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By Larry Weisenthal
Huntington Beach, CA
Associate Clinical Professor of Medicine
University of California
Irvine School of Medicine, Medical Director

At present I have a 14-year-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 Jenna 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 fly as well which in the past has led to her shoulder pain flaring up.

- 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. Basically just from looking at her I get the feeling she is a prime candidate for shoulder probs. Her mother is a local MD. She is keen to read some literature on this.

Any advice or help would be greatly appreciated.

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

1. Bad bone anatomy. Big or down-sloping 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 biceps tendon attaches). Diagnose this with an MRI (14-year-old girls can have poorly ossified acromial head which can be difficult to see on a plain x-ray).

2. Lax/hypermobile joint. Humerus held up against 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’s probably not hypermobile. If it is >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.

Neer Test:
Raise 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 reached 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:
Arms at 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, while examiner forcefully pushes shoulder forward. Pain? Positive test. Note that this position can be achieved also during the swimming stroke, with certain types of high elbow recoveries. Or think a butterfly recovery, with elbows slightly bent and thumbs down and slightly more easy to clear the water this way. But about 35% of elite flyers do recover palms down, thumb leading, so it is not incompatible with fast fly swimming. While your kid 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 being bad because it rotates the vulnerable supraspinatus tendon right underneath the most narrow part of the acromion and coracoacromial ligament (where there is the least space and where the tendon gets squeezed the most).

Oh, one more thing. Rule out that the pain is being caused by epiphysitis. Have the kid’s mom tell you about something called Osgood-schlatter’s syndrome. This is a very common problem in 14-year-old land athletes (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’d clap your mate on the shoulder in a pub watching your favorite ruggers, say, "The Bulldogs," while exclaiming "How ‘bout them dawgs!" immediately after a try). Anyway just 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 doesn’t happen (i.e. you can’t force her down with pain), then you have ruled out epiphystis as a cause. If you can force her down, write back and we’ll talk about what to do about it.

1. Kicking lane until she is having no more pain. My daughter’s team had a 15 year-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 don’t know. But definitely do this; your swimmer is only 14 and a stitch in time saves nine.

2. Posterior rotator cuff strengthening (to strengthen active stabilizers… i.e. the rotator cuff itself… to keep the head of the humerus down where it belongs and not migrate upward. Particularly important if the "elbow bend test" diagnoses hypermobility.

3. 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. Don’t apply 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. Don’t 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. Don’t worry. Your great Aussie-coaching colleague Carew teaches an early exit. Perkins doesn’t finish the stroke but swims with an early exit. So does Franzi Van Almsick, WR holder in the 200 free.

1. Something I call the "Birmingham feather" (after a brilliant young Aussie coach who taught it to my daughter). Think rowing. After the end of the stroke, what does a competitive rower do? He "feathers" the oar so that the flat 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 have any shoulder pain at all. In the article by Yanai and Hay at the University of Iowa published last year, they found that the number one cause of impingement was delayed external rotation (Birmingham feathering) during recovery.

2. Don’t swim with a locked elbow forward reach unless you are Ian Thorpe and have a great kick. Van den Hoogenband never completely straightens his left elbow, and he’s 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 arty wring out. 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 orthopedic Neer impingement test and will be more likely to produce shoulder (rotator cuff) injury.

3. Basically, you want to have thumb ahead of pinky during recovery and entry. At the moment of catch and pull, it’s probably more efficient to have some internal rotation, but 80% of all impingement occurs at recovery and entry, and only 20% during pull through. 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 pinky during 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 the initial part of the pinky during 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 the initial part of the pull 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).

4. Fly is recovering with palms down, thumbs forward.

5. Back is thumb out, pinky in… but when do you rotate the wrist? Many backstrokers rotate immediately, to lead with the pinky as the hand moves out of the water and over the head. This 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 pinky first.

6. Breast… your swimmer is getting pain I presume at the time she rotates her thumbs inward to begin the (high elbow) pull. Internal rotation again. 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 (e.g. if doing a hard lead kicking drill on the side, keep the palm of the hand up, rather than down). While reaching for the wall, do so with thumb up. While raising her hand in class, do so with palm back, thumb outward, etc.

Is she right handed? Right handers should never develop dominant left-sided breathing. Never, never, never. This is one of the cardinal sins in freestyle swimming.

All swimmers are asymmetric. Even elite swimmers. This was documented at the International Canter for Aquatics Research Center in Colorado Springs. Described in Maglischo’s book, Swimming Even Faster. Put any swimmer in the middle of the ocean without visual clues and he will swim in circles. Just like everyone would row in circles. So you want to strengthen the left sided pull (if you are right handed). Otherwise, you are creating a lot of drag as you constantly re-aim to stay on the black line and not veer against the lane line.

This is what van den Hoogenband’s "loping" stroke achieves. But everyone "lopes" a bit just by breathing. You end up getting more body side forces assisting the pull of the non-breathing side arm, as the body rotates back from breathing. Thus, a left sided/right handed breather is accentuating the right/left strength asymmetry, rather than reducing it.

The bonus is that there is often less impingement on the breathing side. Easier to maintain external rotation during recovery and entry and avoid internal rotation.

If your swimmer is right handed, she should be a primary right side breather. This will even out force vectors between right and left and should reduce impingement to her right (sore) side in the bargain. l