Swimmer’s shoulder is an umbrella term that includes many different shoulder pathologies. These pathologies are commonly experienced by swimmers due to the repetitive shoulder movements required in the sport.
Repetitive use of the shoulder, particularly without adequate rest between training sessions, can stress the muscles and ligaments in the shoulder. As a result, about 62% of all swimmers have generalized shoulder laxity (1). This can lead to overload and fatigue, which makes the shoulder susceptible to injury.
However, swimmer’s shoulder can be treated. In this article, we’ll discuss the causes, symptoms, and treatment options for swimmer’s shoulder.
An Overview Of Swimmer’s Shoulder
On average, a swimmer swims 60,000 meters per week. A large proportion of the forward propulsion in swimming is generated by the upper body. 90% of the driving force in the upper body comes from the torque generated by the shoulder.
As a result, the shoulder is put under tremendous load during various swimming strokes to generate this propulsive force. Similar forces act on the shoulder when a person lifts heavy weights overhead or works in a profession or sport with the same shoulder movement.
These forces can lead to swimmer’s shoulder, whether caused by impingement of a nerve, a tear in the rotator cuff muscles, an injury to the labrum, ligament laxity, or even muscle imbalance.
Causes Of Swimmer’s Shoulder
The shoulder is a complex joint with very precise biomechanical dynamics. The versatility of the joint comes at the expense of its vulnerability. The rotator cuff muscles provide just enough support to keep the humerus within the shoulder joint, but with the freedom to allow a wide range of movement.
As the dynamics are so precise, any slight deviation can cause pain. Some reasons why a person may develop swimmer’s shoulder are listed below:
- Muscle Imbalance: If a person performs repetitive motions like elevating the arm overhead, shoulder abduction or adduction, and rotation of the shoulder, it is likely that some muscles will increase in size in response.
As a result, the muscles can grow far larger and too quickly without allowing the shoulder time to adjust. The overgrown muscles can pull or strain the other small muscles, leading to a muscle imbalance. This can cause micro-injuries in the muscles.
- Poor Technique: Athletes lacking good sporting technique and form may be more likely to injure their rotator cuff muscles or shoulder ligaments.
For example, swimmers use the latissimus dorsi and the pectoralis major muscles for their swim stroke through adduction and internal rotation. The subscapularis and serratus anterior muscles are involved in the freestyle stroke.
If the swimmer has a dropped elbow technique (an elbow that is bent on the pull stroke), a sudden increase in training yardage, or bad follow-through in any of the strokes, it could lead to pain and inflammation in the shoulder.
- Inadequate Rest: Ignoring the signs and symptoms of an injury will only worsen the injury. Inadequate rest can aggravate the injury and prolong the recovery timeline.
- Ligament Laxity: Swimmers perform about 30,000 strokes per arm during their swimming career. This quantity of repetitive motions can stress the ligaments of the shoulder and contribute to joint laxity, leading to swimmer’s shoulder.
Signs And Symptoms Of Swimmer’s Shoulder
Swimmer’s shoulder can present with various signs and symptoms. They are listed below:
- Pain during motion of the shoulder
- An inability to lift heavy objects
- An inability to extend the arms overhead
- Reduced range of motion of the joint
- Shoulder weakness
- Swelling in the shoulder
- Tenderness in the shoulder
- Pain in the upper arm
- Shoulder instability
- Shoulder fatigue
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Muscle Spasm In Shoulder
A muscle spasm, also known as a muscle cramp, is a sudden and involuntary contraction or tightening of a muscle or group of muscles. This can occur in any part of the body but is most commonly experienced in the legs, arms, and back. These spasms can last for a few seconds up to many minutes. Occasional muscle spasms may not be something to worry about, but chronic muscle spasms can be a serious issue. In the shoulder, there are many muscles that can go into spasm. These spasms or cramps can cause pain, stiffness, and limited mobility.
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Pain in Front of Shoulder Joint
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Shoulder And Neck Pain On Right Side
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Shoulder Pain Radiating Down Arm to Fingers
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Shoulder Pain When Reaching Across Body
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Shoulder Pain When Sleeping
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Noises in the joints, such as popping, cracking, or clicking, can be quite disturbing and cause concern. That popping feeling is called crepitus. That’s something to be ignored, right? It certainly seems harmless enough—after all, there’s no pain, just that annoying popping when you move your shoulder this way or that. But just because there’s no pain doesn’t mean there’s no problem. There’s actually good news and bad news here. The good news? All that shoulder popping really could be no big deal. The bad news? That popping could be slowly chewing up your shoulder joint, and it may be a warning sign that arthritis is on its way.
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Are Swimmers The Only Ones Who Can Get Swimmer’s Shoulder?
No. Apart from swimmers, athletes and people in the general population who repeatedly perform overhead shoulder movements can also develop swimmer’s shoulder. These include sportspeople such as bowlers, baseball players, tennis players, volleyball players, and badminton players.
It also includes people in certain occupations such as carpenters, construction workers, electricians, and painters. The repetitive overhead motions can injure the rotator cuff muscles and lead to symptoms of swimmer’s shoulder.
Who Is At Risk Of Swimmer’s Shoulder?
Swimmer’s shoulder is seen in about 35% of all elite and senior-level swimmers (2).
Athletes and professionals who perform repetitive overhead motions are at a higher risk of swimmer’s shoulder, irrespective of gender or age.
How Diagnosis Works For Swimmer’s Shoulder
To diagnose a swimmer’s shoulder, your doctor will do the following:
- History: Your doctor will specifically ask about the history of your symptoms, the mechanism of injury, your occupation, any aggravating or relieving factors, and how long you have had the pain.
- Physical Examination: The physical exam is important to diagnose the cause of swimmer’s shoulder. The doctor will examine your shoulders for atrophy and asymmetry.
They will also test the range of motion of the shoulder, strength, and the scapular position at rest and during motion to assess for abnormal movements. These tests are positive when there is pain or dysfunction in the shoulder during the physical exam.
- Special Testing: Special tests, such as the apprehension/relocation test and Hawkins Kennedy test, are used by doctors to check for shoulder instability.
The apprehension test is performed with the person lying down or sitting. The shoulder is in a neutral position at 90° of abduction. The doctor applies slight anterior pressure to the humerus. If there is pain or apprehension with the feeling of sudden dislocation, then the test is positive and it means there is anterior glenohumeral instability.
The Hawkins Kennedy test may be used to help diagnose subacromial impingement. It is done with the individual standing or sitting. The arm is flexed at 90° and the elbow also flexed to 90°. The doctor applies a force with passive internal rotation to the shoulder joint.
If there is severe pain with this motion, then the test is positive and it signifies a compression of the tubercle or impingement of the supraspinatus tendon of the rotator cuff. These special tests can help identify which structure is causing the swimmer’s shoulder.
Imaging For Swimmer’s Shoulder
Your doctor may advise you to undergo imaging tests if they are considering bone or soft tissue injuries as the cause of the swimmer’s shoulder. The imaging tests are as follows:
- X-Ray: X-ray imaging is usually ordered to check for any fractures of the scapula, humerus, or the clavicle which are all integral to the shoulder joint.
- MRI: An MRI can better visualize pathology in the muscles, tendons, ligaments, and cartilage. It can also identify structural causes of the swimmer’s shoulder like a labral cyst. MRI is the imaging modality of choice for swimmer’s shoulder as it can detect if there are multiple causes of the pain.
- MR Arthrogram: An MR arthrogram is an MRI that is done after a joint is injected with gadolinium. MR arthrograms are used when a doctor suspects a labral or tendon tear of the rotator cuff muscles as the cause of the swimmer’s shoulder.
Factors That Can Affect The Assessment Of Swimmer’s Shoulder
The assessment may vary based on severity of symptoms, response to conservative treatment, findings on imaging, persistence of pain, and occupation of the patient.
The symptom severity of the swimmer’s shoulder can prompt doctors to perform extensive imaging of the affected shoulder. However, based on what is causing the swimmer’s shoulder, the doctor may perform advanced imaging.
If the pain and other symptoms persist for months with little relief using conservative measures, surgical exploration via arthroscopy may be advised. This may also be considered if there is no cause found on imaging (which is often the case with microtears).
Treatment Options For Swimmer’s Shoulder
There are many treatment options for swimmers’ shoulders. These include home remedies, medical therapies, and surgical therapies.
Home Remedies For Swimmer’s Shoulder
The first step to treating swimmer’s shoulder is rest. By resting and avoiding aggravating movements, it can help settle the inflammation and allow the shoulder to heal and recover.
Additionally, ice packs can help reduce swelling and inflammation within the joint. Ice packs can be used at 10 minute intervals several times of day for mild to moderate pain relief.
There are various non-surgical treatments for swimmer’s shoulder which are often recommended before surgery is considered. Some of the common conservative treatments for swimmer’s shoulder include:
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Pain medications and NSAIDs are usually used as a first-line treatment along with home remedies like rest and ice. NSAIDS, such as ibuprofen and celecoxib, may be prescribed to reduce inflammation and alleviate pain. They can be taken every eight hours for moderate pain relief.
However, it’s important to note prolonged use can cause gastrointestinal ulcers and harm the kidney, so they are not recommended for long-term pain relief.
Corticosteroid injections are usually only used when other pain medications and conservative treatments have been unsuccessful. They are given directly into the shoulder joint and can help reduce inflammation.
Corticosteroid injections may be prescribed for patients with pain due to inflammation of the bursa, rotator cuff tears, or inflammation of the shoulder joint capsule. These injections can reduce the swelling and inflammation that may be causing the swimmer’s shoulder.
Although not well studied, passive therapies, such as interferential current therapy, trigger point work, cross-friction tendon massage, and chiropractic adjustments, may have some effect on the symptoms of swimmer’s shoulder.
They do not directly treat the injury or the cause of the swimmer’s shoulder, but may provide passive relief from pain, swelling, or inflammation. They are explained in detail below:
- Interferential Current Therapy (IFC): Interferential current is an electrotherapeutic modality used to treat pain. This is an electrical muscle stimulation treatment that uses electrical current to reduce edema and pain in the muscles of the shoulder.
- Trigger Point Massage: Also known as a manual pressure release, trigger point massage is a massage technique where the thumb or tip of the finger is used to apply pressure to a trigger point. This lengthens the muscle and helps relieve muscle tightness.
- Cross-Friction Tendon Massage: Alternatively, cross-friction tendon massage is a massage technique where the muscle that is inflamed is stimulated. This will activate the inflammatory response and trigger the immune response to repair the injured tissue.
- Chiropractic Adjustments: Chiropractic adjustments can be made in the case of nerve entrapment, and is applied to muscles of the neck and shoulder. However, this must be done by a well-experienced chiropractor.
At our Centeno-Schultz Center, the CSC platelet-rich plasma (PRP) treatment is one of the regenerative therapies used to treat swimmer’s shoulder. Precise ultrasound-guided PRP injections can be used to treat partially torn ligaments and tendons.
The platelet-rich plasma is obtained from the same person and is processed with additional nutrients to promote healing. It is then injected into the shoulder joint with growth factors to help the torn or damaged tissues recover. PRP is a good alternative for those people who are not keen on surgery or who are not suitable candidates for surgery.
Surgery is usually only recommended if the damage to the shoulder is extensive or there is a severe tear. Arthroscopy is the most common surgical treatment option for swimmers’ shoulders.
Arthroscopy is a minimally-invasive surgery that can be used to treat a swimmer’s shoulder due to impingement syndrome. In this surgery, the surgeon uses a small camera or scope to visualize the joint.
The surgeon can make incisions around the shoulder joint to create more space around the joint and relieve any impingement. This is also known as a subacromial decompression.
Rotator cuff tears can also be repaired via arthroscopy. During arthroscopic exploration of the shoulder, the surgeon can remove long-standing hypertrophied, inflamed, or scarred tissue. If this does not work, then debridement or removal of the labral tissues and repair is done via open surgery.
Physical Therapy As A Complementary Treatment For Swimmer’s Shoulder
Physical therapy is recommended as a complementary therapy for swimmer’s shoulder. At Centeno-Schultz Center, our physical therapy team can create a specific program to help modify the swimming stroke technique and the movement of the shoulder joint.
Using a prescribed set of exercises, our physical therapists also incorporate strategies to allow any tears to heal while strengthening the surrounding muscles and ligaments of the joint. These exercises can also activate the smaller muscles in the back and shoulder.
After surgery, physical therapy is often used in conjunction with anti-inflammatory medications to help recovery and restore function. It can take anywhere between 4-8 weeks of physical therapy for the shoulder joint to return back to normal.
How Can You Prevent Swimmer’s Shoulder?
You can prevent swimmer’s shoulder by taking the following steps:
- Practice Proper Body Mechanics: Whether you’re in the water or out, having proper body dynamics while using the shoulder is essential. You must move with good posture and the right technique to prevent unnecessary stress on the shoulder joint.
- Avoid Repeated Stress On The Shoulder: If your occupation requires you to perform overhead movements repetitively, then try and find a way to limit this movement.
This may include using a step ladder, machine, or finding another way of doing the task. Additionally, try to avoid loading your shoulder and injuring the rotator cuff tendons.
- Rest The Shoulder When Tired: Don’t force the shoulder to move when the joint is already hurting or fatigued. This will slow down the repair or may even worsen any injuries.
- Sleep On Your Back: If you sleep on your side, it can put more pressure on your shoulder. If the shoulder is inflamed, the pain can worsen when side sleeping. In contrast, sleeping on your back keeps the shoulders aligned.
For better protection, cross your arms over your chest when lying on your back so the shoulders are well supported.
- Strengthen The Rotator Cuff Muscles: Exercises to address muscle imbalance and poor posture can improve impingement symptoms. For example, internal and external rotator cuff strengthening exercises with bands can help prevent swimmer’s shoulder by strengthening the rotator cuff muscles.
Stretches For Swimmer’s Shoulder
Stretching exercises are good for swimmer’s shoulder as they improve the flexibility of the shoulder joint. The best stretches for the swimmer’s shoulder are as follows:
- Shoulder External Rotation Exercises: Shoulder external rotation exercises include seated or side-lying external rotation.These exercises can stretch the rotator cuff muscles by holding the weight against gravity.
To start, lie on your side with your hips and knees slightly bent, supporting your head with your hand. Grab a light weight in the opposite hand that is not supporting your head and place your elbow on your side with the weight touching your abdomen.
Lift the weight up slowly and stop when it is perpendicular to the floor. Return to the starting position.
- Lat Stretch: You can do a lat stretch with the help of a bar. Find an immovable bar and hold onto it with one hand. Bend your knees to 90° and squat. Place the opposite hand on your knee.
Keep grasping the bar while you retract the shoulder blade (as if you’re pulling the bar without moving your arm). For a stronger stretch, sink lower into the squat and put pressure on the hand resting on the knee to stretch the lats deeply.
- Pec Major Stretch: This stretch is also known as the standing wall stretch or doorway stretch. Place your arm against a wall with the elbow slightly higher than the shoulder. Step forward while simultaneously turning your body away from the arm.
- Thoracic Spine Mobility Stretch: Set a foam roller on the floor and lie down on it, keeping it perpendicular to the middle of your back. Bend your knees.
Keep your feet on the ground while crossing your arms over your chest. Sit up slightly to crunch your abs to extend your thoracic spine over the foam roller. This will stretch out the spinal muscles over the scapula and help ease the pain of swimmer’s shoulder.
Get Help For Your Shoulder Right Away
You don’t have to live with the symptoms of swimmer’s shoulder. There are various treatment options for this condition. Your doctor can prescribe the most suitable one based on the cause and severity of your symptoms. Talk to one of our board-certified doctors today.
John Schultz, MD
John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate and PRP for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI).
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- De Martino I, Rodeo SA. The Swimmer’s Shoulder: Multi-directional Instability. Curr Rev Musculoskelet Med. 2018;11(2):167-171. doi:10.1007/s12178-018-9485-0
- Matzkin E, Suslavich K, Wes D. Swimmer’s Shoulder: Painful Shoulder in the Competitive Swimmer. J Am Acad Orthop Surg. 2016;24(8):527-536. doi:10.5435/JAAOS-D-15-00313