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Swimmer's Shoulder
Authors

Donald D. Davis1; Morgan Nickerson; Matthew Varacallo2.

Affiliations
1 Wellstar Atlanta Medical Center
2 Penn Highlands Healthcare System

Last Update: September 4, 2022.

Continuing Education Activity

Swimmers have significant susceptibility for shoulder injuries due to the involvement of the shoulders required for
various strokes and the high volume of repetitions required during training. Swimmer's shoulder is a term can
represent numerous shoulder pathologies. These include impingement syndrome, rotator cuff tendinitis, labral
injuries, ligamentous laxity or muscle imbalance causing instability, muscular dysfunction, and neuropathy from
nerve entrapment. Interprofessional team members must be able to differentiate between these different etiologies.
This activity describes the pathophysiology, etiology, presentation and management of swimmer's shoulder and
stresses the role of team-based interprofessional care for affected patients.

Objectives:

Identify the etiology of swimmer's shoulder.

Describe the presentation of swimmer's shoulder.

Outline the treatment and management options available for swimmer's shoulder.

Summarize how an optimally functioning interprofessional team would coordinate care to enhance outcomes
for patients with swimmer's shoulder.

Access free multiple choice questions on this topic.

Introduction
Swimmers have a significant potential for shoulder injuries due to the unique nature of the different strokes involved
in swimming as well as the high volume of repetitions needed during training. Swimmer’s shoulder is a term that can
represent numerous shoulder pathologies. These include impingement syndrome, rotator cuff tendinitis, labral
injuries, instability secondary to ligamentous laxity or muscle imbalance/dysfunction, neuropathy from nerve
entrapment, and anatomic variants. In order for the athlete to return to the sport in an appropriate and timely manner,
the clinician must be able to differentiate between these different etiologies. [1][2]

Etiology
Swimming is a unique activity because it requires primarily the upper body for the propulsive force, with 90% of the
driving force provided primarily by the torque generated from the shoulder. To swim at an elite level, each swimmer
must log between 60,000 and 80,000 meters per week, which is equivalent to 30,000 strokes per arm. Fundamentally,
the swim stroke requires the shoulder to move to range-of-motion extremes while tremendous muscular force is
exerted upon the shoulder. [3][4][5]

Epidemiology
The incidence of swimmer's shoulder, depending on the study, ranges from 3% to 70%. When defined as shoulder
pain that interferes with training or progress in training, the incidence is reported as approximately 35% in elite and
senior level swimmers. [6]
Pathophysiology
Swimming strokes can be broken down into pull-through and recovery phases. The latissimus dorsi and the pectoralis
major are the primary contributors to propulsive forces of the swim stroke by adduction and internal rotation. The
subscapularis and serratus anterior muscles also play an integral role in the freestyle stroke. [7][8][9][6][8]The
freestyle stroke can be divided into six dinstinct parts/phases:

Hand entry

Forward reach

Pull through

Middle pull through

Hand exit

Middle recovery

It is important for the athlete to have a properly balanced shoulder regarding muscle strength. Improper muscle
balancing can cause the onset of shoulder pain. An absolute or sudden increase in training yardage and poor
technique can also be associated with the onset of pain. The coaching staff can observe a dropped elbow during the
recovery phase of the freestyle stroke as one of the early signs of possible injury.

History and Physical

As is the case with most physical ailments of the body, a thorough physical examination is imperative for diagnosing
a swimmer’s shoulder pain. The shoulders should be checked for atrophy and symmetry, the range of motion should
be measured. Special attention should be paid to scapular positioning at rest and symmetry in motion to assess for
abnormal motion. Strength testing likely will produce pain, and in advanced cases, the shoulder may fail to resist the
examiner’s force.

Special testing may provide further insight. The apprehension/relocation test and sulcus signs provide insight into
instability. The Hawkins test is a useful and sensitive exam in the diagnosis of subacromial impingement. In patients
with positive laxity test results, the examiner also should check other joints for laxity to rule out a generalized
condition. [7]

Evaluation
Plain radiographs are obtained initially to rule out any abnormal anatomic variations. Following evaluation by a sports
medicine physician, an MRI may be ordered to better identify pathology in the muscles, tendons, ligaments, and
cartilage or to exclude other structural causes, such as labral cysts. Although many shoulder diagnoses can be reached
based on the physical examination alone, MRI is useful in confirming a diagnosis or when shoulder pain appears to
have more than one source. An MRI arthrogram can be considered when a labral or tendon tear is suspected,
Although imaging is an important part of the diagnosis, caution is warranted in interpreting imaging because
repetitive motion creates asymptomatic pathology in many athletes.

Treatment / Management
Nonsurgical Management

Eliminating acute inflammation is the priority in shoulder rehabilitation. After a swimmer, first experiences pain, ice,
NSAIDs, and rest can prevent progression. If pain continues or worsens, a 7-day to 10-day course of NSAIDs and rest
is ideal but often proves difficult if the injury occurs during the middle or late part of the season. At a minimum, effort
should be made to reduce yardage to below the point of pain. For swimmers with impingement, tendinitis, or scapular
dyskinesis, a subacromial and/or glenohumeral corticosteroid injection may be beneficial diagnostically and for pain
reduction.[10][11]

Stretches that focus on the posterior capsule are important for preventing and reversing impingement. When they are
coupled with overstretching of the anterior capsule, swimmers can create imbalances that worsen impingement. The
swimmer can stretch the posterior capsule by horizontally adducting the arm and using the contralateral arm to pin it
against the body.

Disproportionately increased adduction strength and internal rotation are unavoidable consequences of swimming.
Overdevelopment of the pectoralis major and latissimus dorsi muscle groups creates a force that displaces the humeral
head anteriorly, leading to joint instability. Additionally, rotator cuff strengthening will lead to muscular balance
restoration, which will reduce or eliminate impingement. As muscle endurance and strength improve, sport-
mimicking exercises can be attempted, followed by low-yardage workouts at slow speeds, as long as the swimmer is
pain-free, and progressing slowly until the swimmer can return to competition.[12][13]

Surgical Management

Surgery is appropriate for structural pathologies. An athlete may elect symptomatic management rather than surgery
so that he or she may continue competing until the pain begins to interfere with daily life. For swimmers with
persistent multidirectional instability, a capsular plication or inferior capsular shift procedure should be considered.
Athletes should be aware. However, that training volumes may need to be reduced permanently to avoid pain. A
subacromial exploration and removal of the hypertrophied, inflamed, and scarred tissue (thereby maintaining the
structural integrity of the shoulder) is an option for athletes who obtain only limited relief from physical therapy. For
swimmers with a labral tear in whom nonsurgical treatment has failed, the next treatment option is labral debridement
or repair.

Differential Diagnosis

Multidirectional instability

Partial articular side tear of rotators cuff

Partial-thickness bursal sided rotator cuff tear

Posterior inferior humeral ligament avulsion

Rheumatoid arthritis

Shoulder dislocation

Subacromial bursitis

Superior labrum lesions

Supraspinatus tendonitis

Thoracic outlet syndrome

Enhancing Healthcare Team Outcomes

Swimmer's shoulder is best managed by an interprofessional team that includes the orthopedic nurse. The shoulder
provides the greatest range of motion of all joints in the body but also possesses the greatest inherent instability. As a
result of the complexities, combinations, and variations encountered when examining the painful swimmer’s shoulder,
a correct diagnosis can be challenging. A range of provocative tests and imaging studies is critical in identifying the
source of the pain and in determining the appropriate treatment. Although some pathology may be managed
symptomatically by ice and NSAIDs, athletes with persistent pain should seek evaluation by a sports medicine
physician who may be able to offer more aggressive treatments. Physical therapy can be especially helpful in
balancing muscle groups, reducing in-season symptoms, and potentially preventing future injuries.

Most swimmers do have a good outcome with treatment, but recurrence is not uncommon. Hence, the efforts of a
strong interprofessional team for ongoing management will yield the best patient results. [14]

Review Questions
 Access free multiple choice questions on this topic.

Comment on this article.

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