What Is ‘Swimmer's Shoulder’?

Overview

The colloquial term ‘swimmer’s shoulder’ is most commonly associated with the condition shoulder impingement syndrome, in which tendons become sore and inflamed, limiting movement.

However, in some cases, other shoulder issues such as rotator cuff tears, tendinitis, scapular dyskinesis or general shoulder pain can be included under the broad umbrella term of ‘swimmer’s shoulder’.¹ These are common complaints in regular swimmers, especially competitive swimmers, due to the repetitive movements and strain that the sport places on the shoulder joints. These often result in microtraumas – a series of small injuries to different tissues caused by repetitive strain.² This can be painful, limiting and really problematic for the sufferer, so seeking treatment and managing symptoms is important.

Anatomy of the shoulder

The shoulder is a complicated joint, with many components that are susceptible to injuries. The shoulder is a shallow synovial ball and socket joint, which allows a large range of motion at the expense of stability. 

The humerus, the bone in the upper arm, forms the ball part of the joint, and the scapula, or shoulder blade, forms the socket part. Cartilage covers the articulating surfaces, and synovial fluid lies between them, both of which contribute to minimising friction and thereby assisting smooth movement.³ There is a complicated network of ligaments, tendons and muscles in the area. The rotator cuff is a set of four muscles which work in harmony during movement to maintain the ball’s central position in the socket and to stabilise the shoulder joint.⁴

Shoulder impingement syndrome is a condition in which tendons (especially those of the rotator cuff muscles) in the shoulder catch or rub on surrounding tissues, often becoming irritated, inflamed and painful as a result. This inflammation can prevent the smooth movement of the components of the shoulder joint. Repeated use will exacerbate inflammation, especially if it involves raising the arm over head height, and further limit the range of motion.⁵ This is the condition most commonly associated with the term ‘swimmer’s shoulder.’ 

The term ‘swimmer’s shoulder’ may also encompass other injuries and conditions such as rotator cuff muscle damage – which can result in pain, weakness, and difficulty moving the arm – or scapular dyskinesis. Scapular dyskinesis is when the scapula (shoulder blade) begins to sit out of its correct position. This can cause winging (protrusion) of the shoulder blade and can be painful. These conditions can also have a domino effect, whereby acquiring one injury can lead to the causation, or worsening, of other conditions.⁶

Competitive swimmers are particularly at risk of these problems, as the shoulder is so important in the sport, being responsible for: a great deal of power, stabilising the body position in the water, and generating the twisting motion of front crawl (freestyle) and backstroke. 

In butterfly stroke, the shoulder joint complex is put under a lot of pressure to generate propulsion during the underwater phase of the stroke.¹

Therefore, not only is a lot of strain placed on the shoulder during swimming, but without excellent functional shoulder movement, the swimmer can become weak, body position can quickly become incorrect, and the motion can become very painful for the individual.

Causes of ‘swimmer's shoulder’

Swimming as a sport includes lots of repetitive movements carried out under strain, especially in strokes involving large ranges of motion overhead. 

The stroke most commonly caused by a ‘swimmer’s shoulder’ is a front crawl (freestyle), as it is very repetitive and involves a lot of strain on the shoulder in overhead positions. 

Repetitive movements in a strained position can damage shoulder structures, leading to rotator cuff and tendon damage, or cause the structures in the shoulder to become inflamed and damaged, causing impingement. 

Competitive swimmers can clock tens of thousands of strokes per arm per week, and therefore it is no surprise that this strain can cause and exacerbate irritation, inflammation and injury to the complex tissues in the shoulder.⁷

A sudden increase in training intensity or in the distance to swim can cause or exacerbate these shoulder injuries. Additionally, incorrect stroke technique or body position can result in strain being placed on the shoulder, which can cause injuries to flare up or inflammation of muscles and tendons.⁸

Some subtle modifications can be made to the front crawl stroke, which will prevent shoulder impingement and other injuries. For example, having the head a little higher during the arm’s entry into the water means that the shoulder is under less strain and is less stretched. This can reduce the strain on the tendon that is associated with the swimmer’s shoulder.⁹

Additionally, breathing on alternate sides during front crawl, as opposed to just one side, has been associated with a better prognosis for, and prevention of, 'swimmer's shoulder' by ensuring equal use and development of both shoulders. This elimination of reliance on just one side for breathing reduces strain on the shoulder.^9,10

It has also been shown that there is a difference in swimming technique between swimmers with healthy or painful shoulders. The difference in technique is usually an overcompensation to avoid the positions in which the pain is at its worst and in which the impingement is causing pain. In front crawl, this involves a shortened stroke so the arms do not finish the underwater pull phase of the stroke at the sides of the body. Also, when the hand enters the water at the start of the stroke, swimmers with painful shoulders will often enter the water with their hands wider and elbows lower to offset the pain often caused by overhead movements.⁷

Symptoms and diagnosis of ‘swimmer's shoulder’

The main symptom of 'swimmer's shoulder'  is pain, especially when the arms affected are in overhead positions. The patient also often has a restricted range of motion and, specifically, an inability to lift their hands over their head. A physical examination of the injured shoulder may find areas exhibiting pain when pressed or pressured or weakness in the shoulder. In some cases, the individual may even experience a crunching or grinding sensation with movement.¹¹

Scapular dyskinesis can also often be seen by looking at the patient. Medical professionals will be able to see protrusion of the shoulder blades if the condition is bad enough to be visible.¹²

A physical assessment to determine the presence of a 'swimmer's shoulder' can include feeling the joint to determine areas of sensitivity, weakness, distended anatomy or deformities. Asking the patient to perform movements such as raising their arms up or reaching forward can determine limited or painful areas of motion. Strength tests can also determine areas of weakness.

If more advanced diagnostic tests are required, imaging such as X-rays, MRI scans or ultrasounds can be used to assess the integrity and functionality of bones, tendons, muscles, and nerves and evaluate the extent of any damage.¹

Treatment options for ‘swimmer's shoulder’

Treatment of 'swimmer's shoulder' primarily tries to avoid the need for surgical intervention and uses conservative treatment to alleviate and manage pain and symptoms.

Upon diagnosis, the first method of treatment involves rest, i.e. stopping using and putting strain on the affected arm, because the injury is commonly caused by repetitive or strenuous movement. The severity of the injury will dictate the required rest period. This can be difficult and frustrating for competitive swimmers, especially mid-season. Ice or cold treatments can help to reduce inflammation and swelling, which may contribute to pain and limit motion. Anti-inflammatory medicines can also be prescribed to help reduce inflammation.^1,8,10

Physiotherapy is the next step to help alleviate pain from the 'swimmer's shoulder' and promote tissue healing. The physiotherapist can use various tools to reduce inflammation and tendonitis and break up scar tissue, such as electrical therapy and ultrasound. Physiotherapists may also prescribe exercises to strengthen shoulder muscles to help restore muscle balance and joint stability, as well as exercises to increase available mobility to help restore the range of motion of the shoulder. Keeping some degree of movement is important, with a careful assessment of the level required to ensure the patient utilises and maintains the range of motion they still have without further straining the injured shoulder.^1,8

In more extreme cases, in which the pain and injury to the shoulder are severe, steroid and corticosteroid injections may be used to help reduce inflammation and alleviate some of the pain. 

In the very worst cases, surgical intervention may be necessary to release restricted motion due to inflamed structures catching on other structures within the shoulder during arm movement by widening the space that the tendons have available to pass through. However, surgical intervention is only utilised in advanced cases that cannot be managed more conservatively by other means.^1,13

Rehabilitation and recovery from ‘swimmer's shoulder’

During rehabilitation for the swimmer’s shoulder, the patient should return to training gradually, building strength and distance steadily over time. A sudden increase in training intensity and distance is one of the risk factors for developing ‘swimmer’s shoulder’, so if training is started too quickly, it can cause a relapse and even worsen the condition.¹³

The patient should also be made aware of the condition and understand the things required for long-term management. Keeping their swimming technique safe, maintaining the use of exercises to keep the range of motion, and introducing short rest periods any time pain or symptoms are felt are advisable in order to manage the condition and prevent it from worsening. Working with the coaching team to maintain good technique and manageable training loads can be an effective management strategy.

Prescribed exercises should also be continued to maintain range of motion and strength in order to prevent reoccurrence of the condition. Following the medical advice given at consultation precisely is important to ensure recovery goes as planned.

Prevention strategies for ‘swimmer's shoulder’

Prevention strategies are the most effective way to avoid the necessity for lengthy rest and rehabilitation periods due to developing a ‘swimmer's shoulder’. 

Most importantly, ensuring proper technique during swimming, particularly when doing butterfly strokes in which there is an overhead reach in the stroke, can help prevent the shoulder from being placed under strain in dangerous positions.⁸

Additionally, front crawl training should include breathing on both sides – to protect against uneven development of shoulder muscles and maintain muscular balance.⁹ Consistent strength training targeted on the shoulder can help to reduce damage from strains and injuries, while strength training of the whole body, especially the core, can help to improve body position and stability without inappropriately relying on the shoulders. Warming up and cooling down before and after strenuous activity can also prevent and minimise injuries to muscles and tendons potentially acquired during exercise.¹⁴

Finally, a detailed training plan can help to prevent or manage symptoms. This can be achieved by incorporating other forms of exercise, such as running and cycling to minimise demands on the shoulders, monitoring training volume to prevent overexertion, which may lead to repetitive strain injuries, and scheduling rest days to ensure the body is not overused. Crucially, if pain and restricted mobility are felt, it is advisable to stop training and seek medical advice whilst managing symptoms.

Complications and recurrence of ‘swimmer's shoulder’

It is very important that the patient seeks help for a 'swimmer's shoulder' early in the condition for the best outcome and prognosis. As soon as pain, restricted movement, weakness or any other symptoms are experienced, seeking immediate help and advice from a medical professional is essential. Failure to treat 'swimmer's shoulder' early enough could result in the exacerbation of the condition to the point of permanent damage being done to the structures in the shoulder.¹⁵ This could cause the symptoms to become more permanent and could result in chronic pain in the region.¹⁶

Additionally, the overcompensation in the swimming strokes has been discussed above, whereby an individual changes the path of their stroke to avoid painful positions. Such overcompensation can result in the strain being moved away from the shoulder to other regions such as the neck, back, or elsewhere, potentially resulting in other problematic injuries.

Summary

'Swimmer's shoulder' is an umbrella term for several conditions but usually refers to shoulder impingement syndrome, in which the tendons in the shoulder catch on other structures and become swollen, thickened, inflamed and painful, thereby limiting motion. The term may also refer to scapular dyskinesis, where the shoulder blade sits slightly in the wrong position or damage to the four muscles of the rotator cuff.

'Swimmer's shoulder' is often a result of repetitive strain or damage to the shoulder. It is characterised by pain, restricted mobility, and difficulty lifting the arm above the head. 

If these symptoms are experienced, they need to be managed with rest, anti-inflammatories, ice for the swelling, and then a physiotherapist providing rehabilitation and strengthening exercises. Early intervention can limit the length of rest periods, improve prognosis, minimise symptoms and shorten the time for rehabilitation.

If you suspect you or someone you know might be suffering from a 'swimmer's shoulder' or any other joint pain, it is important to make an appointment with a health professional for a comprehensive examination. They can then offer appropriate advice or further actions to help alleviate symptoms, reduce the problem, minimise or eliminate pain, and assist in healing and recovery.