Swimmer’s

Shoulder
AT E M J O S H UA T Z M / 1 1 5 1 0
A R R E N M A K I WA T Z M / 1 1 5 0 4
M O D E R AT O R : D R . C H I M U KA M WA A N G A
Introduction
•Swimmer's shoulder is the term used to describe the
problem of shoulder pain in the competitive swimmer
due to overuse injury to the soft tissue envelope around
the shoulder.
•It’s a broad name for a few different issues that cause
similar symptoms.
•It gets its name from who it usually affects — swimmers
and other athletes who use their shoulders a lot to
move their arms overhead.
Relevant Anatomy
 Relevant Anatomy
•The shoulder joint is a complex combination of bones, joints, ligaments, muscles
and tendons, allowing a wide range of motion to perform everyday activities and
compete in sports.
•The following structures are;
1. Three bones (Scapula, clavicle, proximal humerus)
2. Two joints (Acromioclavicular joint, glenohumeral joint)
3. Ligaments (Glenohumeral ligament, coracohumeral ligament, transverse
humeral ligament and coracoacromial ligament.)
•The muscles of the shoulder play a critical role in providing stability to the shoulder
joint.
•The primary muscle group that supports the shoulder joint is the rotator cuff
muscles.
 Relevant Anatomy
•The four rotator cuff muscles include:
i. supraspinatus,
ii. infraspinatus,
iii. teres minor,
iv. and subscapularis.
•Other muscles that form the shoulder girdle
include
i. the pectoralis major,
ii. pectoralis minor,
iii. the deltoids,
iv. trapezius,
v. and the serratus anterior.
Muscles acting on shoulder joint
Blood Supply of Shoulder
Nerve Supply of Shoulder
Epidemiology
•Depending on the study, swimmer's shoulder incidence ranges from 3% to 70%.
•When defined as shoulder pain that interferes with training or progress in
training, the incidence is approximately 35% in elite and senior-level swimmers.
•Some studies report that around 91% of swimmers suffer from this condition
during their entire sports career.
•This results in many swimmers missing training sessions and important
competitive events.
Epidemiology
•Swimmers will often complain of pain
in the subacromial region (i.e. front
and lateral side of shoulder).
•The pain is usually low or not present
when starting the swim, but worsens
with repeated use in swimming.
 Risk Factors
•There are a multitude of both intrinsic and extrinsic factors that may influence
the development of Swimmer’s Shoulder.
•Extrinsic factors include:
i. Training volume—absolute and sudden increases
ii. Technical errors in performance of stroke
iii. Use of hand paddles
•The main factor in the development of a swimmer’s shoulder seems to be the
high training where swimmers are subject to early fatigue due to the high
training volume.
 Risk Factors
•Intrinsic factors include many structures that a
physical therapist will assess and possibly treat. Scapula Dyskine
•They include:
i. Posture increased thoracic kyphosis,
ii. Excessive laxity/general joint hypermobility
iii. Scapular dyskinesia
iv. Core stability
v. Rotator cuff muscular imbalances
vi. Lack of flexibility/stiffness in the shoulder,
cervical, and thoracic spine.
Risk Factors
•Also, a past history of a traumatic injury to the shoulder, such as a dislocation,
fracture, or fall, may be reported more frequently in the groups with shoulder
complaints.
 Etiology
•The various causes include,
i. impingement syndrome,
ii. rotator cuff tendinitis,
iii. shoulder labrum injuries,
iv. shoulder instability,
v. neuropathy from nerve entrapment (pinched nerve) ,
vi. and anatomic variants.
•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
 Pathophysiology
•The following are the key components of the pathophysiology of swimmer’s
shoulder.
i. Impingement syndrome.
ii. Rotator cuff tendinopathy.
iii. Labral Pathology.
iv. Glenohumeral instability.
v. Inflammatory response.
Pathophysiology
1. Impingement Syndrome:
Pathophysiology
2. Rotator Cuff Tendinopathy:
Pathophysiology
3. Labral Pathology:
Pathophysiology
4. Glenohumeral instability:
Pathophysiology
5. Inflammation Response:
 Clinical Presentations
• Symptoms • Signs
i. Swelling or Inflammation
i. Weakness
ii. Limited range of motion
ii. Clicking sensation
iii. Tenderness or sensitivity
iii. Shoulder pain iv. Muscle atrophy
iv. Loss of stroke efficiency v. Asymmetry
v. Numbness or tingling vi. Altered swimming mechanics
vi. Burning sensation vii. Scapula Winging/Scapula Dyskinesia
viii. Postural abnormalities (rounded shoulders)
vii. Increased sensitivity to cold or
pressure ix. Decreased Shoulder Strength during internal
and external rotation
 Diagnostics
•These include the following;

i. Clinical History

ii. Physical Examination

iii. Imaging
Clinical History
•Pain Description: Ask the patient to describe the pain, including location,
intensity, and nature

•Note when the pain occurs, particularly during or after swimming.

•Duration and Onset

•Range of Motion (ROM): Test ROM in all planes (flexion, extension, abduction,
adduction)

•Palpation: Check for tenderness over the rotator cuff tendons, biceps tendon,
and subacromial bursa.
 Neer’s Test
•For: External Impingement
•Posture: Patient seated with examiner standing
•Fixation: Ipsilateral scapula to prevent protraction
•Test: Passive forward elevation of the arm
•Positive: Pain in the shoulder
•Modifications: Internal and external rotation of
humerus
 Hawkin’s Test
•For: External Impingement
•Posture: Patient seated with arm in 90° forward
elevation
•Test: Passive forced internal rotation at different
degrees of ab/adduction
•Positive: Pain in the shoulder
 Empty Can Test
•For: External Impingement
•Posture: Patient seated with arm in 90°
abduction, 30° horizontal adduction and full
internal rotation
•Test: Resist abduction/flexion
•Positive: Pain in the shoulder; muscle weakness
•Modification: Repeat with full external rotation
to reduce pain
Posterior Internal Impingement
•For: Internal Impingement
•Posture: Patient supine, 90° abduction and
maximal external rotation
•Test: Maximal Passive external rotation
•Positive: Pain POSTERIORLY
 O’Brien Test
•For: SLAP
•Posture: Patient standing in front of examiner.
Arm 90° forward flexion, 10-15 ° adduction and
full internal rotation
•Test: Resist Flexion. Repeat with supinated wrist
•Positive: Pain over ACJ when in internal rotation
OR Pain in shoulder
 Differential diagnosis
•Labral tear
•Subacromial bursitis
•Frozen shoulder
•Cervical radiculopathy
•Rheumatoid arthritis
•Posterior inferior humeral ligament avulsion
•Multidirectional instability
 Investigations
• These include
i. X-ray
ii. MRI(Magnetic Resonance Imaging)
iii. Ultrasound
iv. Blood test
v. Angiography
X-ray
•Often the initial imaging test, especially if there is a suspicion of a fracture or
bone abnormality.
Magnetic Resonance Imaging
•Recommended for patients with persistent shoulder pain, especially if there is a
history of trauma or a suspicion of rotator cuff tear or labral tear
Ultrasound
•Ultrasound can detect bursitis, which often accompanies shoulder impingement
in swimmer’s shoulder.
•It’s also good at identifying any fluid accumulation or inflammation in the soft
tissues surrounding the shoulder joint.
Blood Test
•This can be used rule out infections or inflammatory conditions
•If there is suspicion of an infection (e.g., septic bursitis) or an underlying
systemic inflammatory disease (e.g., rheumatoid arthritis) contributing to
shoulder pain
•Blood tests like C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR)
can check for inflammation.
Angiography
•Swimmers may develop arterial thoracic outlet syndrome (TOS) due to repetitive
overhead movements, which can compress blood vessels near the shoulder.
•Angiography can visualize blood flow to determine if arteries are compressed,
leading to pain, numbness, or circulation issues in the arm.
•It can be used to check for any vascular damage or abnormalities, such as
aneurysms or stenosis (narrowing of blood vessels), that may contribute to
shoulder pain or dysfunction.
Treatment(non surgical)
•Pain relieving medication (NSAIDs)
•Ice and heat therapy: applying ice to reduce inflammation and heat to improve
blood flow.
•Physical therapy: exercises to strengthen the shoulder muscles, improve range
of motion, and correct biomechanics.
•Rest: taking a break from swimming or other overhead activities is crucial.
 Treatment(surgical)
•In rare cases, surgery may be necessary to repair damaged tendons or ligaments
for example;
i. subacromial decompression and
ii. arthroscopy.
 Complications
•Some of the complications that may be seen after surgical management include:
i. Infection
ii. Persistent pain
iii. Decreased range of movement of the shoulder (stiffness)
iv. Prolonged rehabilitation requirements from re-tears or failed repairs
v. Arthrofibrosis
vi. Nerve Damage
vii. Blood clots (Deep Vein Thrombosis or Pulmonary Embolism)
References
1. https://www.ncbi.nlm.nih.gov/books/NBK470589/.
2. https://emedicine.medscape.com/article/93213/
3. https://my.clevelandclinic.org/health/diseases/17535-
swimmers-shoulder
4. https://www.verywellhealth.com/swimmers-shoulder-5203248
5. https://www.coastalorthoteam.com/blog/swimmers-shoulder-
signs-symptoms-stretches-and-treatment