Fix these errors and reduce swimming shoulder pain today!

I’ve written extensively on shoulder pain in swimmers. In fact, if you haven’t read any of my articles, start with these:

If you want a comprehensive guide and resource on swimming shoulder pain, check out the COR Swimmer’s Shoulder System.

Swimming Shoulder Pain

Swimming shoulder pain is rampant within the sport. A recent study by Sein (2010) reports swimming shoulder pain in 91% of 13-25 year old elite swimmers. Of this, Strong shoulders for preventing swimming shoulder pain84% showed a positive impingement sign, and 69% of those demonstrated supraspinatus tendinopathy on an MRI. Now, this is cherry picking one study, as some research suggest the shoulder pain rate as low as 50% in swimmers. Whether you believe shoulder pain is 50 or 91%, it is likely under reported as healthy swimmers report more daily impairment than injured baseball players! Moreover, swimmers likely under report shoulder pain as Hibberd (2013) indicated only 14% of swimmers with shoulder pain have been to a physician or physical therapist, while 47% of this group used pain medication weekly for controlling shoulder pain (Hibberd 2013).

Overall, 85 percent of high school-aged club swimmers reported mild shoulder pain in the past year, 61 percent reported moderate shoulder pain, and 21 percent reported severe shoulder pain. Of these, only 14 percent had been to a physician or physical therapist. Seventy-three percent report using pain medication to manage their shoulder pain and 47 percent used it one or more times per week (Hibberd 2013).

Ineffectiveness of Swimming Shoulder Pain Programs

Krabak (2013) surveyed swim coaches and noted injury prevention was the primary reason for dryland. Yet, many in the swimming community believe band rotator cuff exercises can fix the swimming shoulder pain epidemic, but even research shows a 6-week swimming shoulder pain prevention program in division I college swimmers does not improve strength shoulder blade control (Hibberd 2012)! This program prescribed is much more comprehensive than the more common band internal and external rotations and it still isn’t effective!

I believe the swimming community is still missing the boat for swimming shoulder pain, especially in regards to the rotator cuff muscle.

Here are 10 Rotator Cuff Conundrums in Swimming Shoulder Pain

1. Fatiguing the Rotator Cuff Muscle: I provided a simple rotator cuff activation exercise for Swimming World, Protect Your Shoulders With This Rotator Cuff Activation. I proposed that simple activation of the rotator cuff before swimming is necessary before a workout, not full on strengthening. The idea behind this theory is strengthening work will fatigue the cuff before a workout, alter swimming biomechanics, and increase one risk of injury. This is paramount as shoulder muscle strength vastly reduces during a swimming workout. Do we truly want to fatigue the muscles protecting our shoulder joint and impair biomechanics? Too bad many physical therapists still suggest this strategy…

Rotator Cuff distraction in swimming shoulder pain
Depicting of the stabilization role of one of the rotator cuff muscles

2. Pain isn’t always the Rotator Cuff Muscle: Many coaches believe any shoulder pain stems from the rotator cuff. I’ve heard elite coaches discuss how shoulder in the front represented one rotator cuff issue, while pain in the back was fine…this simplistic approach is not only incorrect, but likely why many swimmers fight through pain, further exacerbate pain and result in retiring. Injuries are complex, as the shoulder is a complex joint. Pain isn’t a yes/no question, it is much more complex and not always a rotator cuff muscle!

3. Ineffective Strengthening Programs: As I wrote in the intro, ineffective strengthening programs are too common in the world of swimming. Moreover, poor exercise execution is as common as kickboards on deck. When performing shoulder strengthening you should feel it in the shoulders, not the low back, or any other area! Also, we know eccentric muscular contractions create more force, so why are swimmers rushing through this phase during rotator cuff movements? Ensure slowness during any rotator cuff exercise for reducing swimming shoulder pain.

4. Neglecting the Role of the Rotator Cuff Muscle: One primary role of the rotator cuff is stabilization of the humerus (upper shoulder bone) into the glenoid (the shoulder blade). If these muscles are fatigued or not strong in this role, excessive motion occurs at the joint, increasing the stress at the joint. Make sure to strengthen your rotator cuff with stabilization exercises.

5. Roator Cuff Damage Will Occur in Swimming: This may sound confusing, but rotator cuff damage will occur if you are an elite swimmer. Millions and millions of strokes increase shoulder stress and create damage at these muscles. If you are a competitive swimmer, this happens. To my next point…

6. Damage Doesn’t Equal Pain: Just because rotator damage will occur during the life of a swimmer, this doesn’t mean you will have pain, dysfunction, and need surgery. Allan Phillips has written extensively about the disconnect between rotator imaging and actual shoulder pain. The overuse (which will occur whether you’re a high or low volume program) from swimming will damage the rotator cuff, but correlations between shoulder rotator cuff damage and pain are low. Don’t let rotator cuff damage confuse you, it isn’t the cause of all shoulder pain.

7. Not Challenging Oneself: Many have the misconception prevention exercises are easy. Like all areas, progressive overload is key! Too many swimmers are not challenged during prevention exercises, performing the same dinky movements that little kids perform. Challenging the muscle is key to improving muscle strength and hypertrophy, contributors to swimming shoulder pain prevention.

8. Mental Staleness of Exercises:  “3 rounds of 30 band external rotations and 30 internal rotations before you hop in the water” is a routine done around many pool decks by swimmers for 10 – 20 years of swimming. The band external rotation isn’t a bad exercise, but it can be boring, too easy, and create disgust with injury prevention and rehabilitation. Why not put them on the ground, have them crawl around for some rotator cuff activation? What about weighted walks? Push-ups with partner pertubations? Throw these into your program for increased difficulty and enjoyment!

9. Soft Tissue: If you follow my work, you know I’m a soft tissue proponent. Not only have I seen it help thousands of swimmers improve swimming shoulder pain and movement, the scientific literature is showing positive effects of this approach. In swimming, the posterior rotator cuff is beat up from all the internal rotations. Self soft tissue, also known as self massage or self myofascial releases, can help reduce pain, improve arterial circulation, and likely increase blood flow to damaged areas. Why wouldn’t you utilize this tool as a recovery and prevention method?

10. Rotator Cuff Coordination: As discussed, swimming damages the rotator cuff muscles. This damage impairs the ability for specific cells within the joint to sense position (joint proprioception). Impairing this sense causes muscular delay and altered coordination. At first, this may sound insignificant, but if a muscle intended for stabilizing the joint is delayed extra motion at the joint occurs. Imagine the extra motion at the shoulder occurring every stroke, increasing the shoulder stress, resulting in pain and injury. Exercises encouraging rotator cuff coordination and reaction is key for keeping these sensing cells healthy and strong.

Summary

Injury prevention and rehabilitation programs within the sport of swimming play a huge role within the sport. Just remember, swimming biomechanics and volume are also a HUGE contributor. Make sure you are swimming with correct biomechanics and have your strokes analyzed by those with a background in biomechanics. Now, fix these errors and help the swimming community reduce swimming shoulder pain today!

If you’ve been having shoulder pain and live in the Bay Area, schedule a physical therapy session!

Written by Dr. John Mullen, DPT, CSCS owner of COR.