The Swimmer s Shoulder Corey Kunzer PT, DPT, SCS ATC, CSCS Becca Gsumer, PT, DPT Mayo Clinic 26 th Annual Symposium on Sports Medicine November 12 th, 2016 2016 MFMER slide-1
Disclosures No relevant financial relationships or conflicts of interest exist 2016 MFMER slide-2
Objectives Understand the epidemiology and etiology of swimmer s shoulder Understand the mechanics of the freestyle swim stroke Be able to develop an effective rehabilitation plan to enable your patient to return to swimming pain-free 2016 MFMER slide-3
Swimmer s Shoulder Epidemiology 90% of propulsive power comes from upper extremities in swimming Swimmers average Practice 2x/day 5-7 days/week 10 strokes / 25 m lap 10,000 m/day = 4,000 rev/shoulder/day Allegrucci et al, 1994; Heinlein et al, 2010; Waivenhaus et al, 2012 2016 MFMER slide-4
Swimmer s Shoulder Epidemiology Overall incidence of shoulder pain: 40-69% Non-Elite: 27% Division I Collegiate: 67% Elite: 52-57% Prevalence: 40-91% 10-18 year old: 47% Senior developmental: 66% Elite: 73% Allegrucci et al, 1994; Heinlein et al, 2010; Spigelman et al, 2014; Waivenhaus et al, 2012 2016 MFMER slide-5
Greater swimming exposure Previous traumatic injury Subjective report of shoulder instability Reduced participation in another sport Muscular imbalances Correlated with more hours swum per week Higher weekly mileage More arm revolutions per lap Decreased core endurance Kerr et al, 2016, Sein et al, 2010, Tate et al, 2012 2016 MFMER slide-6
Heinlein et al, 2010 2016 MFMER slide-7
Swimmer s Shoulder Etiology 1. Overuse and muscular fatigue 2. Glenohumeral laxity with subsequent shoulder instability leading to impingement 3. Stroke biomechanics Sein et al, 2008, Waivenhaus et al, 2012 2016 MFMER slide-8
Swimmer s Shoulder Etiology 1. Muscle overuse and fatigue Glenohumeral joint is inherently unstable Greatest ROM with most DOF Humerus curvature exceeds shallow glenoid Muscles Stability, motion, function Wanivenhaus et al, 2012 2016 MFMER slide-9
Swimmer s Shoulder Etiology 2. Excessive glenohumeral laxity Repetitive stress adaptations Disrupted static stabilizers Fatigued / weak dynamic Stabilizers Microinstabiltiy Secondary impingement Heinlein et al, 2010 2016 MFMER slide-10
Swimmer s Shoulder Etiology 3. Stroke Mechanics Duration of impingement in stroke: 24.8% Pulling Phase: 14.4% Recovery Phase: 10.4% Stroke Entry Early pull-through Late pull-through Recovery Wanivenhaus et al, 2012, Spigelman et al, 2014, Heinlein et al, 2010 2016 MFMER slide-11
Swimmer s Shoulder Etiology Intrinsic Factors Stroke biomechanics ROM: ER with IR Acquired joint laxity Muscular imbalances Fatigue ( endurance) Changes mechanics Decreases stability Extrinsic Factors Lack muscular strength and endurance Overuse: Frequency Misuse: Improper form / equipment Abuse: Excessive forces Disuse: Time off Tovin, 2006 2016 MFMER slide-12
Education Rest Ice Posture Education How to Treat Strengthening of the Rotator Cuff Strengthening of the Scapula Stabilizers Swimming Biomechanics, Technique, and Specific Drills 2016 MFMER slide-13
Body position Lack of rotation Elbow drops Cross over the middle Swimming Technique 2016 MFMER slide-14
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References Allegrucci M, Whitney SL, Irrgang JJ. Clinical Implications of Secondary Impingement of the Shoulder in Freestyle Swimmers. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy. 1994;20(6):307-318. doi:10.2519/jospt.1994.20.6.307. Heinlein SA, Cosgarea AJ. Biomechanical Considerations in the Competitive Swimmer's Shoulder. Sports Health: A Multidisciplinary Approach. 2010;2(6):519-525. doi:10.1177/1941738110377611. Kerr ZY, Baugh CM, Hibberd EE, Snook EM, Hayden R, Dompier TP. Epidemiology of National Collegiate Athletic Association men's and women's swimming and diving injuries from 2009/2010 to 2013/2014. British Journal of Sports Medicine Br J Sports Med. 2015;49(7):465-471. doi:10.1136/bjsports-2014-094423 Sein ML, Walton J, Linklater J, et al. Shoulder pain in elite swimmers: primarily due to swim-volume-induced supraspinatus tendinopathy. British Journal of Sports Medicine. 2008;44(2):105-113. doi:10.1136/bjsm.2008.047282. Spigelman T, Sciascia A, Uhl T. RETURN TO SWIMMING PROTOCOL FOR COMPETITIVE SWIMMERS: A POST OPERATIVE CASE STUDY AND FUNDAMENTALS. International Journal of Sports Physical Therapy. 2014;9(5):712-725. Tovin BJ. Prevention and Treatment of Swimmer s Shoulder. North American Journal of Sports Physical Therapy : NAJSPT. 2006;1(4):166-175. Wanivenhaus F, Fox AJS, Chaudhury S, Rodeo SA. Epidemiology of Injuries and Prevention Strategies in Competitive Swimmers. Sports Health: A Multidisciplinary Approach. 2012;4(3):246-251. doi:10.1177/1941738112442132. 2016 MFMER slide-18
Corey Kunzer, PT, DPT, SCS, ATC, CSCS Supervisor and Sports Physical Therapy Residency Coordinator Mayo Clinic Sports Medicine Email: Kunzer.Corey@mayo.edu Mayo Clinic Sports Medicine Center Dan Abraham Healthy Living Center 200 First Street SW Rochester, MN 55905 Phone: 507-266-9100 Questions Mayo Clinic Sports Medicine Center Mayo Clinic Square 600 Hennepin Ave Minneapolis, MN 55403 Phone: 612-313-0520 sportsmedicine.mayoclinic.org 2016 MFMER slide-19