CARLILE COACHES' FORUM

Produced, edited, and copyrighted by
Professor Brent S. Rushall, San Diego State University
Volume 6, Number 2: February 4, 2001

SHOULDER PROBLEMS WITH SWIMMERS: AN EXPLANATION BY DR. LARRY WEISENTHAL

[This is an edited transcript of a response by Dr. Weisenthal in response to a question.]

The following is a private e-mail from a swim coach in Australia. His problem/question and my answer may be of interest to coaches working with talented teenage swimmers with shoulder pain.

The Communication

At present, I have a 14 yr-old girl who is starting to develop shoulder pain. Unfortunately she is, perhaps, the most talented of all my swimmers. I think she has the potential to be quite a good distance swimmer. Her freestyle pull is near textbook perfect. She maintains the highest elbow at catch and pull through of any swimmer I have seen (this may actually be exacerbating the problem). I may be panicking too early, however, having gone through my own shoulder problems as well as sharing the heartache and frustration another swimmer felt through her injury/recovery; I want to be sure she is looked after early. The pain has come and gone before. There does seem to be some correlation with yardage increases and pain. The last few weeks we have been covering a little more work (peak of about 10K a day this week). We have been doing a little more fly as well, which in the past has lead to her shoulder pain flaring up.

Below is a summary of when and where she feels pain:

Right shoulder only (she does breathe to both sides, however she definitely favors the left side)

Freestyle - pain at catch and at end of pull through

Fly - pain during recovery

Back - not too bad however sometimes pain at end of recovery and start of pull

Breast - pain at start of pull through (not too bad though) - sometimes upon picking a heavy object up or by pushing herself up off the ground she feels like she is 'pulling freestyle' i.e. the pain?

The pain is a dull ache and lasts all day. It is not sore to touch. Physios suggested to her that there was weakness in stabilizers of scapula. She does have quite hunched over posture. She is a slender girl. Just from looking at her, I get the feeling she is a prime candidate for shoulder problems. Her mother is a local MD. She is keen to read some literature on this.)

Any advice or help would be greatly appreciated.

My Answer

Short version of the shoulder story (I will go into more detail later):

90% of these problems are from impingement. The symptoms you describe are consistent with this. This can be reduced by some simple stroke modifications (see below).

Two causes (besides technique).

Bad bone anatomy. Big or downsloping or spurred acromion (bone you feel when you clap yourself on the shoulder) or else thickened coracoacromial ligament (runs from the lateral tip of the acromion to a little boney knob in the front of the scapula to which the short head tendon of the biceps attaches). Diagnose this with an MRI (14 yr-old. girls can have a poorly ossified acromial head, which can be difficult to see on a plain x-ray).

Lax/hypermobile joint. The humerus is held up against the scapula by ligaments called the joint capsule. Most good swimmers are very flexible (because their joint capsules are loose). Have her hold her arm straight-ahead while standing up (elbow down, palm up). Look at the angle between the (upper) arm and forearm. Is it 180 degrees? Then she is probably NOT hypermobile. Is it more than 180 degrees? Then she very well may be hypermobile. Problem with hypermobility is that the head of the humerus can migrate upwards, smashing the superior rotator cuff (supraspinatus) tendon against the "roof" of the shoulder (acromion and coracoacromial ligament). This is worse during the stroke; usually worst right at the very start of catch and pull through. This is because when downward/rearward pressure is applied, the head of the humerus is forced upward.

Oftentimes, swimmers have both problem #1 AND problem #2.

Tests for Impingement (in addition to MRI to define anatomy)

Neer Test

Raise the arm overhead, pointing straight up. Rotate hand so palm is outward. Dr/Coach then presses against palm, forcing hand over the top of the head. Does this hurt? If so, it is a positive test. Note that this is a position commonly advocated for swimmers: Swimmer on the side, hand reaching straight forward, palm down. Is there any wonder that swimming causes shoulder problems when some swimmers are taught to swim by performing a Neer Test on themselves with each stroke?

Hawkins Test

With arms at the side, lift elbow up to the side, so that (upper) arm is at shoulder level, parallel to ground, fingertips pointing straight down. Now, rotate thumb backwards, while securing wrist to keep fingers pointing straight down, at the same time the examiner forcefully pushes the shoulder forward. Pain? Positive test. Note that this position can be achieved also during the swimming stroke, with certain types of high elbow recoveries. Alternatively, think of a butterfly recovery, with elbows slightly bent and thumbs down and slightly backward facing, with pinkies and back of hand leading. Does your kid recover fly with thumbs down? Have her recover thumbs forward, palm of hand parallel to water. Coaches like thumbs down, back of hand forward, because it is slightly easier to clear the water this way. However, about 35% of elite flyers do recover palms down, thumb leading, so it is compatible with fast fly swimming. While your swimmer is actually having pain (not just trying to prevent pain), she might even tilt her thumbs slightly upward during recovery, to completely avoid internal rotation. Internal rotation is bad because it rotates the vulnerable supraspinatus tendon right underneath the narrowest part of the acromion and coracoacromial ligament (where there is the least space and where the tendon is squeezed the most).

What Else To Do?

One more thing. Rule out that the pain is being caused by epiphysitis. Have the swimmer's mum tell you about something called Osgood-Schlatter's syndrome. This is a VERY COMMON problem in 14-yr-old land athletes (e.g., soccer, basketball, running). The lower patellar tendon attaches to the top of the tibia right over a growth plate (epiphysis). Traction of the tendon against the growth plate can hurt like heck. Cure is aging enough so that the growth plate closes. Same thing can happen in the shoulder, where the acromial epiphysis can get inflamed from repetitive motion. This is very easy to diagnose. Put two fingers on the top of the acromion, right near the ("drop off") end of the top of the shoulder bone (where you would clap your mate on the shoulder in a pub watching your favorite rugby team score a try. Press firmly on the top of the bone with two fingers and see if you can force her to the ground, not with pressure, but by eliciting pain. If this does not happen (i.e., you cannot force her down with pain), then you have ruled out epiphysitis as a cause. If you CAN force her down, write back and we will talk about what to do about it.

Presuming the problem is garden-variety impingement syndrome; here is what to do.

Keep her in a kicking lane until she is having no more pain. My daughter's team had a 15-yr-old girl with a nearly identical problem who kicked for about 12 weeks straight last winter, but, 10 weeks after resuming full stroke swimming, swam a 4:47 400 IM (LCM). Will it take 4 or 8 or 12 weeks? I do not know. However, definitely do this; your swimmer is only 14 and recovery now will save much worse problems in the future.

Perform posterior rotator cuff strengthening to strengthen active stabilizers, that is, the rotator cuff itself, which will keep the head of the humerus down where it belongs and not migrate upward. This is particularly important if the "Hawkins elbow-bend test" (see above) diagnoses hypermobility.

Stroke modification.

Rule number 1. Avoid/minimize internal rotation of the hand/forearm/(upper) arm complex. Internal rotation is counter-clockwise on right and clockwise on left.
Rule number 2. See # 1.
Rule number 3. Do not apply any downward/backward forces at the catch until the forearm has descended well into the high elbow position. The problem with paddles is that there is a tendency to begin the pull much too early, as it takes longer for the hand to drop to the catch position while wearing a paddle. The problem with a too-early pull is that the head of the humerus is forced upward.
Rule number 4. Do not have a big, strong push back to "finish the stroke." This produces a "wring-out" effect, crimping off the small arteriole, which supplies blood to the supraspinatus tendon. Do not worry. Your great Aussie coaching-colleague Carew teaches an early exit. Perkins does not finish the stroke but swims with an early exit. So does Franzi Van Almsick, WR holder in the 200 free.

How to Avoid Internal Rotation

Something I call the "Birmingham feather" (after a brilliant young Aussie coach who taught it to my daughter). Think of rowing. After the end of the stroke, what does a competitive rower do? He/she "feathers" the oar so that the flat part of the blade is parallel to the surface of the water. This is what Coach Birmingham taught my daughter to do. She still does it. So does my other daughter. So do I. As long as we remember to do this, none of us has any shoulder pain at all. In the article by Yanai and Hay (U of Iowa) published last year, they found that the number one cause of impingement was delayed external rotation (Birmingham feathering) during recovery.

Do not swim with a locked elbow forward reach unless you are Ian Thorpe and have a great kick. Van den Hoogenbond never completely straightens his left elbow, and he is the fastest freestyle swimmer (100/200) in history. A female distance swimmer shouldn't ever swim with a locked elbow stroke unless she is Astrid Strauss on steroids with an unbelievable kick racing Janet Evans in the '88 Olympics. Otherwise, swim like Brooke Bennett or Diana Munz. Shorter stroke; faster turnover; no Neer test, no internal rotation during recovery and entry. Early exit to avoid supraspinatus artery wring out. A locked elbow stroke only makes sense in the context of a great kick (e.g., US distance ace Erik Vendt). Otherwise, in a weak kicker (e.g., most female distance swimmers or swimmers such as Claudia Poll and Lindsay Benko), the more rapid turnover is needed to conserve momentum, which is rapidly lost with locked elbow stroke in the absence of a good kick. Locked elbow stroke recapitulates orthopedic Neer impingement test and will be more likely to produce shoulder (rotator cuff) injury.

Basically, you want to have the thumb ahead of the little finger during recovery and entry. At the moment of catch and pull, it is probably more efficient to have some internal rotation, but 80% of all impingement occurs at recovery and entry, and only 20% during the pull. However, if the swimmer is still having pain, then even keeping the thumb slightly forward (toward the direction that the swimmer is moving in or toward the approaching wall) of the little finger during the pull through will eliminate internal rotation at all times, and minimize impingement as well. To allow for an effective angle of attack, the entry should be a little wider than usual, so that it resembles the initial part of the butterfly pull (where the hand typically enters wider than in freestyle and the start of the pull is an inward diagonal).

In butterfly, recover with palms down, thumbs forward (see above).

In the backstroke exit, the thumb should be out, little finger in, but when do you rotate the wrist? Many backstrokers rotate immediately, to lead with the little finger as the hand moves out of the water and over the head. That is internal rotation (bad). You want to keep the thumb forward, pointing to the direction of travel until just before entry, when you feather the hand to enter flat with the back of the hand.

In breaststroke, I presume your swimmer experiences pain at the time she rotates her thumbs inward to begin the (high elbow) pull. That again is internal rotation. It is hard to describe how to modify this without seeing her swim in person. Maybe just a slight reduction in internal rotation (i.e., thumbs not so much inward) is all it will take to give her some relief.

Generally, avoid internal rotation wherever possible. For example, if doing a hand-led kicking drill on the side, keep the palm of the hand up, rather than down. While reaching for the wall, do so with the thumb up. While raising her hand in class, do so with palm back, thumb outward, etc. etc. etc.

Larry Weisenthal
Huntington Beach, Callifornia

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