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Swim away from shoulder pain - rotator cuff tendinopathy in swimmers

Rotator cuff tendinopathy is the most common shoulder pathology seen in swimmers. The incidence rate is reported as high as 69% of swimmers showing evidence of tendinopathy. It is important to assess the entire kinetic chain to determine the intrinsic contributing factors.



Let’s guide you through how we resolve rotator cuff tendinopathy here at Breathe using our Roadmap to Recovery:

  • Step 1. Pain Reduction

  • Step 2. Activation

  • Step 3. Movement

  • Step 4: Strengthening / Sports Performance


Pain reduction

To manage and reduce symptoms, it is important to understand these four concepts:

  • understanding diagnosis

  • stretches/mobility exercises

  • hands-on treatment

  • movement strategies


Rotator cuff tendinopathies in swimmers is usually caused by reduced flexibility in the glenohumeral joint, which then passes this motion requirement onto the scapulothoracic joint or the spine. On the other hand, hypermobility leading to excessive translation of the humeral head can also increase the potential for other shoulder injuries. People with potential rotator cuff tendinopathy are likely to present with:

  • pain over lateral upper arm

  • pain is load dependant (minimal pain at rest)

  • pain sleeping on shoulder (compression on tendon)

  • increased pain with physical activity or exercise especially with movements above the head.

The following are key contributing factors to shoulder pain in swimmers:

  • Reduced rotation and/or extension of the thoracic spine—important in relation to body roll

  • Tightness or improper motor control around the scapula

  • Muscular imbalance around the shoulder, in particular, internal and external rotators

  • Incorrect swimming technique

  • Too much training with hand paddles or drag-increasing devices

  • Improper land training, weight training or stretching

  • Suboptimal core strength and/or control.


Through analysis of the mechanism of injury and the presenting symptoms, physiotherapy management starts with modifying the aggravating activity to allow for sufficient rest and recovery. It is important for athletes to involve the coach in this process as this will allow for continuity of training.


Some modifications which can be used are:

  • reduce the swimming session distance

  • reduce intensity/frequency of training sessions

  • minimise the use of pull buoys, swim paddles and kickboards

  • technique modifications from your swimming coach

  • specific swimming related warm-up exercises.

Rotator cuff tendinopathy can be managed conservatively through a program which focuses on a gradual build in load. Physiotherapy will aim to assist in the correction of biomechanical overloading factors such as reduced mobility, muscle imbalances etc. Regaining mobility will allow for better swimming technique and prevent future reoccurrences of injury. Therefore, a hands-on treatment combined with the above activity modification and mobility exercises works well during the initial injury stages. These can be combined with deep tissue release and dry needling to enhance recovery outcomes.


Activation

One of the leading causes of rotator cuff tendinopathy in athletes is due to their swimming technique. Poor technique can lead to the overloading of soft tissue and/or bony structures due to altered biomechanics. It is also important to identify muscle imbalances in the shoulder such as the internal and external rotators.

Once the pain has subsided, your shoulder muscles are ready to start activating and strengthening to build their load capacity. Early muscle activation exercises should focus on unilateral loading of the upper limb. Example exercises can include:


2 arm push: Mimics the swimming movement without moving the shoulder above the head. Focus on keeping a strong pelvis and core position.



2 arm rows: Pull arms back to have your elbows at 90 °. Focus on keeping a strong pelvis and core position.



Banded external and internal rotation: Keep elbows tucked into ribs. Focus on moving your arm straight in and out without the shoulder rising.



Movement

Once you can activate the correct muscles and your pain has reduced, we can incorporate your swimming technique and biomechanics to reduce the stress on your shoulder. Some great movements for you to practice are:


  1. W Y T: This will mimic a swimming motion on dry land. Focus on drawing shoulder blades back towards each other and keeping the head and neck in a neutral position.

  2. Single arm row to external rotation: This is a progression of what we have worked on above. Stand in a split stance pose focusing on a strong pelvis/core position.

  3. Single arm internal rotation punch: Like the above exercise, focus on a strong pelvis/core position. This is an advanced exercise for you internal rotator muscles.


Strengthening / Sports Performance


To avoid rotator cuff injuries in the future, it is important to continue weekly strength and conditioning sessions. These sessions should aim to continually progress your strength and mobility through exercises such as bird dogs. Programs which incorporate the entire kinetic chain will have the most success in enhancing swimming performance and reducing further injury.




Reference:

Brukner, P., & Khan, K. (2017). Brukner & Khan's clinical sports medicine : injuries (5th edition). McGraw-Hill Education Australia.


Sein ML, Walton J, Linklater J, et al. Shoulder pain in elite swimmers: primarily due to swim-volume-induced supraspinatus tendinopathy. Br J Sports Med. 2010;44:105-113.


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