Sorting Swimmers Shoulders

Daniel Butler & Lennard Funk

In swimming the majority of propulsion comes from the upper limbs.  This coupled with repetitive overhead movements, means competitive swimmers can achieve over a million overarm movements a year. Shoulder problems are therefore common in swimmers. Most can be managed without the involvement of a shoulder specialist, but when they cannot, referral to a shoulder specialist is indicated. 

We reviewed all competitive swimmers presenting to our practice over a six-year period. Inclusion criteria was a competitive swimmer of club level and above, with a period of failed non-operative management of more than 6 months prior to referral.
There were fourteen swimmers that met the selection criteria, with a mean age of 20 years. This comprised 9 international athletes, two club level and three Paralympic swimmers.

The predominant swimming stroke was: 
- Freestyle: 6
- Butterfly: 2
- Breaststroke: 1
- Backstroke: 3
- Freestyle/Backstroke: 1

Based on clinical examinations and MR Arthrogram imaging the diagnoses consisted of:
- Labral tears: 6
- SLAP – 3
- Bankart – 3
- Internal Impingement – 3
- Subacromial impingement – 4
- HAGL – 1

Treatments included specialist physiotherapy, injections and surgery. Six had arthroscopic labral repair surgery, four had physiotherapy alone and three had a corticosteroid injection.  All labral repairs underwent surgical arthroscopic repair. All impingement and internal impingement cases had physiotherapy and a steroid injection if required. A specialist swimming therapist and/or a specialist shoulder therapist provided the physiotherapy. These therapists worked with the referring therapist in most cases.

There were a number of interesting findings from this study:
1. There was no correlation between swimming stroke and type of injury, although the majority of our patients were freestyle swimmers.
2. Despite the belief that hyperlaxity is associated with shoulder pathology, only 38% of our swimmers had a high score (>6). This is similar to the study by Bak et al., who found a hyperlaxity incidence of 22% in painful swimmers shoulders. 
3. The majority of swimmers had good scapula rhythm, with no visible dyskinesis., even in those with chronic impingement.
4. None of the six who underwent arthroscopy had impingement as the leading indication
5. No swimmers with impingement underwent surgery. Their mean return to swimming was 1.6months.  
6. All labral tears required surgery and failed non-operative management. 
7. The mean time to return to swimming after arthroscopic labral repair was 2.9 months.

This study showed that the appropriate use of clinical tests and the balance between conservative and surgical treatments lead to good outcomes for swimmers suffering from shoulder injuries. The appropriate choice of treatment along with the advances in imaging and shoulder rehabilitation meant no swimmers with impingement underwent surgery.  

In summary, competitive swimmers who present to shoulder surgeons have the best opportunity of reaching their pre-injury level if the management is carefully considered and appropriate for each swimmer, regardless of the injury. Chronic impingement can be effectively managed with conservative treatment, whilst labral tears require surgical repair.