Transcript The Hyper-mobile Shoulder - Warrenton Masters Swim and

For coaches?
Swimmers’ Blessing
Swimmers’ Curse
Steven Kalandiak, MD, Shoulder and Elbow Surgery
University of Miami, Miller School of Medicine
ASCA Conference Fort Lauderdale, FL, September 2009
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Scott Rodeo, MD
Chair – USA Swimming Sports Medicine
George T. Edelman, MPT, OCS, MTC
http://www.usaswimming.org/USASWeb/DesktopDefault.a
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Elite competitive swimmers put their shoulders
through millions of stroke cycles over the
course of their careers.
Michael Phelps – 80K/wk
20 lap/K x 80K/wk x 50wk/yr = 80,000lap/yr
80K x 13-14cycles/lap = approx 1M cycles/yr
Ouch!
The Problem
The same hypermobile
joints that allow elite
swimmers to compete
at the level they do
also predispose them
to overuse injuries.
Proper mechanics, appropriate therapeutic
exercises, and rest and rehabilitation are not
only essential to fast swimming, but are also
important to maintaining shoulder health.
This talk reviews the structure and inner workings
of the shoulder joint, the injuries swimmers are
likely to suffer, and the prevention and
treatment of these problems.
McMaster and Troup - 1993 - 1262 US swimmers
Prevalence of interfering shoulder pain varied
between 10% (age group) to 26% (national
team) at any given time and increased with
time in the sport.
50 to 80% have training interrupted at some point
in their careers.
Wolf et al, 2009 - Injury data for University of Iowa
swimming and diving team 2002-07
94 swimmers
71% injury rate, 37% resulted in missed time
Shoulder/upper arm was the most frequently injured,
followed by the neck/back
Increased number and risk of injuries in freshman
Conclusion: Give particular attention to swimmers
making the transition to a higher level of training
Impingement/tendonitis
Internal impingement
SLAP tear
Anteroinferior instability
Multifactorial
Impingement, laxity, instability and labral
pathology can all coexist in the same shoulder
Maladaptive movement patterns (scapula) can
also coexist
Brushøj, Bak et al, 2006
Eighteen competitive Danish swimmers had arthroscopy for
therapy-resistant shoulder pain.
Most common findings at arthroscopy was labral pathology in
11 (61%) and subacromial impingement in 5 (28%).
Nine swimmers (56%) returned to preinjury competition level.
Findings suggest that ‘‘Swimmer’s shoulder’’ covers a variety of
pathologies including labral wearing and subacromial
impingement.
Arthroscopic debridement of labral tears or bursectomy has a
low success rate with regard to return to sport.
Scapular dyskinesias were common in this patient group.
Training (yardage/intensity)
Repetitive microtrauma
“acquired capsular laxity”
?? Incorrect stretching ??
Muscle imbalance
Flaws in technique
Rapid increase in training distance, intensity or
frequency problematic
Pressing on past the point where technique fails
either reinforces poor mechanics or causes
injury (or both)
Go slow – increase only one per week
Elite athletes need months to years to achieve full
fitness
“acquired capsular laxity”
when baseline laxity
increases, it can
become pathologic
?? Can incorrect
stretching contribute??
1,000,000 stroke cycles a year!
Repeatedly moving through unbalanced shoulder
positions can further stretch already loose
tissue, creating pathologic instability
Improper mechanics (poor technique or technique
breakdown due to fatigue) can worsen this
Could inappropriate (capsular) stretching also
contribute to excess laxity?
(Edelman at USA Swimming)
Tradition, emulate others
Injury prevention (little real proof)
Relieve muscle soreness
Loosen tight muscle groups
(correct unbalanced joints)
Doorframe stretches (Pectoralis)
Flexibility – Pectoralis and Latissimus tight >
external rotation difficult
Strength – large propulsive adductors and internal
rotators vs. abductors and external rotators
Endurance – serratus and subscapularis prone to
fatigue > scapular dyskinesia
rotator cuff fatigues faster than large muscle
groups > instability > worsening laxity
Poor body roll
Crossing midline
Too straight elbow during pull
Persisting in the face of failing mechanics
?? Unilateral Breathing ??
?? Hand Paddles ??
Scapular plane swimming
Also fingertips not toward bottom, arm timing wrong
Reinforces poor, rather than excellent technique
Puts joints at risk of injury
fatigue accentuates muscle imbalances
scapular control and joint stability decline
Switch stroke, drill, or kick instead
Bilateral breathe to improve stroke symmetry
? increase body roll ?
An error in and of themselves, or do they
just aggravate existing flaws ?
First, second and third line treatment
“You can always operate –
you can never un-operate”
DO NOT swim through the pain
(But ok to swim with it if mild)
relative rest - vary strokes,
decrease intensity and yardage
NSAIDS, ice when aggravated
gradually re-increase workouts
Moderate to severe pain
Minimal swimming
aerobic fitness (legs), and core
technique evaluation by coach
evaluation for muscle imbalance by therapist
transition to home “preventive” exercises
My office phone # is …….
Repair/reattach torn structures
Tighten stretched tissue
Debride (smooth) irreparable tears or rough
surfaces (Masters)
Lengthy rehabilitation
Shoulder muscle development
but not too much
Strength, Endurance, Balance, Flexibility
Of the muscles in the shoulder
and thoughout the body
Do after practice or several hours before
Each set 2 or 3 times per week
Rotator cuff
Scapular stabilizers
Core
Stretching
One second on, one second off
Three sets of two minutes or until lose form
One second up, one second down
Three sets of two minutes or until lose form
15 sec clockwise, 15 sec counterclockwise
Three sets of two minutes or until lose form
One second on, one second off
Three sets of two minutes or until lose form
One second on, one second off
Three sets of two minutes or until lose form
One up, hold “plus” for two, one down
Three sets of two minutes or until lose form
Flat back
2 minute flutter kick or until lose form
advanced
Flat back, then bird dog
Alternate sides – 2 minutes or until lose form
Two 30 second stretched each leg
Don’t lock knee
Two 30 second stretches
Breathe!
Can do on ball
Can stretch, work abs, back or back of shoulders
The hypermobile joints that allow swimmers to
compete also predispose them to injuries.
A controlled increase in yardage and intensity,
attention to proper mechanics, and preventive
exercises are key to good shoulder health.
If problems arise, prompt recognition, relative
rest, and an appropriate search for the
underlying cause(s) are vital to returning the
swimmer to competition.
Questions?