Written by: Dr David Ness, CCSP, ART, CGFI
Swimmer’s shoulder (SS) is a term used by swim coaches to describe pain in one or both shoulders. The pain associated with SS is in the front of the shoulder. Under these muscles passes the supraspinatus muscle and tendon, which is a rotator cuff muscle. This muscle along with the Biceps tendon, are affected when you have SS causing tendonitis and inflammation of both tendons. As well, the ligaments that attach from the scapula (shoulder blade) and the clavicle (collar bone) become irritated and inflammation occurs. When this happens the space that the Supraspinatus tendon has to pass through to connect to the Humerus becomes smaller, pinching and further irritating the tendon. Due to age, hereditary factors, and arthritis the space for this tendon to pass through gets even smaller leading to more inflammation, scar tissue formation, pain, and shoulder weakness. Eventually, overuse of the shoulder that is common from triathlon training could cause a partial or full tear of the Supraspinatus tendon that could require a trip to the orthopedic to repair.
Why does SS happen?
The answer is multi faceted because there are so many factors that can cause SS. The number one cause of SS is instability of the shoulder joint. What that means is that the head of the Humerus, which sits in a very shallow cavity called the Glenoid cavity (on the scapula) is not staying centered in the joint during movements like swimming crawl. Usually, there is weakness of the Subscapularis muscle. This muscle opposes the action of the Supraspinatus. When the Subscapularis muscle is weak, the Humerus slides to far forward in the Glenoid cavity decreasing the space anteriorlly where the Supraspinatus tendon passes. This coupled with other factors like a degenerated Acromioclavicular joint, and inflammation of the ligaments around the anterior shoulder further decrease the space for the Supraspinatus tendon to pass through. When you swim the tendons rubs or gets pinched between these structures causing gradual breakdown of the tendons resulting in tendonitis or tendonosis. There is also a congenital variant to the acromion process that could further decrease the space for the tendon to pass through called a hooked acromion process.
When you add these factors together with the amount of time triathletes spend swimming you understand how at sometime you may develop this condition.
So what do you do if you have SS?
To get an accurate diagnosis you must see a sports medicine professional. X-rays should be taken to rule out arthritis of the AC joint or having a hooked acromion process. After an examination where the doctor tests for rotator cuff tear, bicep’s injury, and impingent signs, range of motion of the shoulder along with muscle testing of all the rotator cuff muscles should be performed. After these tests an accurate diagnosis can be made.
If no tear is suspected physical therapy is recommended to reduce pain, inflammation, and to strengthen the shoulder. If physical therapy fails after 4-6 weeks usually a trip back to the orthopedic for an MRI is done. This can check for rotator cuff tears, bicep’s injury, and cartilage damage, which may require surgery. In the presence of a normal MRI where surgery is not needed but physical therapy has failed. Active release treatment to the scapula, rotator cuff muscles, and arm muscles can remove the scar tissue in the injured muscles, tendons, and ligaments. This will restore normal range of motion, strength, and relive pain. Once the shoulder is clear of scar tissue, exercises to strengthen the shoulder can begin. Rehab of the shoulder should include exercises that not only strengthen and balance the rotator cuff, but also strengthen the scapula stabilization muscles that hold the scapula on your upper back. Arm exercises to strengthen and balance the Biceps and Triceps should also be included in the rehab program.
Once you have full range of motion without pain, and full strength of all the muscles of the shoulder swimming should be pain free and training can resume or be increased.
Dr. David Ness is a certified sports chiropractor, practicing in New Paltz. He has worked the last 4 years at the Lake Placid Iron man event as part of the ART treatment team. As well, Dr. Ness has been the ART provider for the HVTC for the past three years providing free ART care after club races. Dr. Ness also provides treatment at NYTC races around the NY metro area, and continues to work as part of the SOS Triathlon post-race care team. Dr. Ness can be reached at (845) 255-1200.