Swimming is a rigorous sport that has been included in the modern Olympics since 1896. Because of its popularity, it is common for children to start competitive swimming at 5 or 6 years of age. In a typical 2-hour pool session, an elite-level competitive swimmer may swim between 6,000 and 7,000 yd, or about 3.5 to 4 miles. This amounts to swimming an average of 20+ miles per week, which is the aerobic equivalent of running 80+ miles. This high yardage means that competitive swimmers perform between 1,500 and 4,000 stroke cycles per day, or about 1,000,000 stroke cycles per year. Since female swimmers, on average, have shorter arm strokes, they may perform an additional 660,000 stroke cycles per year.

The current understanding is that swimming selectively strengthens the anterior chest musculature and internal rotators of the shoulder, and, when combined with repetitive microtrauma to the shoulder, fosters an imbalance in the dynamic stability of the joint. It is therefore prudent to adjust training programs accordingly, especially for beginning swimmers, to minimize the risk of future injury. The terms laxity and instability are commonly used when referring to joint pathology, and there is a significant difference between the two definitions. Laxity refers to the normal, painless freedom of movement around a joint, while instability refers to the pathologic tendency of a joint to subluxate or dislocate, resulting in pain or functional impairment. Asymptomatic, increased range of motion (ROM), or laxity, of the shoulder can be found in a large portion of swimmers, especially those at the highly competitive level. Significant controversy surrounds whether swimmers acquire shoulder laxity as a result of repetitive motion, or whether swimmers with inherent shoulder laxity are more efficientin the water, which leads them to stay in the sport longer and compete at a higher level.

Regardless of its origin, shoulder laxity is facilitated by the repetitive overuse and muscular imbalances associated with swimming. This laxity may lead to instability and secondary impingement, causing shoulder pain.

Stretching: Help or Hindrance?
Similar to athletes in other competitive sports, most swimmers conduct a stretching routine prior to exercise. Unfortunately, stretching may be more harmful than helpful. For example, some of the stretches serve to stretch the anterior capsule of the shoulder. If the capsule is overstretched, the risk of instability and subsequent injury permanently increases. Any stretching should be specific to the individual and designed by your physical therapist to correct specific muscular or capsular tightness. Because swimmers tend to have a relatively tight posterior capsule, which can promote impingement pain, swimmers without pain should focus on stretching the posterior capsule and anterior chest musculature. Swimmers with shoulder pain should be instructed to cease all anterior capsule stretching and instead focus on posterior capsule stretching. Swimmers with multidirectional instability or a history of subluxation should avoid all stretching.

A Role for Weight Training
Most swimmers incorporate either weight lifting or dry land exercises into their training routine. Before embarking on a high-volume training program, all young swimmers, especially those with a previous injury, should be screened for glenohumeral joint laxity and be instructed in a shoulder conditioning program. Care should be taken when performing exercises that require shoulder abduction and external rotation, such as lat pull-downs and the military press, which may cause apprehension and possible subluxation of the unstable shoulder.

1.    Bilateral breathing for at least 80% of your training sessions. There are many times (especially in the open water) when unilateral breathing is the better option, but for a healthy, balanced freestyle stroke, bilateral breathing is the way to go in training.
2.    Good, symmetrical body rotation. This can be worked on through a range of different body rotation drills, often employing fins for support.
3.    Hand entry into the water is finger tip first, not thumb first despite what you may have been taught when you learned to swim!
4.    Avoiding midline cross over at the front of the stroke.
5.    Developing and maintaining of good upper body posture.
6.    Targeting a high elbow (bent arm) catch and pull through.
7.    Make sure to vary workout distance and intensity.

Rehabilitation Steps
If you are experiencing shoulder pain these are the typical phases that you will need to go through. It is best to seek out treatment sooner rather than later to be able to move through these phases quicker and have less down time.

Acute phase tasks consist primarily of rest and activity modification, which includes avoiding overhead activities, especially in the impingement zone above 90° of abduction. For the acutely inflamed shoulder, it is recommended to maintain normal ROM and decreasing irritation of the shoulder.
Recovery phase goals are to achieve normal active and passive ROM, strength, muscular balance, and scapular control. High numbers of repetitions with light weights or low-resistance resistance bands are used initially to develop endurance and to avoid further damage to the rotator cuff. The priority of this phase is to restore the normal kinematics of the shoulder by normalizing ROM and returning the muscles to their proper strength ratios.
Functional phase. The purpose of this phase is to resume sport-specific activities. The athlete may resume activity by using a swim bench, followed by slow laps in the pool, and gradually integrate into the prior workout routine. The swimmer should not be allowed to return to full training unless he or she can consistently maintain proper shoulder mechanics despite a fatiguing workout.

When to Consider Surgery
As with most other sports-related injuries, surgery for shoulder pain is considered a last resort, and pain itself should not be the only indication for surgical stabilization. Some possible indications for surgery include paresthesias (eg, "dead arm" syndrome), recurrent instability, or difficulty with activities of daily living. Furthermore, a surgical evaluation should only be sought if 3 to 6 months of conservative treatment have failed. The decision to perform surgery is not without consequences. It is important for swimmers to understand that surgery will most likely result in decreased ROM and may reduce their level of performance.

If you or someone you know is a swimmer with shoulder pain, please contact our office for a consult.