As described in Swimmer’s Shoulder, Parts 1 and 2, the shoulder is prone to repetitive overuse injuries in swimmers, especially due to internal rotation of the humerus while elevated above the head. This post will offer suggestions for preventative measures and corrective therapy. It is not meant to be a substitute for professional medical care. The suggestions are culminations of my personal experiences as a physical therapy major in college who won the battle against swimmer’s shoulder (impingement syndrome) through significant research in medical journals, advanced coursework in anatomy and kinesiology focused on the shoulder, and interviews over the course of my personal therapy with athletic trainers and physical therapists.
The best therapy is preventative therapy, because if the impingement syndrome can be avoided, the swimmer will never need to decrease his or her training yardage or workout intensity.
Forearms Parallel to the Water during Stroke Recovery
To prevent shoulder impingement, proper stroke technique is important. The swimmer should avoid internal rotation where the humerus is fully elevated, so that the greater tubercle of the humerus clears the acromion process. In plain English, this means that when raising the arm above the head over the water in butterfly and freestyle, the forearm should be parallel to the water’s surface. A swimmer focusing on “high elbows” late in the recovery will put the shoulder at high risk for tendinitis. Rather, the swimmer should keep the elbows low once they are past shoulder-height.
Avoid Kicking with Palms Down
If you are prone to getting swimmers shoulder, avoid spending a lot of time with your arms extended in front of you in internal rotation (palms facing down if you are on a kickboard), which exactly the position most often used during kick sets. Instead, hold onto the sides of the board with your palms facing inward and your elbows down, which relieve pressure against the coracoacromial arch. Another alternative is to kick with no board and your palms together (snorkels make it easier to breathe). Better yet, kick with your arms at your sides (either using a snorkel or on your back).
Warm Up before Sprints or Butterfly
Avoid sprinting and two-armed butterfly until the shoulders are warm and loose. For at least the first 10 minutes of swimming, start out swimming slowly, with pauses for gentle stretching. Any “butterfly” before the shoulders are ready should be smooth and easy 1-armed drill.
For those swimmers lucky enough to train at a complex with a warm pool (such as a diving well) and a cold pool for workouts, loosen the shoulders faster by first swimming in the warm pool before working out in the cold pool.
Other ways to warm up the shoulders safely, especially if a swimmer has a history of shoulder pain, include applying heat such as with a hot pack, sitting in a hot tub, or taking a warm shower. Another is to do a sawing motion, keeping the elbows below shoulder height.
If you are one of the athletes or coaching the athletes who have shoulder issues, warming up on land will alleviate stress before entering a workout. A five-minute warm-up on land is sufficient, but remember to not fatigue your rotator cuffs as they are your stabilizers in the pool that will fatigue enough during practice.
“Warm Up” before a Season
If a swimmer has taken some time off between seasons, it is likely that their shoulders have lost some mobility and that the structures surrounding the shoulder joint are not prepared for the stresses of sprinting or high-yardage workouts. The increase in yardage should be gradual over a number of weeks. This will allow the tissues in the shoulder to adapt to the stresses swimming places on them.
The swimmer certainly needs to take responsibility here, and reinforced by the coach, by gradually increasing the yardage done, even if on their own, before starting a season with a coach.
Maintaining a strength-training program targeting the shoulders, as described below, is also important during the off season, and will allow for all-out efforts in the pool earlier in the season without injury.
A commonly made mistake is that a swimmer may only concentrate on strengthening the internal rotators and extensors (Pec minor, Lats, and Triceps), leading to muscular imbalance. This was my biggest mistake in my early years of swimming. I thought I was doing it right by only strengthening my Pecs, Lats, and Triceps. My reasoning was that the only motive for using my Deltoids and Rotator Cuff muscles was to carry my arms over the water. I was WRONG! They are needed to hold the head of the humerus in place during the power portion of each stroke.
If the muscles opposing the major swimming muscles are strengthened, the risk of developing swimmers’ shoulder will be reduced. Most important of these are the rotator cuff muscles, which functions to pull the head of the humerus downward and away from the arch of bones and ligaments known as the coracoacromial arch. Those relatively small muscles must balance the torque created by the strong downward and inward-rotational sweep of the swimmer’s arms at the beginning of the stroke as the swimmer strives for an early vertical forearm.
Shoulder Exercises in the Water
An easy way to think about how to create muscular balance is to watch what motions your arms make during the underwater portion of your swimming stroke, and then retrace that motion in reverse. This can be done powerfully as an exercise in the water in several ways.
Bobs. While the swimmer is in deep water (1 or 2 meters above the swimmer’s head), start with the hands at the swimmer’s sides with the head above the water and the feet pointing toward the bottom of the pool. Using the back of the hands as paddles, the swimmer quickly raises both hands above the head, forcing the swimmer under water. A quick jump off the bottom while the swimmer is placing the arms again at the sides allows for a breath and finishes the bob for one repetition. Repeat these bobs non-stop for at least 10 repetitions. Focus on pushing the water forcefully against the back of the hands all the way to the streamline position, and don’t let the arms leave the sides until the body is under enough water that the hands stay under water for the entire motion.
Fans. With the swimmer’s back against the wall and the water at neck-height, start with the hands at the swimmer’s sides, palms facing the wall. With a strong, fast motion, raise the arms straight in front of the swimmer, with the back of the hands leading. Return the arms to the sides and repeat.
Swim Backwards. This is a goofy-looking drill, but it’s a lot of fun! The easiest way to do this is with a pull buoy between the swimmer’s legs while wearing a snorkel and nose plugs. With the toes pointed toward the other end of the pool and the swimmer lying on the stomach in the water, push off the wall with the hands. Keeping the arms under water, place the arms at the side and use the back of the hands for propulsion, with each stroke ending with the arms above the head in streamline position. Bring the arms back to the side and repeat. It feels a lot like a breaststroke pullout in reverse. It can take a swimmer a little while to get used to this drill, but if done properly, it will strengthen all the muscles that keep the powerful swimming muscles in balance.
Shoulder Exercises on Dry Land
The more traditional approach to strengthening the Rotator Cuff, Deltoids, and Biceps is to use weights, stretch cords, or cable machines. There are many exercises to choose from, but below are the five that I used to recover from and prevent recurrence of shoulder impingement syndrome. These simple exercises focus on movements which target the specific muscles mentioned previously.
If the swimmer is rehabilitating, use very light weight and target 25 repetitions. If the swimmer’s shoulders are healthy, target a weight that the swimmer can do approximately 10 repetitions before failure. Weights which are too heavy for the untrained muscle can cause muscle strains and other injuries.
External Rotation. Strengthen the rotator cuff by working on external rotation. A good way to do this is by pulling a stretch cord or cable anchored at elbow-height across the body while keeping the elbow approximately 10 degrees from the side. Try using a rolled towel or something similar (pull buoy) between the elbow and side. This helps with circulation in the rotator cuff and ensures that the infraspinatus will be engaged. For the right arm, start with the right hand on the left side of the body. Keeping the upper body and right elbow in a fixed position, pull the resistance while rotating the arm toward the right side of the body, as far as is comfortable. Return to the starting position and repeat 10 to 25 times, as quickly as is comfortable. Then switch hands and perform for the left arm. If the swimmer needs to cheat by rotating the body or using the triceps, reduce the resistance. This same exercise can also be performed with the swimmer lying on the side and holding a weight.
Scap Pushup. Strengthen the serratus anterior by performing Scaup Pushups, which essentially are straight-armed push-ups. Start in the plank position, hands right below the shoulders. Keep the elbows locked and relax the shoulders to lower the body and then push the body as high as possible. If this is too challenging to perform comfortably, the same movement can be done from a kneeling position or even pushing against a wall while standing. Maintain high hips and long neck.
Superman with Scapular Retraction. This exercise helps improve hunched shoulders by strengthening the lower and mid trapezius muscles. Lying on the stomach with arms outstretched at 90 degrees, squeeze the shoulder blades together (). Lift the head, shoulders, and arms off the ground for 15 to 30 seconds. Focus on keeping the shoulders back toward the feet (not shrugged) for proper scapular position and engagement of the lower traps. This exercise can also be performed with light weights in each hand, which further engages the posterior deltoids.
Arm Curls. Strengthen the biceps by doing upper-arm curls. Though not always associated with the rotator cuff, both the long head and short head of the biceps cross the shoulder joint and provide stability. The long head passes along the top of the humoral head and aids in humoral head depression to keep impingement from occurring. Try not to overdo this exercise by becoming a body builder. Do it for preventative measures and work on strengthening the biceps in more complex movements, such as a Bent-Over-Row. byron2
Arm Raises. Strengthen the anterior and lateral deltoids by performing arm raises, both with the arms out to the side and straight out in front. In both movements, raise the arms until parallel with the floor, then lower them slowly and repeat. However, if the swimmer experiences pain during arm raises, skip them altogether until they can be performed without pain, because while the deltoids provide shoulder stability, their flexion can cause impingement, especially if inflammation is already present.
Because the pectoralis minor, latisimus dorsi, and triceps muscles become very strong while training for swimming, they also need to be stretched. Any stretches you perform should focus on the muscle rather than on the joint. Utilizing a foam roller has proven to be a safe way to stretch, but my personal favorites are some of the old stand-by’s that some physical therapists may warn against. The danger with these stretches is that they can cause unnecessary stress on the shoulder joint. If pain is felt in the joint itself, stop. The stretch should be felt in the muscle with a mild discomfort. Readjust and try to find the angle that targets the large muscle you are trying to stretch. Make certain that the shoulders are not hunched, but that the scapulae are back and down.
Once a swimmer has shoulder pain, rehabilitation must commence.
Recognizing the Symptoms
The typical symptoms of shoulder impingement syndrome are shoulder pain and weakness of the shoulder muscles. Although the injury is at the very top of the arm, the pain is often deferred, meaning it may seem painful in other places up to six inches away from the actual inflammation.
Rest and Ice
Swimmer’s Shoulder is the pain felt from inflammation of tendons at the top of the arm. To reduce inflammation, the first thing to do is stop doing what caused the inflammation. This means the swimmer should refrain from activities requiring arms over the head. The swimmer’s season will not be lost by taking a few days off. On the contrary, continuing to swim while injured will keep the swimmer from making a 100% effort, all while not allowing for the body to heal.
An important part of rehabilitation is cross-fiber friction massage across the affected tendons. This creates a mobile scar and increases circulation. Although quite uncomfortable (similar to the pain from using a foam roller), this massaging can speed the recovery process. A swimmer can self-administer this massage and should do so before swimming. The two important spots to vigorously massage back and forth are at the front and rear of the shoulder. Palpate until the sore spots are found. Although the most lateral (outside) of the shoulder usually hurts as well, it does not need to be massaged.
As long as they can be performed without pain, all the previously described exercises should be used in rehabilitation, using light weights and high repetition (such as 25) or even with no weights and timed, fast motion (such as 10 seconds as many reps as possible). Some experts claim that exercises should begin with isometric resistance with the muscles in the shortened (flexed) position, and then at various points through the range of motion until eventually in the stretched position. Most will say that exercises with elevation of the humerus above 90 degrees do more harm than good, so the elbow should remain by the athlete’s side as much as possible. Whatever the strength training method, pain should be the limiting factor.
These treatments are for primary and secondary impingement. However, if there are bony changes or severe tearing of soft tissue, surgery may be required. Great care should be taken before deciding upon surgery because it can take over a year to fully recover. A qualified medical professional should make this determination.
How to Train while Recuperating
If possible, complete avoidance of over-head activities will best facilitate recuperation. Fortunately, there are many activities which may be safely performed while giving the shoulders a chance to heal.
Core Body Strengthening. Most core body exercises keep the elbows below the shoulders. Refer to the Swimmer Strength Video Page for a number of excellent core exercises. Modify as needed to keep the elbows below the shoulders. The basics include crunches and flutter kicks.
Kicking with Arms at Side. Why not use the shoulder-recuperation time to take the swimmer’s kicking to the next level? While on the swimmer’s back with arms at the side, the swimmer can perform dolphin kick, flutter kick, and even breaststroke kick. For turns, try to flip while keeping the arms at the sides. If a snorkel is available, this is an excellent choice for kicking on the swimmer’s front with the arms at the sides.
Leg Strength. Lunges, squats, leg presses, calf raises, and many other leg exercises obviously do not cause problems with the shoulder.
Leg and Ankle Flexibility. Stretch the hamstrings, gluts, quads, and ankles while the shoulders are resting.
Wrist, Hand, and Finger Strength. Wrist curls, ball squeezing (with a variety of ball sizes), towel squeezing, paper-crumpling, sculling in the water with elbows below the shoulders, and even giving someone a massage will all help the swimmer be faster once able to perform the entire stroke.
Return to Swimming
Once inflammation is reduced and pain has subsided, begin with an easy warm-up. If the swimmer is pain free, gradually increase the effort. If pain starts again, back off for another day and continue to rest and rehabilitate.
Remember that there are different kinds of pain the swimmer will feel during the rehabilitation process. Burning muscles from lactic acid build-up is a good kind of pain. However, a dull ache or sharp twinges coming from inside the shoulder are signs that the swimmer is not ready to resume full activity.
If the swimmer continues to have pain for longer than a week, seek advice from a qualified professional.
Incorrect stroke technique and relative weakness of the scapulothoracic and humeral head depressors and external rotators are the major culprits in the acquisition of shoulder impingement syndrome. If the swimmer and coach understand the mechanisms of shoulder elevation, they will together be able to prevent and treat swimmer’s shoulder. And that concludes it with this in depth 3 part shoulder series.