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The Swimmer’s Shoulder: Multi-directional Instability

  • Injuries in Overhead Athletes (J Dines and C Camp, section editors)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Purpose of Review

Swimmer’s shoulder is the term used to describe the problem of shoulder pain in swimmers. Originally described as supraspinatus tendon impingement under the coracoacromial arch, it is now understood that several different pathologies can cause shoulder pain in competitive swimmers, including subacromial impingement syndrome, overuse and subsequent muscle fatigue, scapular dyskinesis, and laxity and instability.

Recent Findings

Swimmers may develop increased shoulder laxity over time due to repetitive use. Such excessive laxity can decrease passive shoulder stability and lead to rotator cuff muscle overload, fatigue, and subsequent injury in order to properly control the translation of the humeral head. Generalized laxity can be present up to 62% of swimmers, while a moderate degree of multi-directional instability can be present in the majority. Laxity in swimmers can be due to a combination of underlying inherent anatomical factors as well as from repetitive overhead activity.

Summary

The role of excessive laxity and muscle imbalance are crucial in the swimmer’s shoulder and should be well understood since they are the primary target of the training and rehabilitation program.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Kennedy JC, Hawkins RJ. Swimmers shoulder. Physician Sports Med. 1974;2(4):34–8.

    Google Scholar 

  2. Kennedy JC, Hawkins R, Krissoff WB. Orthopaedic manifestations of swimming. Am J Sports Med. 1978;6(6):309–22.

    Article  PubMed  CAS  Google Scholar 

  3. Bak K. The practical management of swimmer’s painful shoulder: etiology, diagnosis, and treatment. Clin J Sport Med. 2010;20(5):386–90.

    Article  PubMed  Google Scholar 

  4. Bak K, Faunø P. Clinical findings in competitive swimmers with shoulder pain. Am J Sports Med. 1997;25(2):254–60.

    Article  PubMed  CAS  Google Scholar 

  5. Brushoj C, Bak K, Johannsen HV, Fauno P. Swimmers’ painful shoulder arthroscopic findings and return rate to sports. Scand J Med Sci Sports. 2007;17(4):373–7.

    PubMed  CAS  Google Scholar 

  6. Ciullo JV. Swimmer’s shoulder. Clin Sports Med. 1986;5(1):115–37.

    PubMed  CAS  Google Scholar 

  7. McMaster WC. Shoulder injuries in competitive swimmers. Clin Sports Med. 1999;18(2):349–59.

    Article  PubMed  CAS  Google Scholar 

  8. Rupp S, Berninger K, Hopf T. Shoulder problems in high level swimmers: impingement, anterior instability, muscular imbalance? Int J Sports Med. 1995;16(8):557–62.

    Article  PubMed  CAS  Google Scholar 

  9. Sein ML, Walton J, Linklater J, Appleyard R, Kirkbride B, Kuah D, et al. Shoulder pain in elite swimmers: primarily due to swim-volume-induced supraspinatus tendinopathy. Br J Sports Med. 2010;44(2):105–13.

    Article  PubMed  Google Scholar 

  10. • Matzkin E, Suslavich K, Wes D. wimmer's Shoulder: Painful Shoulder in the Competitive Swimmer. J Am Acad Orthop Surg. 2016;24(8):527–36. https://doi.org/10.5435/JAAOS-D-15-00313. The authors reviewed all the pathologies that can cause shoulder pain. They highlighted the importance of understanding the biomechanics of the stroke to better understand the etiology of shoulder pain in swimmers. The importance of the imaging and clinical examination were analyzed as well. Results with nonoperative and operative treatments were summarized for better comprehension.

    Article  PubMed  Google Scholar 

  11. McMaster WC, Troup J. A survey of interfering shoulder pain in United States competitive swimmers. Am J Sports Med. 1993;21(1):67–70.

    Article  PubMed  CAS  Google Scholar 

  12. Prevention TBJ. Treatment of Swimmer’s Shoulder. N Am J Sports Phys Ther. 2006;1(4):166–75.

    Google Scholar 

  13. Weldon EJ III, Richardson AB. Upper extremity overuse injuries in swimming: a discussion of swimmer’s shoulder. Clin Sports Med. 2001;20(3):423–38.

    Article  PubMed  Google Scholar 

  14. Wanivenhaus F, Fox AJ, Chaudhury S, Rodeo SA. Epidemiology of injuries and prevention strategies in competitive swimmers. Sports Health. 2012;4(3):246–51.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Beach ML, Whitney SL, Dickoff-Hoffman S. Relationship of shoulder flexibility, strength, and endurance to shoulder pain in competitive swimmers. J Orthop Sports Phys Ther. 1992;16(6):262–8.

    Article  PubMed  CAS  Google Scholar 

  16. King D. Glenohumeral joint impingement in swimmers. J Athl Train. 1995;30(4):333–7.

    PubMed  PubMed Central  CAS  Google Scholar 

  17. Pink M, Perry J, Browne A, Scovazzo ML, Kerrigan J. The normal shoulder during freestyle swimming. An electromyographic and cinematographic analysis of twelve muscles. Am J Sports Med. 1991;19(6):569–76.

    Article  PubMed  CAS  Google Scholar 

  18. Pink MM, Tibone JE. The painful shoulder in the swimming athlete. Orthop Clin North Am. 2000;31(2):247–61.

    Article  PubMed  CAS  Google Scholar 

  19. Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Orthop Sports Phys Ther. 1999;29(1):31–8.

    Article  PubMed  CAS  Google Scholar 

  20. Su KP, Johnson MP, Gracely EJ, Karduna AR. Scapular rotation in swimmers with and without impingement syndrome: practice effects. Med Sci Sports Exerc. 2004 Jul;36(7):1117–23.

    Article  PubMed  Google Scholar 

  21. Rodeo SA. Swimming. In: Krishnan SG, Hawkins RJ, Warren RF, editors. The shoulder and the overhead athlete. Philadelphia, PA: Lippincott: Williams & WIlkins; 2004. p. 350.

    Google Scholar 

  22. Rupp S, Berninger K, Hopf T. Shoulder problems in high level swimmers: impingement, anterior instability, muscular imbalance? Int J Sports Med. 1995;16(8):557–62.

    Article  PubMed  CAS  Google Scholar 

  23. Zemek MJ, Magee DJ. Comparison of glenohumeral joint laxity in elite and recreational swimmers. Clin J Sport Med. 1996;6(1):40–7.

    Article  PubMed  CAS  Google Scholar 

  24. McMaster WC, Roberts A, Stoddard T. A correlation between shoulder laxity and interfering pain in competitive swimmers. Am J Sports Med. 1998;26(1):83–6.

    Article  PubMed  CAS  Google Scholar 

  25. Allegrucci M, Whitney SL, Irrgang JJ. Clinical implications of secondary impingement of the shoulder in freestyle swimmers. J Orthop Sports Phys Ther. 1994;20(6):307–18.

    Article  PubMed  CAS  Google Scholar 

  26. Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD. Clinical implications of scapular dyskinesis in shoulder injury: The 2013 consensus statement from the ‘Scapular Summit’. Br J Sports Med. 2013;47(14):877–85.

    Article  PubMed  Google Scholar 

  27. Jobe FW, Kvitne RS, Giangarra CE. Shoulder pain in the overhand or throwing athlete. The relationship of anterior instability and rotator cuff impingement. Orthop Rev. 1989 Sep;18(9):963–75.

    PubMed  CAS  Google Scholar 

  28. Madsen PH, Bak K, Jensen S, Welter U. Training induces scapular dyskinesis in pain-free competitive swimmers: a reliability and observational study. Clin J Sport Med. 2011;21(2):109–13.

    Article  PubMed  Google Scholar 

  29. Scovazzo ML, Browne A, Pink M, Jobe FW, Kerrigan J. The painful shoulder during freestyle swimming: an electromyographic cinematographic analysis of twelve muscles. Am J Sports Med. 1991;19(6):577–82.

    Article  PubMed  CAS  Google Scholar 

  30. Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD. Clinical implications of scapular dyskinesis in shoulder injury: The 2013 consensus statement from the ‘Scapular ummit’. Br J Sports Med. 2013;47(14):877–85.

    Article  PubMed  Google Scholar 

  31. Borsa PA, Scibek JS, Jacobson JA, Meister K. Sonographic stress measurement of glenohumeral joint laxity in collegiate swimmers and age-matched controls. Am J Sports Med. 2005;33(7):1077–84.

    Article  PubMed  Google Scholar 

  32. Page P. Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes. Int J Sports Phys Ther. 2011;6(1):51–8.

    PubMed  PubMed Central  Google Scholar 

  33. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: Spectrum of pathology. Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003;19(6):641–61.

    Article  PubMed  Google Scholar 

  34. Torres RR, Gomes JL. Measurement of glenohumeral internal rotation in asymptomatic tennis players and swimmers. Am J Sports Med. 2009;37(5):1017–23.

    Article  PubMed  Google Scholar 

  35. Walker H, Gabbe B, Wajswelner H, Blanch P, Bennell K. Shoulder pain in swimmers: A 12-month prospective cohort study of incidence and risk factors. Phys Ther Sport. 2012;13(4):243–9.

    Article  PubMed  Google Scholar 

  36. Riemann BL, Witt J, Davies GJ. Glenohumeral joint rotation range of motion in competitive swimmers. J Sports Sci. 2011;29(11):1191–9.

    Article  PubMed  Google Scholar 

  37. 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):160–167, discussion 168-169.

  38. Bedi A, Rodeo SA. Os acromiale as a cause for shoulder pain in a competitive swimmer: a case report. Sports Health. 2009 Mar;1(2):121–4.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Frizziero A, Benedetti MG, Creta D, Moio A, Galletti S, Maffulli N. Painful os acromiale: conservative management in a young swimmer athlete. J Sports Sci Med. 2012;11(2):352–6.

    PubMed  PubMed Central  Google Scholar 

  40. Warner JJ, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Patterns of flexibility, laxity, and strength in normal shoulders and shoulders with instability and impingement. Am J Sports Med. 1990 Jul-Aug;18(4):366–75.

    Article  PubMed  CAS  Google Scholar 

  41. • Rodeo SA, Nguyen JT, Cavanaugh JT, Patel Y, Adler RS. Clinical and ultrasonographic evaluations of the shoulders of elite swimmers. Am J Sports Med. 2016;44(12):3214–21. The authors evaluated the shoulder pain in 42 swimmers of the 2008 US Olympic team. Shoulder pain was reported by 29 of 42 (66%) athletes. Morphological changes consistent with tendinosis were common in the biceps (33/46 shoulders; 72%) and supraspinatus/infraspinatus (44/46 shoulders; 96%). Subacromial impingement seen in 34 of 41 shoulders (83%). Tendinosis was more common in swimmers with a positive sulcus sign, suggesting a role for shoulder laxity.

    Article  PubMed  Google Scholar 

  42. • Hill L, Collins M, Posthumus M. Risk factors for shoulder pain and injury in swimmers: a critical systematic review. Phys Sportsmed. 2015;43(4):412–20. https://doi.org/10.1080/00913847.2015.1077097. The authors performed a systematic review on the risk factors for shoulder pain in swimmers. A total of 29 papers were included in their final analysis. Eighteen risk factors for shoulder injuries in swimmers were found, and classified in four areas: shoulder joint anatomy and strength, activity history, demographics, and musculoskeletal anatomy. However, poor study methodology or limited available data caused constrained estimation of injury risk to the shoulder for almost all of the investigated risk factors.

    Article  PubMed  Google Scholar 

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Correspondence to Ivan De Martino.

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This article is part of the Topical Collection on Injuries in Overhead Athletes

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De Martino, I., Rodeo, S.A. The Swimmer’s Shoulder: Multi-directional Instability. Curr Rev Musculoskelet Med 11, 167–171 (2018). https://doi.org/10.1007/s12178-018-9485-0

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  • DOI: https://doi.org/10.1007/s12178-018-9485-0

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