward (i.e., beyond 180 degrees).

The 90-degree position occurs during recovery and, combined with internal rotation, is the type of recovery many stroke technicians teach. It can actually recapitulate something called the Hawkin's test, which is one of the standard stress tests performed by orthopedists to produce impingement and pain in patients for purposes of diagnosis.

The 180-degree (and beyond) position, combined with internal rotation (e.g., stretched straight forward with the body rolled to the side) nicely recapitulates another orthopedic test for impingement called the Neer test.

Rules to Prevent Shoulder Problems

So, here are the "rules" to prevent/reduce shoulder problems:

Reduce the time in full forward flexion/abduction (i.e., pointing toward end of the pool in the direction where the swimmer is going). The longer that arm is out there, the more the tendon is being squeezed. Harvard's Tim Martin, who never unbends his elbow and who "goes for depth" immediately, is the extreme example of this. He doesn't look pretty, but he also doesn't hurt. Basically, his arm recovery and hand/forearm entry are not dissimilar to those butterflyers who recover and enter with bent elbows.

Reduce or, preferably, eliminate internal rotation. A straight arm recovery like that of Janet Evans or Michael Klim or Suzu Chiba is great at reducing internal rotation during recovery. The recovery motion that is taught on many pool decks maximizes internal rotation. It is deadly. The reason why internal rotation is bad is that it places the supraspinatus tendon at the most vulnerable position with respect to impingement-right smack dab against the acromion and coracoacromial ligament. External rotation, in contrast, rotates the supraspinatus tendon out from underneath these structures.

I taught my daughter a Klim-style recovery, which worked greatly to decrease impingement during recovery. This is what I use in my own sorry efforts to imitate a freestyler in my morning lap swimming.

A young Aussie coach named Paul Birmingham thought that, for my daughter, this produced too much in the way of lateral force, which was being transmitted (action/reaction) to her trunk, making her trunk unstable (and increasing drag) during recovery. He came up with a "patch," which works brilliantly.

Basically, as soon as the swimmer's hand exits the water (and, again, it should be a relatively early exit to reduce "wring-out" of the tendon's blood supply), she "feathers" it (just as you would an oar or canoe paddle). By doing this, she recovers with a relatively high and traditionally bent elbow, but with her thumb facing forward instead of to the side-toward the ear-or even backward.

Thumb forward is external rotation; thumb inward or especially backward is internal rotation. External rotation is good; internal rotation is bad.

This "feathering" to achieve external rotation gives the swimmer's recovery sort of a funny look. As she feathers her hand, it looks as though there is a fluttering look to her fingers-as if she's doing some sort of stylistic dance. It might not be pretty, but it is very effective in reducing impingement stress during recovery.

For others, the Michael Klim straight arm recovery might work better.

At entry, it's now most fashionable to achieve a maximally stretched-out position to maximize stroke length, which correlates with performance in every event. The exception here would be the women's middle distance and distance swimming, where the only thing which correlates is ability to maintain stroke rate throughout the race.