1. Objectives
• Briefly discuss the phases of the freestyle swimming
stroke.
• Discuss the prevalence and incidence of shoulder
pathology in swimmers
• Identify ROM adaptation and flexibility patterns among
injured and uninjured swimmer’s shoulders
• Review GIRD, total arc of motion, and external rotation
deficiency
• Learn evidence based evaluation and management
strategies based on the current body of literature
7. Prevalence of Shoulder Pain
(Competitive swimmers)
40-91%
3:1 female : male
Bak et al, 1997; Ciullo, 1986; McMaster 1999;
rupp et al. 1995; Sein, et al. 2010; Harrington, et
al. 2014
11. Am J Sports Med. 1991 Nov-Dec;19(6):569-76.
The normal shoulder during freestyle swimming. An
electromyographic and cinematographic analysis of twelve
muscles.
Pink M1, Perry J, Browne A, Scovazzo ML, Kerrigan J.
12.
13. Glide
• Begins as hand enters
water
• Elbow slightly higher
than hand
Normal Painful
• Arm placed further
from midline
• Humerus lower and
‘dropped elbow’
• Late / decreased
recruitment of upper
trapezius
14. Early Pull Through
• Occurs from end
of glide to when
hand reaches
max extension
and begins
downward
motion
Normal Painful
• Decreased
serratus anterior
activity
• Increased
rhomboids
activity net
loss of scapular
upward rotation
and protraction
15. Late Pull Through
• Occurs from
90◦ of flexion
to when the
hand exits the
water
• Early hand exit (to
avoid extremes of
internal rotation?).
• Increased activity in
rhomboids to
retract and elevate
the scapula
Normal Painful
16. Recovery
• Occurs from
when the hand
exits the water
to just before
hand entry
• No water
resistance
Normal Painful
• Decreased
anterior
deltoid
activity
• More lateral
hand entry
17. • Scapular dyskinesias increase in frequency
throughout a training session
• Swimmers are subject to early fatigue due to
high training volume
• Serratus anterior muscle fatigues earlier in
painful swimmers
18. Breathing Patterns
• Unilateral breathing associated with
small tilt angle on breathing side
**High incidence of shoulder impingement
on ipsilateral side
• Case for adopting B/L breathing
23. Swimmers’ painful shoulder
arthroscopic findings and return rate
to sports
C. Brushøj1 , K. Bak2 , H. V. Johannsen3 , P. Faunø4
• Labral pathology (61%)
• Subacromial impingement (28%)
• Bursal sided tear of supraspinatus tendon
• Impingement of posterior rotator cuff
• Inflammation of Biceps - LH
25. Outcomes
• 59% able to compete at pre-injury level after
2-9 months.
– 7 without shoulder pain (44%)
– 2 with some pain
– 7 never returned (44%)
Brushej, et al. 2007
27. GIRD ‘Glenohumeral Internal Rotation
Deficiency’
• Hypermobile ER,
hypomobile IR
• Most overhead athletes
(including swimmers)
demonstrate this motion
disparity
28. ‘The Disabled Throwing Shoulder’
series… old news?
• Burkhart, et al 2003
– GIRD: loss of IR shoulder motion on dom.
extremity
– Caused by posteroinferior capsular contracture
– Increased external rotation is an acquired
secondary cause
– GIRD is at the core of many throwing injuries
29. …but now we know there is more to
the story…
• Kevin Wilk, George Davies, Mike Reinold,
Kibler… change of heart?
• Lots of new data
• ‘TROM’ = TOTAL RANGE OF MOTION
30. GIRD: normal vs pathologic
• Manske, et al. 2013 (and Kevin Wilk, George Davies, Mike
Reinold…)
– ‘Loss of GH IR is a normal phenomenon that should be
expected’.
– ANATOMIC: IR loss of <18-20 degrees with symmetrical
TROM B
– PATHOLOGIC: IR loss >18-20 with corresponding TROM
loss >5 when compared bilaterally
31. Says Who?
• Pitchers whose TROM comparison was >5 were
2.5x more likely to sustain shoulder injury
• TROM should be symmetric, and not >186
• If we stretch to increase IR PROM, we may be
increasing TROM and thus INCREASING risk of
injury
– Increased demands on dynamic and static stabilizers
of GH joint
Wilk, et al. 2012
32. ERD: the new GIRD
• External rotation deficiency
– Pitchers with <5 degrees extra ER on dominant
side 2.3x increased risk of shoulder injury
33. Summary
• GOOD / OKAY:
– Symmetrical TROM
– Dominant arm has at least 5 degrees MORE ER than
non-dominant (THROWERS ONLY)
– IR loss within 18-20 degrees when compared B
• BAD:
– IR loss >18-20 with corresponding TROM loss >5 when
compared bilaterally
…….what about swimmers?
34. • Significant predictors: ER ROM and previous
history of shoulder injury
• Low (<93°) and high ER (>100°) were assoc.
with increased risk of injury
35. • Hypermobile in shoulder ABD, ER, and flexion
• Hypomobile in shoulder internal rotation
• Little correlation between hypermobility or
hypomobility and shoulder pain
36. GIRD vs PST (posterior shoulder
tightness)
• Borsa, et al. No association between joint
laxity and ROM (in healthy subjects)
– Laxity measured by Telos device
– Posterior joint laxity was more commonly
associated with IR deficit
**IR loss due to osseous
adaptations and posterior
soft tissue tightness
Wilk, 2009
37. • Resolution of symptoms after physical therapy
treatment for internal impingement was
related to posterior shoulder tightness but
NOT correction of GIRD
42. Keep in Mind Arm Dominance!
• NORMAL for arm dominance to be associated
with:
– Forward shoulder posture
– Loss if IR ROM
– Posterior shoulder tightness
*Dominant arm involved: effects accentuated
*Non-dominant arm involved: effects absent
44. • Symptomatic, >12 yrs of age:
– Pectoralis minor tightness
– Decreased core endurance
• Symptomatic, <12 yrs of age:
– Reduced shoulder flexibility
– Weakness of middle trap & shouder int. rotators
– Tightness of latissimus dorsi
45. • Measured:
– PROM IR and ER @90
– Strength: scapular depression, adduction, IR, ER
– Core endurance (side bridge, prone- bridge)
– Pectoralis minor muscle length
A cross-sectional study examining shoulder
pain and disability in Division I female
swimmers.
Harrington S1, Meisel C, Tate A.
46. Results
• Pectoralis minor muscle length was the only
variable which had a statistically significant
difference between groups (painful and non
painful shoulder).
47. Takeaways?
• GIRD: may not be pathologic
• ERD and TROM more important than GIRD
– Ideal between 93 – 100?
• Look at posterior shoulder tightness
– May be source of pathologic IR loss
• Measure pectoralis minor
• Strengthen scapular stabilizers! (serratus
anterior!)
55. • A Single application of
MET for GHJ horizontal
abductors provides
immediate improvements
in both GHJ horizontal
adduction and IR ROM
• Dosage:
• 5 sec contraction @
25% effort, 30 sec
stretch, x3
