Swimming is generally regarded as one of the safest and best exercises we can pursue through our entire lives.It results in tremendous aerobic benefit, whole body balance, flexibility, and strength. However, nearly every swimmer or triathlete has had a painful shoulder while swimming or “swimmer’s shoulder.” In fact, studies show that between 40 and 91 percent of swimmers at all levels suffer from shoulder pain at any given time! Does this mean the shoulder is really injured, or is it just overused and inflamed and will resolve on its own?Determining the difference between pain and true injury can be difficult. “Swimmer's shoulder” is the most common orthopedic ailment in swimmers—but hopefully, after reading this article, you will gain a better understanding of the problem and how to manage it.
The main shoulder (glenohumeral) joint is similar to a golf ball on a tee. It is a shallow joint with very little bony stability. This lack of bony contact allows for tremendous range of motion but makes the shoulder inherently unstable. Luckily, all shoulder support does not come solely from the bones. There is additional stability provided by the joint capsule and ligaments that wrap around the shoulder like rubber bands, holding the ball on the tee. Further stability is provided for by the labrum cartilage which acts as a “bumper” blocking the golf ball from falling off the tee. In addition to these static stabilizers, there are strong dynamic shoulder stabilizers: the four rotator cuff muscles. Any of these tissues may be become overworked and angry with swimmer’s shoulder.
The most common source of swimmer’s shoulder occurs from irritation of the stabilizing tissues around the shoulder joint. The shoulder capsule or the rotator cuff muscles may suffer microinjury, which results in inflammation and diffuse pain. Impingement is a term when these irritated tissues around the shoulder can “pinch” in between bones of the joint—usually causing more pain in the anterior shoulder with the catch phase or posterior shoulder on the recovery phase of swimming.
Irritation of the glenohumeral (GH) or acromioclavicular (AC) joints, where the collar bone meets the front of the shoulder, is also a common cause of a painful shoulder with swimming. These types of joint pains may occur because of damage to the cartilage lining the joint or from underlying arthritis. If the GH joint is involved, it often results in deep pain and sometimes, painful clicking. When the AC joint is inflamed, it usually results in localized swelling and tenderness over the easily-visible joint at the top of the shoulder. When these problems occur, the recovery is usually slower and may become chronic and may require medical treatment.
Some other, less common causes of a painful shoulder may involve the nerves of the arm. Sometimes these nerves can become irritated from a disc problem or arthritis in the cervical spine or from compression of the nerves in the shoulder, causing radiating pain or even weakness and numbness down the arm. These problems can become quite severe and if they exist you should be evaluated by a physician.
The pain from swimmer’s shoulder can be vague or more specific in the front or the back of the shoulder. It can be localized or radiate, and it can be exacerbated with the underwater pull or the recovery phase of the stroke. Sometimes the pain is minimal and the biggest problem is just a loss of speed, power, or pace! The cause of swimmer’s shoulder is usually not from one thing alone but from multiple factors, involving stroke mechanics, overuse, and generalized laxity of the joint.
No matter what the source of pain is, a less efficient stroke increases the risk. Athletes with shorter strokes and higher stroke count are more likely to develop swimmer’s shoulder. Inadequate body roll in the water, dropping the elbow on recovery phase, or a wider hand entry into the water increases the risk for swimmer’s shoulder or may indicate compensation for the already existing condition.
When managing swimmer’s shoulder, start with a warm up that is long and slow and train around the discomfort by avoiding painful strokes and positions (especially freestyle and butterfly). Adjust training with relative rest by using the kickboard or fins and avoid pull sets, paddles and drag suits. A thorough evaluation of stroke mechanics is paramount here! If the training cannot be adjusted and the pain cannot be controlled, a period of 3 days of absolute rest, ice, and up to a week of anti-inflammatory medications is the next step. Pain that recurs upon resumption of training should be evaluated by a medical professional.
When I evaluate triathletes with shoulder pain in my office, I begin with a thorough history and a physical exam. If I need more data to make a diagnosis, I will perform imaging which may include an X-ray, ultrasound, or MRI. These tests can assist in pinpointing what is causing the pain and can help guide treatment. Keep in mind, however, that imaging studies don’t always correlate with the pain. I evaluate the images in the context of the complaint. If the stroke mechanics and relative rest periods have been ineffective, treatment with a swimming-knowledgeable physical therapist can be helpful. If the athlete isn’t progressing with the PT, an injection of corticosteroid could be considered to reduce inflammation and assist in pain control and the rehabilitation process, but a discussion of the pros and cons of this treatment should occur first.
The shoulder is one of the most complex joints in the body and is the most commonly injured joint in swimming. A proper evaluation and diagnosis can really help with guiding treatment. Seeking a proper assessment from an experienced medical professional is important—especially if your shoulder does not improve with a period of relative rest from swimming and other overhead activity. Most of the time, swimmer’s shoulder can be managed conservatively through rehabilitation and proper stroke mechanics. Rest assured, almost everybody with swimmer’s shoulder eventually heals well and is able to return to the great lifelong endeavor of swimming!
Todd S. Shatynski, MD, CAQSM is a sports medicine physician at Capital Region Orthopaedics (https://www.theboneandjointcenter.com/experts/todd-shatynski-md) and faculty with the sports medicine fellowship at Albany Medical Center in Albany, NY. He is a team physician with University at Albany and with Triathlon Australia and also is an elite-level triathlete himself, having qualified and completed Ironman World Championships in Kona, Hawaii.