1. A physiotherapeutic approach to shoulder instability in the competitive swimmer

2. 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.

3. 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

4. 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

5. 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.

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

7. 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

8. Mobilisers

9. Mobility demands

10. Mobility demands

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

12. ……… million!!

13. 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

14. 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

15. 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

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

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

18. 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

19. 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

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

21. Beightons Score
Hypermobility

22. 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)

23. 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………

24. 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?

25. 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

26. 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: /bjsm
Shoulder Pain in Elite Swimmers: Primarily Due to Swim-volume-induced Supraspinatus Tendinopathy
Mya Lay
Orthopaedic Research Institute, Australia
Judie
James
Castlereagh Imaging, Australia
Richard Appleyard
Brent Kirkbride
New South Wales Institute of Sport, Australia
Donald Kuah
George AC

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