Musculoskeletal Injuries in Competitive Swimmers JEFFREY E. JOHNSON, M.D.  Mayo Clinic Proceedings  Volume 62, Issue 4, Pages 289-304 (April 1987) DOI: 10.1016/S0025-6196(12)61906-5 Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 1 Diagram of shoulder anatomy, showing anterior shoulder girdle musculature and coracoacromial arch formed by coracoid process, coracoacromial ligament, and acromion. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 2 Stroke mechanics for freestyle swimming. For the right arm, three phases are identified: hand entry (top), mid pull-through (middle), and end of pull-through (bottom). For the left arm, three stages are likewise depicted: elbow lift (top), mid recovery (middle), and hand entry (bottom). Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 3 Adduction of arm, as in late pull-through phase of freestyle swimming, is mechanism that causes “wringing out” of supraspinatus and biceps tendons. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 4 Impingement of supraspinatus and biceps tendons between humeral head and coracoacromial arch can occur with abduction and internal rotation of humerus, as in recovery phase of freestyle stroke. Note how serratus anterior muscle rotates scapula into abduction as humerus is abducted to allow a greater range of shoulder motion. Scapular rotation also delays impingement of greater tuberosity under coracoacromial arch until humerus is maximally abducted to near 180°. With fatigue or underdevelopment of serratus, humeral impingement may occur at an earlier point in recovery stroke at a lower angle of shoulder abduction. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 5 Shoulder impingement test maneuver forces greater tuberosity of humerus against anteroinferior surface of acromion. Reproduction of patient's shoulder pain constitutes a positive test result. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 6 Upper-arm counterforce brace, used as aid in treating early phases of “swimmer's shoulder.” (Also see Figure 7.) Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 7 Upper-arm brace is placed over biceps tendon high on affected arm. The strap makes biceps muscle a more effective humeral head depressor and thereby diminishes subacromial impingement. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 8 Stretching exercise for shoulder internal rotators. Handheld weight with shoulder at 135° of abduction allows gentle stretching. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 9 Strengthening exercise for shoulder external rotators. Surgical tubing attached to a stationary object offers resistance for effective strengthening. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 10 The backstroke flip turn is initiated by forceful shoulder internal rotation and forward flexion with arm in extreme abduction and external rotation and hand firmly planted against wall of swimming pool. This action causes considerable stress on anterior shoulder joint ligaments. With arm in this position, subscapularis muscle glides superiorly and is unable to help resist anteriorly directed force of humeral head. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 11 Shoulder apprehension test. Shoulder is placed in 90° of abduction and stressed in maximal external rotation while the humeral head is pushed anteriorly with the examiner's thumb from behind. A positive test result reproduces pain or sensation of impending subluxation. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 12 Correct and incorrect mechanics of breaststroke whip kick. Knees should be abducted no more than width of pelvis during recovery phase and middle of kicking phase. Knees should not achieve full extension until legs are together at end of kicking phase. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions

Fig. 13 The extremes of repetitive ankle dorsiflexion and plantar flexion may lead to extensor tendinitis in competitive swimmers. Mayo Clinic Proceedings 1987 62, 289-304DOI: (10.1016/S0025-6196(12)61906-5) Copyright © 1987 Mayo Foundation for Medical Education and Research Terms and Conditions