This document discusses shoulder issues in competitive swimmers. It begins by outlining the objectives, which are to discuss the phases of the freestyle stroke, prevalence of shoulder injuries in swimmers, range of motion patterns in injured vs uninjured swimmers, and evidence-based evaluation and management strategies. It then provides details on each phase of the freestyle stroke and how mechanics may differ in painful shoulders. A high prevalence of shoulder pain in competitive swimmers is noted. Various intrinsic and extrinsic risk factors for "swimmer's shoulder" are reviewed. The concepts of glenohumeral internal rotation deficit (GIRD) and total arc of motion are discussed in the context of throwing athletes and how these apply to swimmers. Evaluation and treatment strategies

1. Objectives
• Briefly discuss the phases of the freestyle swimming
stroke.
• Discuss the prevalence and incidence of shoulder
pathology in swimmers
• Identify ROM adaptation and flexibility patterns among
injured and uninjured swimmer’s shoulders
• Review GIRD, total arc of motion, and external rotation
deficiency
• Learn evidence based evaluation and management
strategies based on the current body of literature

4. Shoulder Revolutions per Week
1000 1000 300

5. 4000 rev / day
30,000 rev /
week

6. 90%

7. Prevalence of Shoulder Pain
(Competitive swimmers)
40-91%
3:1 female : male
Bak et al, 1997; Ciullo, 1986; McMaster 1999;
rupp et al. 1995; Sein, et al. 2010; Harrington, et
al. 2014

8. KNOW THE
STROKE

9. Freestyle
Fastest & most frequently performed
80%

10. Glide
Early pull-through
Mid pull-through
Late pull-through
Recovery
http://www.swimsmooth.
com/breathing.html

11. Am J Sports Med. 1991 Nov-Dec;19(6):569-76.
The normal shoulder during freestyle swimming. An
electromyographic and cinematographic analysis of twelve
muscles.
Pink M1, Perry J, Browne A, Scovazzo ML, Kerrigan J.

13. Glide
• Begins as hand enters
water
• Elbow slightly higher
than hand
Normal Painful
• Arm placed further
from midline
• Humerus lower and
‘dropped elbow’
• Late / decreased
recruitment of upper
trapezius

14. Early Pull Through
• Occurs from end
of glide to when
hand reaches
max extension
and begins
downward
motion
Normal Painful
• Decreased
serratus anterior
activity
• Increased
rhomboids
activity net
loss of scapular
upward rotation
and protraction

15. Late Pull Through
• Occurs from
90◦ of flexion
to when the
hand exits the
water
• Early hand exit (to
avoid extremes of
internal rotation?).
• Increased activity in
rhomboids to
retract and elevate
the scapula
Normal Painful

16. Recovery
• Occurs from
when the hand
exits the water
to just before
hand entry
• No water
resistance
Normal Painful
• Decreased
anterior
deltoid
activity
• More lateral
hand entry

17. • Scapular dyskinesias increase in frequency
throughout a training session
• Swimmers are subject to early fatigue due to
high training volume
• Serratus anterior muscle fatigues earlier in
painful swimmers

18. Breathing Patterns
• Unilateral breathing associated with
small tilt angle on breathing side
**High incidence of shoulder impingement
on ipsilateral side
• Case for adopting B/L breathing

19. Swimmers at Risk
• Small tilt angle

20. Mr. Smooth
https://www.youtube.com/watch?v=IyR7JYllk9U

22. Bak, K. 2010

23. Swimmers’ painful shoulder
arthroscopic findings and return rate
to sports
C. Brushøj1 , K. Bak2 , H. V. Johannsen3 , P. Faunø4
• Labral pathology (61%)
• Subacromial impingement (28%)
• Bursal sided tear of supraspinatus tendon
• Impingement of posterior rotator cuff
• Inflammation of Biceps - LH

24. Surgical Treatment
• Distal clavicle excision
• CA ligament resection
• Debridement
• Decompression

25. Outcomes
• 59% able to compete at pre-injury level after
2-9 months.
– 7 without shoulder pain (44%)
– 2 with some pain
– 7 never returned (44%)
Brushej, et al. 2007

26. Etiology of ‘Swimmers Shoulder’
Extrinsic Factors
• Training volume – sudden
increase
• Technical errors
• Hand paddles
Intrinsic Factors
• Excessive laxity / general
joint hypermobility
• Posture, core stability,
increased thoracic kyphosis
• Scapular dyskinesias
• GIRD (glenohumeral
internal rotation deficit)
• Rotator cuff imbalance
• Hypomobility (posterior
capsule, rotator cuff,
pectoralis minor)

27. GIRD ‘Glenohumeral Internal Rotation
Deficiency’
• Hypermobile ER,
hypomobile IR
• Most overhead athletes
(including swimmers)
demonstrate this motion
disparity

28. ‘The Disabled Throwing Shoulder’
series… old news?
• Burkhart, et al 2003
– GIRD: loss of IR shoulder motion on dom.
extremity
– Caused by posteroinferior capsular contracture
– Increased external rotation is an acquired
secondary cause
– GIRD is at the core of many throwing injuries

29. …but now we know there is more to
the story…
• Kevin Wilk, George Davies, Mike Reinold,
Kibler… change of heart?
• Lots of new data
• ‘TROM’ = TOTAL RANGE OF MOTION

30. GIRD: normal vs pathologic
• Manske, et al. 2013 (and Kevin Wilk, George Davies, Mike
Reinold…)
– ‘Loss of GH IR is a normal phenomenon that should be
expected’.
– ANATOMIC: IR loss of <18-20 degrees with symmetrical
TROM B
– PATHOLOGIC: IR loss >18-20 with corresponding TROM
loss >5 when compared bilaterally

31. Says Who?
• Pitchers whose TROM comparison was >5 were
2.5x more likely to sustain shoulder injury
• TROM should be symmetric, and not >186
• If we stretch to increase IR PROM, we may be
increasing TROM and thus INCREASING risk of
injury
– Increased demands on dynamic and static stabilizers
of GH joint
Wilk, et al. 2012

32. ERD: the new GIRD
• External rotation deficiency
– Pitchers with <5 degrees extra ER on dominant
side 2.3x increased risk of shoulder injury

33. Summary
• GOOD / OKAY:
– Symmetrical TROM
– Dominant arm has at least 5 degrees MORE ER than
non-dominant (THROWERS ONLY)
– IR loss within 18-20 degrees when compared B
• BAD:
– IR loss >18-20 with corresponding TROM loss >5 when
compared bilaterally
…….what about swimmers?

34. • Significant predictors: ER ROM and previous
history of shoulder injury
• Low (<93°) and high ER (>100°) were assoc.
with increased risk of injury

35. • Hypermobile in shoulder ABD, ER, and flexion
• Hypomobile in shoulder internal rotation
• Little correlation between hypermobility or
hypomobility and shoulder pain

36. GIRD vs PST (posterior shoulder
tightness)
• Borsa, et al. No association between joint
laxity and ROM (in healthy subjects)
– Laxity measured by Telos device
– Posterior joint laxity was more commonly
associated with IR deficit
**IR loss due to osseous
adaptations and posterior
soft tissue tightness
Wilk, 2009

37. • Resolution of symptoms after physical therapy
treatment for internal impingement was
related to posterior shoulder tightness but
NOT correction of GIRD

38. Posterior shoulder tightness
Tyler Test

40. **BOTH are good, supine slightly better

42. Keep in Mind Arm Dominance!
• NORMAL for arm dominance to be associated
with:
– Forward shoulder posture
– Loss if IR ROM
– Posterior shoulder tightness
*Dominant arm involved: effects accentuated
*Non-dominant arm involved: effects absent

43. Other risk factors…

44. • Symptomatic, >12 yrs of age:
– Pectoralis minor tightness
– Decreased core endurance
• Symptomatic, <12 yrs of age:
– Reduced shoulder flexibility
– Weakness of middle trap & shouder int. rotators
– Tightness of latissimus dorsi

45. • Measured:
– PROM IR and ER @90
– Strength: scapular depression, adduction, IR, ER
– Core endurance (side bridge, prone- bridge)
– Pectoralis minor muscle length
A cross-sectional study examining shoulder
pain and disability in Division I female
swimmers.
Harrington S1, Meisel C, Tate A.

46. Results
• Pectoralis minor muscle length was the only
variable which had a statistically significant
difference between groups (painful and non
painful shoulder).

47. Takeaways?
• GIRD: may not be pathologic
• ERD and TROM more important than GIRD
– Ideal between 93 – 100?
• Look at posterior shoulder tightness
– May be source of pathologic IR loss
• Measure pectoralis minor
• Strengthen scapular stabilizers! (serratus
anterior!)

48. The evidence based examination

49. Pec Minor Length

50. Pectoralis Minor
• Supine, elbows extended
• Inferomedial coracoid
process caudal edge of
4th rib at sternum
• Exhale before
measurement
• Intrarater reliability: good
– excellent
• Interrater: poor -
moderate
Struyf, et al. 2014

51. Pectoralis Minor

52. Vertical towel roll placed
under thoracic spine

53. Doorway stretch wins!

54. Posterior Shoulder Tightness

55. • A Single application of
MET for GHJ horizontal
abductors provides
immediate improvements
in both GHJ horizontal
adduction and IR ROM
• Dosage:
• 5 sec contraction @
25% effort, 30 sec
stretch, x3

56. THAT’S ALL!

57. Good Resources:
• Chris Johnson, PT: YouTube Channel
– Exercise videos, tests, etc.
• ‘Mr. Smooth’ : great animations of swimming
technique
– www.swimsmooth.com
– Also, stroke animations app

58. LAB!!

59. Lab To-Do
• IR / ER measurement
– positioning
– optimal scapular stabilization
• Measure posterior tightness
• Pec minor length
– Novel pec minor stretch
• Treat!
– MET
– Cross body stretch
– Modified cross body stretch
– Sleeper’s stretch
– Modified sleeper’s stretch

60. Who has tight posterior shoulder?

61. Modified sleepers stretch
• Method reduces
impingement
• Have patient do a
quarter turn towards
their back
• GH joint in
scapular plane

62. Cross body stretch

63. Modified cross body stretch

64. Standing cross body stretch

65. APPENDIX

66. The Backstroke

67. The Butterfly

68. The Breastroke