1. For coaches?

2. 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

3. Google Yahoo Scott Rodeo, MD Chair – USA Swimming Sports Medicine George T. Edelman, MPT, OCS, MTC http://www.usaswimming.org/USASWeb/DesktopDefault.a spx?TabId=451&Alias=Rainbow&Lang=en

4. 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!

5. The Problem The same hypermobile joints that allow elite swimmers to compete at the level they do also predispose them to overuse injuries.

6. 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.

7. 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.

8. 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

23. Impingement/tendonitis Internal impingement SLAP tear Anteroinferior instability

29. Multifactorial Impingement, laxity, instability and labral pathology can all coexist in the same shoulder Maladaptive movement patterns (scapula) can also coexist

30. 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.

31. Training (yardage/intensity) Repetitive microtrauma “acquired capsular laxity” ?? Incorrect stretching ?? Muscle imbalance Flaws in technique

32. 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

33. “acquired capsular laxity” when baseline laxity increases, it can become pathologic ?? Can incorrect stretching contribute??

34. 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)

35. Tradition, emulate others Injury prevention (little real proof) Relieve muscle soreness Loosen tight muscle groups (correct unbalanced joints)

37. Doorframe stretches (Pectoralis)

40. 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

42. Poor body roll Crossing midline Too straight elbow during pull Persisting in the face of failing mechanics ?? Unilateral Breathing ?? ?? Hand Paddles ??

43. Scapular plane swimming

46. Also fingertips not toward bottom, arm timing wrong

47. 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

48. Bilateral breathe to improve stroke symmetry ? increase body roll ? An error in and of themselves, or do they just aggravate existing flaws ?

49. First, second and third line treatment “You can always operate – you can never un-operate”

50. 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

51. 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

52. My office phone # is …….

53. Repair/reattach torn structures Tighten stretched tissue Debride (smooth) irreparable tears or rough surfaces (Masters) Lengthy rehabilitation

54. Shoulder muscle development but not too much

55. 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

56. Rotator cuff Scapular stabilizers Core Stretching

57. One second on, one second off Three sets of two minutes or until lose form

58. One second up, one second down Three sets of two minutes or until lose form

59. 15 sec clockwise, 15 sec counterclockwise Three sets of two minutes or until lose form

60. One second on, one second off Three sets of two minutes or until lose form

61. One second on, one second off Three sets of two minutes or until lose form

62. One up, hold “plus” for two, one down Three sets of two minutes or until lose form

63. Flat back 2 minute flutter kick or until lose form advanced

64. Flat back, then bird dog Alternate sides – 2 minutes or until lose form

65. Two 30 second stretched each leg Don’t lock knee

66. Two 30 second stretches Breathe!

67. Can do on ball

68. Can stretch, work abs, back or back of shoulders

69. 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.

70. Questions?