Competitive swimmers, recreational, and swimming enthusiasts who experience pinching and sharp shoulder pain while swimming may suffer from shoulder impingement. Can understanding symptoms can help healthcare providers develop an effective treatment program?

Swimmer’s Shoulder

Swimmer’s shoulder, medically known as rotator cuff impingement syndrome, is a common injury among swimmers. It can limit swimming ability and normal arm use for functional tasks. It is caused by persistent and abnormal rubbing and pinching of the structures in the shoulder, causing pain and irritation of the shoulder’s rotator cuff tendons and the bursa. The injury affects 40% to 90% of swimmers at some point. (Wanivenhaus F. et al., 2012) Self-care treatment involves rest, anti-inflammatory medication, and exercise to restore normal shoulder mobility. Most cases resolve within a few months, but physical therapy may be needed along with continued exercises and stretches to maintain pain relief.

Anatomy

The shoulder is a complex joint with extreme mobility. It is comprised of three bones:

• The scapula or shoulder blade.
• The clavicle or collar bone.
• The humerus or upper arm bone.

These three bones combine at various places to make up the joint. Several muscles attach to and move the joint. (Kadi R. et al., 2017) The rotator cuff is one group of four muscles deep in the shoulder surrounding the joint. When lifting the arm, these muscles contract to hold the ball in the joint’s socket, allowing the arm to be raised in a fluid and smooth motion. Several ligaments hold the shoulder joint together and connect the various bones of the shoulder, giving the joint stability when moving. (Kadi R. et al., 2017)

Symptoms

Common symptoms include: (Wanivenhaus F. et al., 2012)

• Swelling in the front or top of the shoulder
• Difficulty reaching up overhead
• Shoulder pain
• Shoulder pain when bearing weight through the arm.
• Symptoms tend to be worse during or immediately after swimming.

This is due to the position of the arms and upper extremities while swimming. (Wanivenhaus F. et al., 2012) Reaching overhead and turning the hand inward can cause the rotator cuff tendons or shoulder bursa to become pinched underneath the acromion process of the shoulder blade, similar to the motion that occurs during the crawl or freestyle stroke. When pinching/impingement occurs, the tendons or bursa can become inflamed, leading to pain and difficulty with normal arm use. (Struyf F. et al., 2017) The condition may also occur due to the laxity of the shoulder ligaments. (Wanivenhaus F. et al., 2012) It is theorized that the ligaments in swimmers become stretched and lax, leading to shoulder joint instability. This can cause the shoulder joint to become loose and compress the shoulder structures.

Diagnosis

A clinical examination can diagnose cases of swimmer’s shoulder. (Wanivenhaus F. et al., 2012) The exam can include:

• Palpation
• Strength test
• Specialized tests

One shoulder test that is often used is called Neer’s test. A physician elevates the arm overhead to the maximum degree during this examination. If this results in pain, the rotator cuff tendons may be compressed, and the test is positive. Individuals may begin treatment after the examination, but a doctor may also refer them for diagnostic testing. An X-ray may be taken to examine the bone structures, and an MRI may be used to examine the soft tissue structures, such as the rotator cuff tendons and the bursa.

Treatment

Appropriate treatment of swimmer’s shoulder involves managing pain and inflammation in your shoulder and improving the way your shoulder moves so you avoid pinching structures inside the joint. (Wanivenhaus F. et al., 2012) There are various treatments available and can include:

• Rest
• Physical therapy
• Acupuncture
• Non-surgical decompression
• Targeted exercises and stretches
• Medications
• Injections
• Surgery for serious cases

Physical Therapy

A physical therapist can treat shoulder impingement. They can assess the condition and prescribe treatments and exercises to improve mobility and strength. (Cleveland Clinic, 2023) They may use various treatment modalities to decrease pain and improve circulation to facilitate and expedite healing. Physical therapy treatments can include:

• Ice
• Heat
• Trigger point release
• Joint mobilizations
• Stabilization
• Stretching
• Exercise
• Electrical stimulation
• Ultrasound
• Taping

Medication

Medication may include over-the-counter anti-inflammatory medicine to help decrease pain and inflammation. A physician may prescribe stronger medication to manage inflammation if the condition is severe. While taking medication, the shoulder will need rest, so avoiding swimming or other shoulder movements for a week or two may be necessary.

Injections

Cortisone is a powerful anti-inflammatory medicine. Individuals may benefit from cortisone injections into their shoulders. (Wanivenhaus F. et al., 2012) When injected, cortisone decreases pain, reduces swelling in the rotator cuff and bursa, and improves shoulder mobility.

Surgery

If symptoms are persistent and fail to be alleviated with conservative treatments, surgery may be recommended. An arthroscopic procedure called subacromial decompression may be performed. (Cleveland Clinic, 2023) This type of surgery is done with small incisions, inserting a camera, and tiny tools. During this procedure, inflamed tissue and bone spurs are removed from the underside of the acromion process of the shoulder blade, allowing more space to the shoulder joint. Post-surgery, individuals can gradually return to swimming and all other activities in about eight weeks.

Recovery

Most episodes last about eight to ten weeks, and severe cases last up to three months. (Struyf F. et al., 2017) Often, the symptoms slowly resolve with rest and gentle stretching. As symptoms improve, individuals can slowly return to normal activity and swimming. However, performing prescribed exercises two to three times a week may be necessary to maintain shoulder strength and mobility and help prevent future episodes of shoulder impingement. Individuals experiencing any of these symptoms should visit their physician for an accurate diagnosis of their condition to begin proper treatment. Discuss goals with a healthcare professional and physical therapist.

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Sports Injuries Rehabilitation

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References

Wanivenhaus, F., Fox, A. J., Chaudhury, S., & Rodeo, S. A. (2012). Epidemiology of injuries and prevention strategies in competitive swimmers. Sports health, 4(3), 246–251. doi.org/10.1177/1941738112442132

Kadi, R., Milants, A., & Shahabpour, M. (2017). Shoulder Anatomy and Normal Variants. Journal of the Belgian Society of Radiology, 101(Suppl 2), 3. doi.org/10.5334/jbr-btr.1467

Struyf, F., Tate, A., Kuppens, K., Feijen, S., & Michener, L. A. (2017). Musculoskeletal dysfunctions associated with swimmers’ shoulder. British journal of sports medicine, 51(10), 775–780. doi.org/10.1136/bjsports-2016-096847

Cleveland Clinic. (2023). Swimmer’s shoulder. my.clevelandclinic.org/health/diseases/17535-swimmers-shoulder