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

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

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

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

5. Diving Kinematics Arm position

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

7. Body Characteristics Postural dysfunction

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

9. Body Characteristics Postural dysfunction Scapular dyskinesis Joint laxity

10. Body Characteristics Postural dysfunction Scapular dyskinesis Joint laxity Aerobic fitness

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

12. 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

13. Entry Statistics Velocity –1 meter 18.75 mph –10 meter 36.8 mph Force at impact –2.0 – 2.4 Gs Submerged 128-140 msec 53% decrease in velocity All without a splash

14. 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

15. 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

16. 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

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

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

19. Shoulder Pathology in Divers Labral tears and detachments –ALPSA lesion

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

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

22. 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

23. 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

24. Surgical Correction Suture capsulorrhaphy Rotator interval plication prn

25. Surgical Correction Bankart repair with suture capsulorrhaphy

26. Surgical Correction SLAP repair

27. Surgical Correction Rotator cuff repair or debridement

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

29. Rehabilitation Core based functional rehabilitation which is sport specific

30. THANKS FOR LISTENING