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The Swimmer’s or Tennis Player’s Shoulder

Shoulders are a wonderful part of the human anatomy. They need a great Range of Movement (ROM) to perform every day activities. Just consider the many movements required to dry yourself with a towel!! Swimming and tennis are activities requiring great shoulder ROM. But it doesn't stop or start at the shoulder!

Think feet first, then legs, hip and back.

Tennis players need the ability to rise onto their toes to achieve height to maximise the drive through their torso and follow through when serving. Strong knee and hip flexors and extensors (hamstrings, quads, iliopsoas and glutes) are required for strong leg drive and reach for the tennis serve and drive in the kick component of the swim.

Swimmers should be able to point the toes in a straight line from the knee to the tip of the toes to maximise the kick component of swimming. Calf muscles need to be strong to avoid cramps and assist with that drive. We also need good rotation through the hips and spine, and particularly the thoracic spine or upper back.

Without these components, extra stress will be pushed into the shoulder complex.

The shoulder complex has two components:

1) The shoulder blade (scapula) and rib cage (thorax), broadly referred to as the scapulothoracic joint

2) The actual shoulder joint, where the upper arm (humerus) meets the scapula: the glenohumeral joint (GHJ). The head of the humerus sits in the glenoid fossa of the scapula and is likened to a golf ball sitting on a tee (the glenoid fossa!).

Like all joints, the whole shoulder complex is held together by the capsule, ligaments and tendons, and driven by muscles and nerves. It follows that any disruption along the line from the foot to the arm, or kinetic chain, can contribute to shoulder pain.

The Kinetic Chain

If there is a chink in the kinetic chain, the loss of power from that location results in overload elsewhere. A lack of thoracic rotation, may be transferred to the scapulothoracic joint or GHJ or even both joints. Or it may be the knees or hips that are affected! Issues affecting ROM in the kinetic chain include joint mobility, strength, muscle performance, proprioception, pain, and of course athletic ability.

Although related, flexibility and laxity of joints are different. Some people have naturally loose or lax joints, some experience a loss of movement due to stiff joints. Optimal degree of ROM is required in the joints involved in swimming or tennis. If the ROM in the GHJ is restricted, it may be passed onto the scapulothoracic joint or elsewhere along the kinetic chain. If a joint is lax it can lead to too much movement and increase the potential for injury.

When reviewing the swimmer's overall joint mobility, focus is on the ROM of the shoulder complex. The ability to lift the arm out and away from the body whilst reaching up and forward is critical. It is essential for high elbow through the swim stroke cycle. Thoracic rotation is also important for the pull through phase of swimming and the serve in tennis. Similarly, the ability to internally rotate the GHJ is important for swimmers to achieve early catch and maintain high elbow through the stroke and for the tennis player, to achieve maximum height and power when delivering a serve.

The ability to combine thoracic and shoulder extension to draw the shoulders back in swimming is invaluable to the high elbow position at the beginning of the stroke recovery and streamlining during the swim stroke. Similarly, it is necessary to achieve height to maximise power in the tennis serve.

Strength is required for optimal athletic performance. In swimmers and tennis players, strength about the shoulder muscles is imperative. The external rotators of the shoulder seem to be implicated in most shoulder injuries. Weakness in this area contributes to loss of stability in the GHJ leading to impingement injuries. That said, the skill of the swimmer and speed of muscle contraction are more important than strength alone.

Muscle performace is also an important aspect of swimming and tennis. A good balance between all muscles and joints involved in the sequencing of movement is essential. Observation of the shoulder going through its ROM can be very helpful and any abnormal muscle movements can be addressed and retraining started to improve performance and reduce the risk of injury.

Pain is a cause of reduced scapulohumeral rhythm. Trigger points in a muscle also cause pain and contribute to reduced flexibility. Sometimes it is technique that contributes to shoulder pain. In such cases the involvement of the coach is essential. There are recognised clinical tests that can be used to isolate the cause of shoulder pain. Many factors mask or complicate pain thus great deal of care needs to be taken when diagnosing shoulder injury. Apart from natural athlete ability, of great importance is a knowledge of the individuals training frequency, volume, intensity and position in the competitive cycle. (preseason, early season mid-season etc.)

Treatment must be tailored to the individual. Generally, athletes are aware of acute management techniques, eg RICE principles. Training factors must be controlled. If injury or pain exists, the athlete should not “train or play through it”. Neither is doing nothing an option. Relative rest is critical! Painful activity is avoided. Pain free drills should continue. Coaching input and involvement is imperative.

The athlete's neck can be mobilised or sometimes manipulated to improve coordination as well as alleviate pain. It can also bring on changes in resting muscle activity helping in turn with proprioception and scapulohumeral rhythm. Gains can be assessed by comparing movement and pain to those that existed before treatment. It is essential to accompany treatment with appropriate exercise.

Where there is mostly muscle involvement, trigger points should be addressed using dry needle (like acupuncture) and other soft tissue massage techniques. These techniques not only relieve aching muscle pain, but can also improve range of motion. Appropriate exercise and stretching should accompany these techniques. The stability of the scapula must be addressed. Firstly, stability of the scapula is addressed using static postures of the shoulder complex. Next GHJ movement is introduced to address mobility on the stability. Thirdly, larger controlled ranges of motion address stability through range. Lastly, load is introduced using weights, pulleys or bands to achieve loaded mobility upon stability.

Rotator cuff and functional strengthening exercises are an integral part of good shoulder health. When rotator cuff exercises are completed with a focus on good scapula positioning, improved proprioception and control will be the outcome.

Source: Conservative management of shoulder pain in swimming. Peter Blanch. Physical Therapy in Sport

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