Swimmers and Divers, How Does Surgical Intervention Change? Ben Rubin, M.D. Orthopaedic Specialty Institute Orange, CA

Is There a Difference in the Surgical Treatment of Shoulders in Swimmers and Divers?

Swimmers vs. Divers Kinematics Body characteristics Mechanisms of injury Observed pathology Surgical correction

Diving Kinematics Phases –Approach – open chain –Press – open chain –Flight – open chain –Entry – closed chain Arm position

Diving Kinematics Arm position

Swimming Kinematics Phases –Catch – closed chain Hand entry Catch –Pull through – closed Insweep Finish –Recovery – open chain Arm position

Body Characteristics Postural dysfunction

Body Characteristics Postural dysfunction Scapular dyskinesis –Proximally derived –Distally derived

Body Characteristics Postural dysfunction Scapular dyskinesis Joint laxity

Body Characteristics Postural dysfunction Scapular dyskinesis Joint laxity Aerobic fitness

Body Characteristics Postural dysfunction Scapular dyskinesis Joint laxity Aerobic fitness Training schedule

Mechanisms of Injury Always try to correlate symptoms with mechanics of sport Diving –Pain with front throw or back throw –Circling –Entry Swimming –Catch, pull through, recovery

Entry Statistics Velocity –1 meter mph –10 meter 36.8 mph Force at impact –2.0 – 2.4 Gs Submerged msec 53% decrease in velocity All without a splash

Mechanisms of Injury Diving –Macrotrauma Dislocation, subluxation Occasional RCT with dislocation –Microtrauma Repetitive subluxation (assoc. RCT) MDL becoming instability Scapular dyskinesis (proximal vs. distal) Overuse – capsule and/or cuff strain –Usually associated with laxity/instability

Mechanisms of Injury Swimming –Microtrauma MDL becoming instability Scapular dyskinesis (scapulothoracic weakness or imbalance) Overuse – capsule and/or cuff strain –Macrotrauma Injuries out of the water

Shoulder Pathology When evaluating the shoulders of young athletes, be careful not to describe symptoms (biceps and/or cuff tendinitis, impingement syndrome, etc.) Make a core diagnosis which explains the symptoms Primary SAI is extremely rare in swimmers and divers

Shoulder Pathology in Divers Labral tears and detachments –SLAP lesions (ant, post, combined)

Shoulder Pathology in Divers Labral tears and detachments –Bankart lesions (ant, post, both) –Hill Sachs lesion

Shoulder Pathology in Divers Labral tears and detachments –ALPSA lesion

Shoulder Pathology in Divers Capsule attenuation –Unidirectional instability –MDL with UDI –MDI –Rotator interval lesion –HAGL lesion MGHL deficiency (congenital)

Shoulder Pathology in Divers Rotator cuff tears –Partial thickness PASTA lesions Tensile failure –Full thickness (rare) Internal impingement (rare)

Shoulder Pathology in Swimmers Capsule attenuation –MDL unidirectional instability –Unidirectional and MDI may be a continuum –Rotator interval MGHL deficiency GIRD Tensile injury to cuff

Correction of Pathology Evaluate and modify technique prn Correct scapular dyskinesis if proximally derived Teach scapular positioning if distally derived –Program must be sport specific EUA (always compare sides) Diagnostic arthroscopy

Surgical Correction Suture capsulorrhaphy Rotator interval plication prn

Surgical Correction Bankart repair with suture capsulorrhaphy

Surgical Correction SLAP repair

Surgical Correction Rotator cuff repair or debridement

Surgical Correction Reexamine under anesthesia –Insure stability without compromising ROM required for sport –Refine rehabilitation based on postop ROM and stability

Rehabilitation Core based functional rehabilitation which is sport specific

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