A physiotherapeutic approach to shoulder instability in the competitive swimmer

Introduction Sports Physiotherapist specialising in swimming Founder and practice principal physiotherapist, Newcastle Physiotherapy Former Senior GB International swimmer and British record holder for 200 and 400 I.M Member of the GB Swimming Physiotherapy team, London 2012 Olympic Games Darren Wigg, Bsc (Hons) MCSPSM, HCPC Reg.

What is shoulder instability? Inability to maintain HOH in glenoid Can occur anteriorly (est 98%), posteriorly or multidirectionally Atraumatic instability occurs from repetitive overload or congenital joint features Focus today on atraumatic overload through swimming

Anatomy Ball and socket joint Head of humerus and Glenoid Very small shallow glenoid – ‘golf ball on a tee’ Inherently unstable Necessary for huge multi-directional ROM required

Static stability Superior Glenohumeral Ligament Limits anterior and inferior translation of adducted humerus Medial Gleonohumeral Ligament Limits anterior translation in lower and middle range of abduction Inferior Glenohumeral Ligament Primary static restraint against anterior and posterior and inferiortranslation when humerus is abducted beyond 45 degrees Glenoid Labrum Increases depth of glenoid cavity and increases stability up to 50% Negative intra-articular pressure Assists in maximizing joint congruency.

Dynamic stability Dynamic stability is provided by the rotator cuff Innervated by C5-6 Originate from the scapular All have a different function………

Dynamic stability Supraspinatus initiates abduction and continues through range with deltoid Infraspinatus laterally rotates primarily with arm in neutral Teres Minor laterally rotates and is more active when arm is in 90 degrees of abduction Subscapularis internally rotates, strongest rc muscle providing 53% of total cuff strength

Mobilisers

Mobility demands

Mobility demands

Swimming shoulders Abnormally high number of shoulder rotations per arm, per year How many…..

………..1.32 million!!

Swimming shoulders Shoulder instability and joint hypermobility common in elite level swimmers – why??? Swimmer screening results show hypermobile = better swimmers Beighton’s Score - higher Appears to be advantage for the competitive swimmer Instability can lead to shoulder pain and pathology Subtle balance required between mobility, strength and motor control

Presentation, common subjective findings Constant/intermittent pain, deep ache Often report cluncking or clicking Often insideous onset Aggravating activities: catch and recovery phase of FC,BF and BC, lying on it, overhead activities Easing activities: support, avoidance of aggs, NSAID’S, ice Activity dependent rather than diurnal pattern Often report recent change in training load/type - overload

Posture Swimming predominantly uses the anterior muscles at the front of the shoulder and chest This can cause those muscles to become overactive and short pulling the shoulder forwards. The muscles at the back become underactive, weak and long Kyphotic thoracic spine, protracted shoulder girdle and anteriorly translated HOH can narrow sub-acromial space and predispose swimmers to pain

Presentation, Common objective tests/findings Scapula winging or dyskinesis Painful arc of elevation Positive RC tests and resisted tests Positive instability tests…..

Load and Shift test One hand stabilising over acromion Other hand gripping HOH Compress and glide anteriorly and posteriorly Grade laxity 1-3

Apprehension Relocation Anterior instability Shoulder at 90 abduction Take to full passive LR Apprehension positive if pain and or apprehension Repeat with AP force through HOH If pain free – test positive

Sulcus sign Superior glenohumeral ligament Multidirectional instability One hand on acromian Other hand gripping shaft of humerus above the elbow Positive if sulcus appears below acromian of 2cm or above

Hypermobility assessment Beightons Score for hypermobility Score above 4 Research suggests 10% of population Reduced levels of collagen in connective tissue

Beightons Score Hypermobility

Secondary problems Shoulder instability can predispose the swimmer to shoulder pain due to: Rotator cuff impingement, tears or tendonopathies Sub-acromial bursitis Labral tears Shoulder laxity per se minimal association with impingement (Lay Sein et al 2009)

Typical treatment plan Advice and education surrounding acute pain management and adaption of training - coach Supportive tape Manual therapy: Mobilisation of stiff joints (usually cervicothoracic region) Mobilisation of overactive muscles (usually posterior cuff and subscapularis, pecs, upper trapezius) Exercise therapy: Initially low level scapular stability and control, progressing to more complex sport specific work Rotator cuff conditioning with good scapular control, progressing through larger ROM as able Progressive upper limb weight bearing exercise to stimulate stability muscles Stretching and foam roller/ trigger point ball for tight overactive mobilisers………

Stroke / program analysis Stroke analysis and attentive coaching will help to avoid the common mistakes which contribute to shoulder pain The common faults in technique that reduce efficiency also increase risk of injury Poor frontcrawl technique can predispose a swimmer to shoulder pain Insufficient trunk rotation with a pull that crosses the mid line of the body is the main causative factor Poor core stability in the water can also contribute to the problem Manage training loads ? Most important – most often asked why now?

Delicate balance We can’t strengthen ligaments without surgery! We must strengthen the rotator cuff and scapular musculature to compensate for ligamentous laxity Reduce muscle imbalances Work on improving motor control and upper limb proprioception Improve spinal and shoulder girdle posture Improve technical deficiencies Manage training loads

Conclusions: These data indicate: (1) supraspinatus tendinopathy is the major cause of shoulder pain in elite swimmers; (2) this tendinopathy is induced by large amounts of swimming training; and (3) shoulder laxity per se has only a minimal association with shoulder impingement in elite swimmers. Br J Sports Med doi:10.1136/bjsm.2008.047282 Shoulder Pain in Elite Swimmers: Primarily Due to Swim-volume-induced Supraspinatus Tendinopathy Mya Lay Sein (mlsein@gmail.com) Orthopaedic Research Institute, Australia Judie Walton (j.walton@unsw.edu.au) James Linklater (linklj@telstra.com) Castlereagh Imaging, Australia Richard Appleyard Brent Kirkbride New South Wales Institute of Sport, Australia Donald Kuah George AC Murrell (murrell.g@ori.org.au)

refs Hayes K, Callanan M, Walton J. Shoulder instability: Management and rehabilitation. JOSPT 2002;23(10):497-509.