Beyond Rehab and Return to Play: Swimming None Relevant Disclosures Jake R. Foley, PT, DPT, SCS, CSCS Hugo Klaers, PT, DPT, OCS IAM Highland Park IAM Edina July 7, 2017 Allina Health Sports Medicine Conference Objectives 1. Describe the normal biomechanics and muscle activity of the shoulder girdle during the freestyle stroke. 2. Understand relevant features of upper extremity functional testing as it pertains to the swimmer. 3. Apply the aforementioned concepts to the rehabilitation of the swimmer s shoulder in order to maximize return to sport potential. Background round Brief Epidemiology Outline Freesty le Freestyle Biome chanic Biomechanics s Relevant Functional Interve Intervention ntion Conside Considerations rations AllinaHealthSystem 1
Background 1,2 Epidemiology 1,3,4. Reported injury rates: : 3.78 injuries per 1000 exposures Year round swimmers: 6,000 10,000m per day (Competitive swimmers >14,000m per day) Many swim 5 7 days per week May swim 2x/day, up to 3x/week 60,000 80,000 m swimming per week. 8 10 strokes per 25 m 30,000 rotations per shoulder per week : 4.0 injuries per 1000 exposures Shoulder pain: 40 91% Questions > Answers Laxity? Increased vs. decreased ROM? Females vs. Males Swimming Form? What is swimmer s shoulder? 1 Stroke Generalizations 1978: Anterior shoulder pain during and after workouts More recently: constellation of symptoms, not one specific diagnosis Freestyle Butterfly Backstroke Breaststroke Post-workout muscle soreness GHJ instability Tendinopathy Labral tear Majority of training, even if a specialist Need to normalize mechanics Similar to freestyle; arms utilized synchronously Similar entry to freestyle but supine Resembles initial pull of a butterfly stroke Longer recovery than freestyle **Full disclosure, we are neither competitive swimmers nor swim coaches** AllinaHealthSystem 2
Freestyle Biomechanics of Freestyle 1,5 Freestyle Muscular Activity 1,6 Phase Correct Mechanics Forward & lateral to the head, medial to the shoulder Hand Entry 5 th finger should enter first Pull through Elbow kept higher than hand; points laterally throughout pull Swimmer should use a straight back pull through, not S Shape Recovery All phases Elbow kept higher than the wrist throughout the recovery phase Body roll of ~45 along the longitudinal axis of the body Head in neutral position Line through head and extending length of the spine Figure copyright Scott Heinlein. (Adapted with permission from Colwin CM. Breakthrough Swimming. Champaign, IL: Human Kinetics; 2002:50 70.). AllinaHealthSystem 3
Hand Entry/Glide Phase 1,6 Begins at point when the right hand enters the water Elbow slightly higher than the hand Should enter at 1 o clock (left at 11 o clock ) Muscle Upper Trapezius Lower Trapezius Serratus Anterior Action Upwardly rotate scapula Increase humeral head clearance Pull Phase 1,6 Early initiates at the end of glide: Humerus ~90 flexed (perpendicular to long axis of body) Arm points straight down to the floor of the pool Elbow remains high as GHJ moves into IR/Ext/ADD Swimmer should try to pull directly backward Muscle Pec Major Teres Minor Action Force Couple: Extend, IR, and Adduct Rhomboids Anchor superior angle of scapula (Serratus & Upper Trapezius: upward rotation) Serratus Anterior Pectoralis Major Latissimus Dorsi Teres Major Propel body forward over a relatively fixed hand Mid Pull Phase 1,6 Transition between early & late pull through Occurs when forearm is pointing down to floor of pool Late Begins at 90 flexion ends when hand exits from water Recovery 1,6 Elbow remains slightly flexed; should exit water prior to hand Shorter phase; no resistance from the water Muscle Posterior Deltoid Middle Deltoid Supraspinatus Action Extension & abduction of humerus Muscle Latissimus Dorsi Serratus Anterior Pectoralis Major Latissimus Dorsi Teres Major Action Extends GHJ Assists the Subscapularis with IR Propel body forward over a relatively fixed hand Rhomboids Upper Trapezius Serratus Anterior Deltoids Retract the scapula Initiate body roll to the opposite side Rotate scapula upward Fire sequentially to move the GHJ: Posterior Extend Middle Abduct Anterior Flex AllinaHealthSystem 4
The Workhorses 6 Acute responses to swimming 25 Subscapularis Serratus Anterior Measure Swimming Stroke Response length bilaterally ROM ER (3 5 ) Joint Position Sense Cardiovascular Markers on dominant (breathing side) arm peak blood lactate blood glucose heart rate Take Home 1. Serratus Anterior and Subscapularis are susceptible to fatigue and/or overuse Consistently firing > 20% MVIC 2. Rotator Cuff: distinct and unique functions Evaluate and train accordingly 3. Upward rotation: Essential component of normal swimming biomechanics 4. Talking points with coaches Errors at various phases Ok so now what? AllinaHealthSystem 5
George Davies Functional Algorithm 13 Sensorimotor Open Chain Sport Specific Progression Functional Closed Chain Functional Algorithm 13 Time/ Tissue healing Sensorimotor Open Chain Outcome Measures Kinesiophobia Pain: VAS/NPRS Sport Specific Progression Functional Closed Chain PROM Anthropometric measurements AROM (<10% difference) AllinaHealthSystem 6
Tissue Irritability High Moderate Low Pain >7/10 4 6/10 <3/10 ROM Outcome Measure (SPADI) Consistent and/or Night Pain Pain before end range Intermittent pain at rest and/or night Pain at end range No pain at rest or night Min pain with Overpressure AROM << PROM AROM ~ PROM AROM = PROM High Disability Moderate Disability Low Disability Joint(s) Glenohumeral ACJ/SCJ Cervicothoracic Scapulothoracic, etc Musculotendinous Normalizing ROM Posterior shoulder Subscapularis Latissimus Dorsi/Teres Major Pectoralis Major/Minor Etc. Core Muscle Endurance Biering-Sørensen Test Healthy Norms 14 Males: 146 sec Females: 189 sec Front Plank Healthy Norms 15 Males: 107 sec (50 th percentile) Females: 91 sec (50 th percentile) Deep Neck Flexors Healthy Norms 16 Males: 38.9 sec Females: 29.4 sec Soft Tissue Mobilization Cervico Thoracic Mobility Mat based stabilization Cuff Isometrics Scap Stability Interventions Pec Maj/Min, Lats, Teres Maj/Min, Infra, Subscap, Periscapular Mobilization/Manipulation/ROM Cervical, Abdominals, Glutes 5 x 45 sec hold, 2 min rest 70% 1 RM? AllinaHealthSystem 7
Functional Algorithm 13 Sport Specific Progression Sensorimotor Functional Open Chain Closed Chain Kinesthesia/Proprioception 17 Sensorimotor Shoulder: 90/90 Norms : 3 ± 2 degrees 4 ± 3 degrees Role for Cervical Intervention Functional Algorithm 13 Rhythmic Stabilization Base ER/IR Supine Pendulum 90 deg abd end range rotation Loaded isotonics PNF patterns Progress Scap Control CKC Sport Specific Progression Sensorimotor Functional Open Chain Closed Chain AllinaHealthSystem 8
Rotator cuff Strength Base position 90/90 Strength Ratio 3:2 4:3 Posteriorlydominant Scapular musculature MMT vs. HHD Fatigue 18 Test % BW Mean Reps to Failure Scaption 5% L: 33.5 R: 35.6 Prone Y 3% L: 22.6 R 23.6 Standing Cable Press 30% L: 27.4 R: 26.6 Cuff Base 90/90 at 3% BW Scap <90 >90 at 5% BW Incorporate core Swiss ball Front plank Side plank Intervention Functional Algorithm 13 Sport Specific Progression Sensorimotor Functional Open Chain Closed Chain AllinaHealthSystem 9
Closed Chain Both an OKC and CKC activity Depends on phase of stroke Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) Norms One study: some predictive validity Y Balance Test Upper Quarter Some normative data Healthy Norms Males From toes Norms: 22 30 touches Females From knees Norms: 23 25 touches Reliability ICC:.922 CKCUEST 19,20 CKCUEST 21 touches on CKCUEST Sensitivity 0.79 (0.57-0.91) Specificity 0.83 (0.44-0.97) + LR 4.74 (0.78-28.78) - LR 0.25 (0.10-0.65) OR 18.75 (1.68-209.55) AllinaHealthSystem 10
Intervention Functional Algorithm 13 Push Up Plus Progression Foam Roll/Wall Slide Progression Closed Chain Progression Introduce Plyometrics Sensorimotor Open Chain Sport Specific Progression Functional Closed Chain Seated Shot Put Throw 23 6# medicine ball Four warm up throws Avg. of three maximal effort throws Compare to uninjured Reliability ICC: Dom:.988, NonDom:.971 Norms (athletes) Gender Dominant Non Dominant Male 235 215 Female 129.5 124 Work Capacity Are we assessing this? What test do/should we use? General vs. upper body? UBE: Wingate Test? 6 min arm test? Work load in one minute? # of pushups # of pullups Bicycle Ergometer? Are we training this sufficiently? AllinaHealthSystem 11
Sport Specific Biomechanical analysis Swim coach Biomechanist PT? Progression Criteria 24 Pain free ADL s Pain free and normal ROM Joint kinesthesia: WFL Cuff/Scap strength > 90% LSI Normal scapular kinematics Normal functional testing Sufficient CV base *Interval Sport Program ISP Functional Algorithm 13 Sport Specific Progression Sensorimotor Open Chain Return to swim progression Out of the scope of today s presentation (Contact us if interested) Swimming Soreness Rules Sport Specific Progression Functional Closed Chain AllinaHealthSystem 12
Swimming Soreness Rules 24,25 Patient Report Pain during warm up that does not go away (or pain that goes away and redevelops during session) Pain during warm up that goes away within 500 800 m Pain after lifting or dryland No soreness. Action Take 2 days off, drop 1 level (reduce 300 m or stay at lowest level for full week) Remain at level that led to soreness Take 1 day off Do not advance to next level Advance 1 level per week (200 300 m per day) Closing Thoughts 1. Serratus Anterior and Subscapularis consistently fire > 20% MVIC 2. Evaluate and train the rotator cuff individually 3. Control of upward rotation = essential 4. Test, don t guess 5. Return to pool = progressive, systematic Adhere to the swimming soreness rules 6. Communication = key Swim Coach/MD/ATC/PT/ S and C Coach/Biomechanist Acknowledgements Allina Health Sports Medicine Ned Tervola Krista Lee Family and friends Colleagues IAM Edina IAM Highland Park Fairview Sports and Orthopedic PT Residencies St. Catherine University DPT Program References 1. Heinlein SA and Cosgarea AJ. Biomechanical Considerations in the Competitive Swimmer s Shoulder. Sports Health. 2010. Vol 2, No. 6. 519 525. 2. Ruwe PA, et al. The Normal and the Painful Shoulders During the Breaststroke: Electromyographic and Cinematographic Analysis of Twelve Muscles. Am J Sports Med. 1994;12(22):789 796. 3. Hamman S. Considerations and Return to Swim Protocol for the Pediatric Swimmer after Non Operative Injury. Int J of Sports Phys Ther. 2014;9(3):388 395. 4. Wanivenhaus F, et al. Epidemiology of Injuries and Prevention Strategies in Competitive Swimmers. Sports Health. 2012;4(3):246 251. 5. Spigelman T, Sciascia A, Uhl T. Return to Swimming Protocol for Competitive Swimmers: A Post Operative Case Study and Fundamentals. IJSPT. Vol 9, Number 5, October 2014. 712 725. 6. Pink M, et al. The Normal Shoulder During Free style Swimming: An Electromyographic and Cinematographic Analysis of Twelve Muscles. Am J Sports Med. 1991;19(6):569 576. 7. Virag B, Hibberd EE, Oyama S, Padua DA, and Myers JB. Prevalence of Freestyle Biomechanical Errors in Elite Competitive Swimmers. Sports Health. Vol 6, No. 3. May/June 2014. 218 224. 8. Scovazzo ML, et al. The Painful Shoulder During Freestyle Swimming: An Electromyographic and Cinematographic Analysis of Twelve Muscles. Am J Sports Med. 1991;19(6): 577 582. 9. Pink M, et al. The Normal Shoulder During the Butterfly Swim Stroke: An Electromyographic and Cinematographic Analysis of Twelve Muscles.CORR;288(3):48 59. 10. Pink M, et al. The Painful Shoulder During the Butterfly Stroke: An EMG and Cinematographic Analysis of 12 muscles. CORR. 1993;286(3):60 72. 11. Pink M, et al. The Normal Shoulder During the Backstroke: An EMG an Cinematographic Analysis of 12 Muscles. Clin J of Sport Med 1992;2:6 12. 12. Perry J, et al. The Painful Shoulder during the Backstroke: An EMG and Cinematographic Analysis of 12 muscles. Clin J of Sport Med. 1992;2:13 20. AllinaHealthSystem 13
References 13. Davies GJ. Functional Algorithm for the upper extremity. Unpublished presentation. 2012. 14. McGilll SM, Childs A, Liebenson C. Endurance times for low back stabiization exercises: clinical targets for testing and training from a normal database. Arch Phys Med Rehab. 1999;80(8):941 944. 15. Domenech MA, Sizer PS, Dedrick GS, McGalliard MK, Brismee JM. "The Deep Neck Flexor Endurance Test: normative data scores in healthy adults." PM R. 2011 Feb. Web. 08/18/2012. 16. Hase KA, Brigham CE, Peterson JT, Coste SC. Poster Presentation at ACSM. 17. Daviews et al. Neuromuscular testing and rehabilitation of the shoulder complex. J Orthop Phys Ther. 1993;18(2): 449 458. 18. Pontillo M, Spinelli BA, and Sennet BJ. Prediction of In Season Shoulder Injury From Preseason in Division I Collegiate Football Players. 19. Westerick R, et al. Exploration of the Y Balance Test for Assessment of Upper Quarter Closed Kinetic Chain Performance. International Journal of Sports Physical Therapy. 2012; 7(2): 139 147. 20. Goldbeck TG, Davies J. Test Retest Reliability of the Closed Kinetic Chain Upper Extremity Stability Test: A Clinical Field Test. J of Sport Rehabil. 2000;9(1):35 46. 21. Taylor JB, et al. Upper Extremity Physical Performance Tests in College Athletes. J Sport Rehab. 2014;25(2):146 154. 22. Chmielewski TL, et al.normalization Considerations for Using the Unilateral Seated Shot Put Test in Rehabilitation. J Orthop Sports Phys Ther. 2014;44(7):518 524. 23. Hamman S. Considerations and return to swim protocol for the pediatric swimmer after non operative injury. IJSPT May 2014, Vol 9, Number 3, Pages 388 395 24. Spigelman T, Sciascia A, Uhl T. Return to Swimming Protocol for Competitive Swimmers: A Post Operative Case Study and Fundamentals. IJSPT. Vol 9, Number 5, October 2014. 712 725. 25. Matthew MJ, et al. The effects of swimming fatigue on shoulder strength, range of motion, joint control, and performance in swimmers. Physical Therapy in Sport. 2017;23:118 122. Jake Foley IAM Highland Park jfoley2@fairview.org Questions? Hugo Klaers IAM Edina hklaers1@fairview.org AllinaHealthSystem 14