Swimmers and shoulders: Who's watching out for them?

Did you know that up to 91 percent of competitive swimmers have reported experiencing shoulder pain? Unfortunately most young swimmers will develop such pain—it's just part of the sport.The same used to be true of youth pitchers in baseball.

For years, there was growing evidence that youth baseball pitchers were experiencing a high number of shoulder and elbow injuries. These injuries appeared related to excessive exposure to throwing the baseball. It was an epidemic, a talented 13-year old kid's future ended due to shoulder and/or elbow ligamentous injuries. It got to a point where these kids and their parents were coming to orthopaedic surgeons for the elbow-saving Tommy John surgical procedure. Enough was enough.

In the beginning of 2007, Little League baseball became the first organization to implement a pitch count rule to protect young pitching arms. This is an age-based system in which a pitcher who throws a certain number of pitches must wait several days before competitively throwing again. Even Major League Baseball managers follow pitch counts to protect multi-million dollar shoulders from injury.

So, what's the swimming connection? A recent study looked at 80 elite swimmers aged 13-26 and found that 91 percent had shoulder pain. The mean age of these swimmers was 15.9 year old–kids! The majority of these swimmers competed at state to international level so they were the best of the best.

The study examined whether shoulder pain was related to swimming stroke, laxity (tissue looseness) or training. 52 participants had MRIs performed and 69 percent of those revealed rotator cuff tendonopathy—in other words, degenerative or overuse changes of the rotator cuff tendons.

The higher level of competition was related to a higher incidence of tendonopathy (100 percent, 89 percent, 40 percent in the international, national and club athlete, respectively).

This condition was found in 54 percent of swimmers aged between 13 and 14 years, 77 percent between 15 and 16 years, 100 percent between 17 and 18 years and 71 percent between 19 and 22 years of age—as I said, kids! The study found swimmers averaging 15 hours or more than 35 miles per week, demonstrated overuse changes in the rotator cuff tendons.There was not a relationship between tendonopathy and either the type of stroke or laxity.

Angela Tate, PT, PhD, an associate professor in the physical therapy department at Arcadia University, has a strong interest in swimming, particularly the health of younger swimmers.She wanted to determine if shoulder pain was related to physical characteristics, training methods and exposure, in four varying age groups (from 8-77) representing the swimmer's lifespan.

Dr. Tate examined 236 female participants from youth, high school and master's level swimming programs.She found a history of an instability event, pectoralis minor muscle (front of chest) tightness, reduced posterior shoulder flexibility, middle trapezius and shoulder internal rotation weakness and reduced core muscle endurance were associated with shoulder pain. Interestingly, cross training such as playing soccer or walking, was associated with reduced shoulder pain.

The most dramatic finding was that 18.6 to 22.6 percent of competitive swimmers in each age group experienced shoulder pain and difficulty with functional activities. The high school age swimmers had the greatest amount of pain. Her study found the difference between those swimmers with and without symptoms was related to greater exposure to swimming (years and hours per year/week of swimming).This was especially true of the high school athletes.It has been estimate that a competitive swimmer has approximately 10 stroke cycles per 25 meters. Think about it—swimming 5000 meters in a day equates to 2000 shoulder rotations, 10,000meters, 4000 rotations. That can lead to shoulder pain.

Back to baseball for a moment—in youth baseball, the problem was identified and regulatory steps taken to address the problem.Should we take a look at our swimming programs? Competitive swimmers will practice 5-7 days a week and sometimes twice a day. Often coaches push swimmers to 3000, 5000 or 10,000 meters in each session. Just stand poolside and you can watch a beautiful stroke turn to mush as the serratus anterior (work horse scapular muscle) fatigues and the scapula stops rotating as the flail arm repetitively moves inefficiently overhead. This results in the shoulder's ligamentous system and rotator cuff undergoing microtrauma and pain. Now let's sleep on it and do it again tomorrow!

I am not picking on swim coaches. Currently there is no research to support swim distance guidelines—but there is evidence to force us to ask the question: How much is too much?

Marty Kelley is an advanced clinician and site manager for Penn Therapy & Fitness at Penn Presbyterian Medical Center. He is the past-president of the American Society of Shoulder and Elbow Therapists. He writes about therapy technology and new research.

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