Author Study Design Population Sample Size (pain/injury)summary of Findings Level of Evidence. Level of Certainty

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1 Author Study Design Population Sample Size (pain/injury)summary of Findings Level of Evidence Level of Certainty CLNCAL JONT LAXTY AND NSTABLTY McMaster et al (1998) Bansal et al (2012) 40 Elite USA aged 8 to 161 Elite Male Borsa et al (2005) 42 Collegiate and 44 matched Controls Santos et al Elite with shoulder pain and 8 without shoulder pain Walker et al (2009) Prospective 74 Male and Female Significant correlation between shoulder exam score for joint laxity and swimmers who reported shoulder pain (p<0.05; C 95%)40 Elite (27/40). Shoulder pain was significantly associated with self-reported shoulder instability in swimmers in the age groups years old (p=0.03) and years old (p=0.02) but not in Masters swimmers (p=0.11) compared to swimmers without pain.236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). Atraumatic Anterior nstability (p<0.001) was significantly associated with with Shoulder mpingement syndrome. Multidirectional nstability was not found to be significantly associated with mpingement Syndrome (p>0.01).161 National and nternational Level (State level swimmers 7/61, national 18/91 and international 3/9 swimmers had impingement syndrome). did not have excessive inherent glenohumeral joint laxity (p>0.05). No significant difference in glenohumeral joint displacement between swimmers and age matched controls.42 and 44 Controls (27/42). Shoulder instability during shoulder elevation in the scapular plane was not associated with shoulder pain or impingement in swimmers with diagnosed impingement.8 with no history of pain or injury and 8 swimmers with diagnosed impingement syndrome. Shoulder joint laxity was not significantly associated with shoulder pain in swimmers.74 (28/74 reported significant interfering pain and 17/74 reported significant interfering injury in the shoulder). Moderate NTERNAL/EXTERNAL ROTATON

2 Walker et al (2009) Prospective 74 Male and Female Bansal et al (2007) Beach et al (1995) aged 8 to 161 Elite Male 32 Division Collegiate Rupp et al (1995) 22 and 22 Matched Controls Harrington et al 37 Female Collegiate The significant independent predictors of shoulder injury, adjusted for swim training exposure, were increased ER range of motion (SP: p= 0.008, SS: p = 0.02).74 (28/74 reported significant interfering pain and 17/74 reported significant interfering injury in the shoulder). The study found reduced posterior shoulder range of motion (p<0.05) when assessing the internal rotation when the arm was abducted to 90 degrees in the 8-11 year old swimmers with shoulder pain. No significance was found in any of the other groups (12-14, and Masters).236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). with Shoulder mpingement Syndrome had significantly decreased nternal Range of Motion (p<0.05) and a significantly increased external range of motion (p<0.05) compared to without mpingement.161 National and nternational Level (State level swimmers 7/61, national 18/91 and international 3/9 swimmers had impingement syndrome). No significance (p>0.001) found between shoulder range of motion and swimmers with shoulder pain and those without.32 (69% reported previous pain and 31% reported current interfering pain). No significant difference was found in the nternal/external Rotation Range of Motion between swimmers with shoulder pain and those without22 Cases and 22 Control (14/22 reported previous shoulder pain and 5/22 reported current shoulder pain). nternal and external rotational range of motion was not significantly associated with shoulder pain in both swimmers with and without shoulder pain.37 (12/37 dominant arm, 14/37 non-dominant arm). YEARS OF SWMMNG EXPERENCE Sein et al (2010) 80 The study demonstrated significant changes in rotator cuff

3 Hidalgo-Lozano et al (2012) tendon morphology the longer an athlete has participated in swimming. Supraspinatus thickness was associated with shoulder pain (p<0.05).80 (73/80 report significant shoulder pain and 84% had a positive impingement sign). aged 8 to 17 Elite and 17 con trols Chase et al (2013) Prospective 34 Male and Female Collegiate Hidalgo-Lozano et al (2013) Harrington et al 50 Elite 37 Female Collegiate A significant difference was found between swimmers with shoulder pain and years of swimming experience in age (p<0.05) but not in the other age groups.236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). No correlation was found between shoulder pain intensity and years of training experience.17 healthy swimmers without shoulder pain and 17 swimmers with shoulder pain. Years of swimming was not significantly associated with shoulder injury (p=0.1568).34 (38% of swimmers were diagnosed with a shoulder injury during the season). No correlation was found between shoulder pain intensity and years of training experience.17 with shoulder pain, 18 swimmers without shoulder pain and 15 healthy athlete-control. Years of swimming experience was not significantly associated with shoulder pain.37 (12/37 dominant arm, 14/37 non-dominant arm). TRANNG LOAD, VOLUME AND NTENSTY Sein et al (2008) 80 A significant correlation between the number of hours swum per week (rs=0.39, p<0.005) and weekly mileage (rs=0.34, p=0.01) with supraspinatus tendinopathy. Supraspinatus tendon thickness correlated significantly with their level of training (r=0.28, p<0.05); years in training (r=0.35, p<0.01); hours per week in training (r=0.33, p<0.05); and cumulative use (weekly distance 48 week no of years with coach) (r=0.37, p<0.01). A significant association was also found between supraspinatus tendinopathy and the number of hours swum/week (rs=0.36,

4 Kruger et al (2012) Ristolainen et al Retrospective aged 8 to 282 Masters 268 Finnish Elite level, -Country Skiers and Long Distance Runners p<0.01). who swam more than 15 h/week were more likely to have supraspinatus tendinopathy than those who swam fewer hours, (rs=0.48, p<0.0005). All swimmers who swam more than 20 h/week had supraspinatus tendinopathy. Elite swimmers who trained for more than 15 h/week were twice as likely to have tendinopathy as those who trained for less time (rs=0.48, p<0.0001). There was also a significant association between supraspinatus tendinopathy and the number of kilometres swum per week (rs=0.33, p<0.05). The swimmers who swam more than 35 km/week were more likely to have supraspinatus tendinopathy than those who swam fewer kilometres (rs=0.37, p<0.01). mportantly, all swimmers who swam more than 60 km/week exhibited supraspinatus tendinopathy. Athletes who swam more than 35 km/week (r=0.37, p<0.01) were four times more likely to have tendinopathy than those who swam fewer kilometres. Stepwise multiple regression analysis showed that the dependent variable supraspinatus tendinopathy could be predicted from the independent variable hours swum per week (r2=0.131, p<0.01).80 (73/80 report significant shoulder pain and 84% had a positive impingement sign). n the masters group, the +PDD group swam a greater number of hours per year ( ± hours) than the PDD group ( ± hours), (p<0.05) and a trend was seen for hours swum per week (p=0.06).236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). Shoulder pain was associated with high training volume (p=0.004).282 Masters (62.4% of swimmers reported pain over the 3 year period. 28.7% reported recurring pain and 37.2% reported that pain was severe enough to cease training). njured had reported swimming significantly more during the 12 month period than the uninjured swimmers (1612km vs. 1380, p=0.04). The mean number of kilometers swum was higher in swimmers with at least one injury joint compared to swimmers without an injury (1750 km vs. 1437,

5 Su et al (2004) Pre and Post testing 20 Age Group and 20 controls Walker et al (2009) Prospective 74 Male and Female Hidalgo-Lozano et al (2012) Hidalgo-Lozano et al (2013) 17 Elite and 17 controls 50 Elite Chase et al (2013) Prospective 34 Male and Female Harrington et al 37 Female Collegiate p=0.03).268 (52.1% of swimmers reported a significant shoulder injury). Practice Duration (h/wk) and practice distance (km/wk) were not significantly different between swimmers with shoulder impingement and those without.20 with diagnosed shoulder mpingement and 20 swimmers without. No significant association between shoulder injury and mileage was found (SP: p =0.07; SS: p = 0.1).74 (28/74 reported significant interfering pain and 17/74 reported significant interfering injury in the shoulder). No significant difference was found between shoulder pain and hours of training per week.17 healthy swimmers without shoulder pain and 17 swimmers with shoulder pain. No correlation was found between shoulder pain intensity and hours per week of training.17 with shoulder pain, 18 swimmers without shoulder pain and 15 healthy athlete-control. njury rates and hours of practice were not statistically significant.34 (38% of swimmers were diagnosed with a shoulder injury during the season). Hours swum per week was not significantly associated with shoulder pain.37 (12/37 dominant arm, 14/37 non-dominant arm). HSTORY OF PREVOUS PAN AND NJURY Walker et al (2009) Prospective 74 Male and Female aged 8 to with a history of shoulder pain were 4.1 (95% C: 1.3,13.3) and 11.3 (95% C: 2.6, 48.4) times more likely to sustain a subsequent injury for significant interfering pain (p=0.02) and significant shoulder injury (p=0.001), respectively.74 (28/74 reported significant interfering pain and 17/74 reported significant interfering injury in the shoulder). Previous history of atraumatic trauma or injury was significantly associated with shoulder pain in high school swimmers (p=0.04) and masters level swimmers (p=0.04).236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% Moderate

6 high school swimmers, and 19.4% masters swimmers). Bansal et al (2007) Kruger et al (2012) 161 Elite Male 282 Male and Female Masters There was a strong association between past history of shoulder pain and shoulder impingement syndrome in swimmers with currently diagnosed shoulder impingement (p < 0.001).161 National and nternational Level (State level swimmers 7/61, national 18/91 and international 3/9 swimmers had impingement syndrome). The study found no association between a previous history of trauma and shoulder pain (p=0.845).282 Masters (62.4% of swimmers reported pain over the 3 year period. 28.7% reported recurring pain and 37.2% reported that pain was severe enough to cease training). COMPETTVE LEVEL Zemek & Magee (1996) Sein et al (2008) Kruger et al (2012) 30 Elite and 30 Recreational Controls 80 Male and Female 282 Male and Female Masters The elite group were found to be significantly more injured than the recreational controls (p<0.05).30 Elite and 30 Recreational Elite swimmers demonstrated 67% Shoulder Overuse Dysfunction (pain and injury) than 13% of controls). There was no correlation between laxity and level of competition (p>0.05). n contrast, supraspinatus thickness was positively correlated with level of competition (p<0.05). Athletes at higher levels of competition were more likely to have supraspinatus tendinopathy than those at lower levels of competition (rs=0.56, p<0.0001). Elite swimmers who trained for more than 15 h/week were twice as likely to have tendinopathy as those who trained for less time (rs=0.48, p<0.0001).80 (73/80 report significant shoulder pain and 84% had a positive impingement sign). swimmers were found to have significantly higher incidence of shoulder pain compared to recreational swimmers (p=0.008).282 Masters (62.4% of swimmers reported pain over the 3 year period. 28.7% reported recurring pain and 37.2% reported that pain was Moderate

7 Su et al (2004) Pre and Post testing 20 Age Group and 20 controls severe enough to cease training). Experience was not significantly different between those with shoulder impingement and those without (p=0.39)20 with diagnosed shoulder mpingement and 20 swimmers without. SEX Bak & Faunø (1997) Retrospective 23 with history of therapy resistant shoulder pain. Sallis et al (2001) Retrospective 3767 Male and Female Seven Collegiate Sports Griepp (1985) Prospective 168 Male and Female (12-23 years) Su et al (2004) Kruger et al (2012) Pre and Post testing 20 Age Group and 20 controls 282 Male and Female Masters Chase et al (2013) Prospective 34 Male and Female 23 swimmers (number of injured) Shoulder njury patterns between male and female swimmers were significantly different (p<0.001). Female swimmers had more shoulder (21.05 vs 6.55), injuries than male swimmers (p<0.001).3767 Collegiate Athletes (n for swimmers not available, however it is reported that female swimmers had shoulder injuries compared to male swimmers with 6.55 injuries). The incidence of shoulder pain was not significantly associated with sex.168 (54% of all females reported shoulder pain over the season, 71.9% of males reported shoulder pain over the season). Sex was not significantly different between those swimmers with impingement and those without (p=0.66)20 with diagnosed shoulder mpingement and 20 swimmers without. Gender (p=0.141) was not significantly associated with shoulder pain.282 Masters (62.4% of swimmers reported pain over the 3 year period. 28.7% reported recurring pain and 37.2% reported that pain was severe enough to cease training). No statistical differences found between gender and injury rates in male and female swimmers.34 (38% of swimmers were diagnosed with a shoulder injury during the season).

8 AGE None Griepp (1985) Prospective 168 (12-23 years) Su et al (2004) Pre and Post testing 20 Age Group and 20 controls Walker et al (2009) Prospective 74 Male and Female Kruger et al (2012) 282 Male and Female Masters aged 8 to Chase et al (2013) Prospective 34 Male and Female Harrington et al 37 Female Collegiate The incidence of shoulder pain was not significantly associated with age.168 (54% of all females reported shoulder pain over the season, 71.9% of males reported shoulder pain over the season). Age was not significantly different between swimmers with impingement and those without (p=0.76).20 with diagnosed shoulder mpingement and 20 swimmers without. Age was not significantly associated with shoulder pain74 (28/74 reported significant interfering pain and 17/74 reported significant interfering injury in the shoulder). Age (p>0.05) was not significantly associated with shoulder pain.282 Masters (62.4% of swimmers reported pain over the 3 year period. 28.7% reported recurring pain and 37.2% reported that pain was severe enough to cease training). Age was not significantly associated with shoulder injury in any of the age groups.236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). 34 (38% of swimmers were diagnosed with a shoulder injury during the season).age was not significantly associated with shoulder pain. Age was not significantly associated with shoulder pain.37 (12/37 dominant arm, 14/37 nondominant arm). SWMMNG TRANNG EQUPMENT McMaster et al (1989) 473 Age Group The use of hand paddles was significantly associated with shoulder pain in males (p=0.004; r=0.1992) and females (p=0.000; r=0.4704). Kickboard use was associated with shoulder pain in males (p=0.000; r=0.3051) and females (p=0.005; r=0.1818).473 (27/40 reported shoulder

9 Stocker et al (1995) Puckree & Thomas (2006) 532 Collegiate and 395 Masters 96 aged 8 to pain). Chi-Squared analysis found no statistically significant association between shoulder pain and hand paddle usage in both Collegiate and Masters swimmers (p>0.05).532 Collegiate and 395 Masters level (47% of college and 48% of masters swimmers reported pain lasting longer than 3 weeks in the shoulder). The use of paddles during training did not have any significant effect on the difference between those with and without injuries (p>0.05)96 (64% reported injury to the shoulder). No association between paddle usage and shoulder pain was found.236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). CROSS TRANNG AND STRETCHNG Griepp (1985) Prospective 168 (12-23 years) McMaster et al (1989) 473 Age Group Walker et al (2009) Prospective 74 Male and Female Kruger et al (2012) 282 Male and Female Masters ncreased weight training was associated with increased shoulder pain in male swimmers.168 (54% of all females reported shoulder pain over the season, 71.9% of males reported shoulder pain over the season). A positive correlation was found for stretching in males (p=0.000; r=3737) and females (p=0.000; r=3530). Shoulder pain was associated with weight use for both groups (p=0.000). The correlation for weight training for males (r=0.2796) and females (r=0.3483). n females, perception of weight training causing shoulder injury was significant (p=0.000; r=3483).473 (27/40 reported shoulder pain). Number of dryland strength training sessions per week was not associated with shoulder pain.74 (28/74 reported significant interfering pain and 17/74 reported significant interfering injury in the shoulder). Strength training was not significantly associated with shoulder pain or injury (p=0.239).282 Masters (62.4% of swimmers reported pain over the 3 year period.

10 28.7% reported recurring pain and 37.2% reported that pain was severe enough to cease training). STROKE DSTANCE AND STROKE SPECALTY McMaster et al (1989) 473 Age Group Griepp (1985) Prospective 168 (12-23 years) Walker et al (2009) Prospective 74 Male and Female Wolf et al (2009) Retrospective 94 Collegiate Sein et al (2008) Kruger et al (2012) 80 aged 8 to 282 Male and Female Masters Of all the strokes, butterfly was most likely to cause pain (p=0.000; r=0.6239) and breaststroke was the least likely amongst males and females. Females also reported a significant relationship in stroke adjustment by the coach and improvement in shoulder pain (p=0.001; r=0.4955).473 (27/40 reported shoulder pain). Stroke and distance was not found to be associated with shoulder pain.168 (54% of all females reported shoulder pain over the season, 71.9% of males reported shoulder pain over the season). Stroke specialty or stroke distance were not significantly associated with shoulder pain.74 (28/74 reported significant interfering pain and 17/74 reported significant interfering injury in the shoulder). No significant difference between injuries in sprinters and distance swimmers. There was no significant association between stroke specialty and time missed and no association between stroke specialty and body region injured.94 (number of injuries). No association between preferred swimming stroke and supraspinatus tendinopathy was detected.80 (73/80 report significant shoulder pain and 84% had a positive impingement sign). No differences were found between any of the age groups; 9-13 years old, years old and masters level swimmers (p>0.05). ndividual stroke preference was not found to differ between swimmers with shoulder pain and swimmers without (p>0.05).236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). No statistically significant association was established between swimming stroke and shoulder pain (p>0.05).282 Masters (62.4% of swimmers reported pain over

11 Wymore et al (2012) 187 Elite Collegiate the 3 year period. 28.7% reported recurring pain and 37.2% reported that pain was severe enough to cease training). Days per week of shoulder pain showed no association with stroke specialty (p>0.05). The intensity of shoulder pain was not significantly associated with stroke specialty.187 (43% of butterfly swimmers reported no shoulder pain and 73% reported pain 2 days per week or less. 43% of breaststroke specialists, 42% of freestyle specialists and 41% of backstroke specialists reported no days of shoulder pain). BREATHNG SDE Stocker et al (1995) aged 8 to 532 Collegiate and 395 Masters Bilateral breathing in the 8-11 year old age group was found to be associated with shoulder pain. However, no association was found in breathing side preference in the other age groups and with and without shoulder pain236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). Chi-Squared analysis revealed no significant difference between breathing side and shoulder pain (p>0.05).532 Collegiate and 395 Masters level (47% of college and 48% of masters swimmers reported pain lasting longer than 3 weeks in the shoulder). NTERNAL/EXTERNAL ROTATON STRENGTH Swanik et al (2002) Randomized Experimental Control ntervention 13 and 13 controls aged 8 to Significant results were revealed for the incidence of shoulder pain between the experimental who underwent shoulder functional training to strengthen internal and external rotators and the control group (p=0.02). The trained group had significantly less incidence of injury compared to the untrained group over the 6 weeks.13 experimental and 13 controls. (injured) Analysis revealed a negative correlation between pain and internal/external isokinetic strength (p=0.05). Reduced internal rotation torque was associated with pain and Formatted Table

12 Rupp et al (1995) 22 and 22 Matched Controls Bak & Magnusson (1997) Harrington et al 7 and 8 controls 37 Female Collegiate SCAPULAR KNEMATCS, STRENGTH AND DYSKNESS disability (p<0.05). The middle trapezius weakness was present more often in the 8- to 11-year old shoulder pain group.236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). sokinetic data of those who had shoulder problems and those athletes who had none did not differ significantly. There was no significant correlation between pain history and performance during isokinetic testing. ER/R ratio for swimmers who had shoulder problems and those who didn t were not significantly different (p>0.05).22 Cases and 22 Control (14/22 reported previous shoulder pain and 5/22 reported current shoulder pain). No significant differences could be shown in concentric and eccentric ER:R strength ratios in shoulders with pain and those without. No significant difference in internal and external torque was found between shoulders with pain and those without pain.7 with unilateral shoulder pain and 8 swimmers with no pain. nternal and external rotation strength was not significantly associated with shoulder pain.37 (12/37 dominant arm, 14/37 non-dominant arm). Su et al (2004) Pre and Post testing 22 Age Group and 20 controls The results of the two-way ANOVAs for strength revealed that there was a significant reduction in force after the swim practice for both the shrug and punch tests (p<0.001). However, there were no significant interactions between practice and group, indicating that both groups had similar drops in strength. The results of the three-way ANOVA indicated a significant effect of practice (P<0.001), elevation angle (P<0.001), and group (P<0.044). The two groups were not significantly different before swim practice (p=0.2) but there was a significant difference after practice (p<0.0082).20 with diagnosed shoulder mpingement and 20 swimmers without.

13 Harrington et al aged 8 to 37 Female Collegiate The frequency of obvious scapular dyskinesis was not different between the pain and no pain groups in any age group (p>0.05). Scapular dyskinesis was observed in all age groups, but no significant associations were detected between pain and dyskinesis.236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). Scapular depression, abduction and adduction strength were not significantly associated with shoulder pain.37 (12/37 dominant arm, 14/37 non-dominant arm). CORE STABLTY Harrington et al aged 8 to 37 Female Collegiate Core endurance during side bridge revealed a significantly reduced time in swimmers with shoulder pain in year olds compared to those without pain. However, no other significant differences were found in any of the other age groups or between groups during side bridge, prone bridge and closed kinetic chain stability tests (p>0.05).236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). Core endurance for prone bridge and side bridge were not significantly associated with shoulder pain.37 (12/37 dominant arm, 14/37 non-dominant arm). GLENOHUMERAL TRANSLATON None Borsa et al (2005) 42 Collegiate and 44 matched Controls No significant difference in glenohumeral joint displacement between swimmers and controls were detected (p=0.49). No difference between joint displacement and swimmers with a history of shoulder pain (p=0.68). Significant difference was detected between posterior and anterior movement direction (p<0.001). Post Hoc analysis revealed no significant

14 Lynch et al (2010) Randomized ntervention 14 Collegiate 14 controls difference between the groups of swimmers with no pain and pain.42 and 44 Controls (27/42). A significant reduction in forward head angle and forward shoulder translation was observed following the training program. However, no significant interaction (p=0.389) was found in shoulder pain score following the intervention.14 in ntervention group and 14 in Control (7/14 in intervention study reported decreased pain, 10/14 in control group reported increased pain). SWMMNG SCHOLARSHP STATUS None Wolf et al (2009) Retrospective 94 Collegiate PECTORAL LENGTH No association between swimming scholarship status and injury was found.94 (number of injuries). Harrington et al None aged 8 to 37 Female Collegiate A significant difference was found in the normalized pectoralis minor length at rest in the 15-18year old age group with shoulder pain. However, no differences were found during stretch (p>0.05). No other differences were found in any of the other age groups236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). Pectoralis length at rest and at stretch was significantly associated with shoulder pain (p<0.05).37 (12/37 dominant arm, 14/37 non-dominant arm) TRCEP LENGTH None

15 aged 8 to No association was found between Flexion of triceps length (p>0.05). No other significant differences were found in the other age groups for those with and without pain (p>0.05).236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). LATSSMUS LENGTH None aged 8 to A significant association was found in flexion of latissimus length in 8-11 year olds with shoulder pain (p<0.05). However, no other significant differences were found in the other age groups for those with and without pain (p>0.05).236 (21.4% swimmers aged 8 to 11 years, 18.6% swimmers aged 12 to 14 years, 22.6% high school swimmers, and 19.4% masters swimmers). NADEQUATE TREATMENT Bansal et al (2007) None 161 Elite Male nadequate treatment was found to be associated with impingement and shoulder pain in swimmers (p<0.05).161 National and nternational Level (State level swimmers 7/61, national 18/91 and international 3/9 swimmers had impingement syndrome). SHOULDER FLEXBLTY Griepp (1985) Prospective 168 (12-23 years) A correlation between tightness in the anterior shoulder and subsequent shoulder pain was found (r=0.9769). Additionally, increased shoulder flexibility was shown to be associated with shoulder pain.168 (54% of all females reported shoulder pain over the season, 71.9% of males reported shoulder pain over the season).

16 Ozcaldiran (2002) 42 and 31 Matched Controls Stocker et al (1995) 532 Collegiate and 395 Masters had a greater total flexibility index score than controls (p<0.001). with shoulder pain had a significant positive correlation total flexibility index scores and pain (p<0.05) in both dominant and non-dominant sides.42 and 31 Controls (16/42 reported shoulder pain). Chi-Squared analysis revealed no statistical significance between swimmers who reported shoulder pain and subjective level of joint laxity (p>0.05).532 Collegiate and 395 Masters level (47% of college and 48% of masters swimmers reported pain lasting longer than 3 weeks in the shoulder). Level of Evidence was determined using the criteria outlined by Wright et al (2007) and Obremskey et al (2005). Level of Certainty was determined using the criteria outlined by US preventative services task force guidelines (Sawaya et al, 2007).