Dr. Detective: The Mental Side Of Overcoming A Swimming Injury

Man with hurt shoulder
Photo Courtesy: (c) Stockbyte

By Dr. G. John Mullen, DPT, CSCS, Owner of COR

I often discuss the steps to experiencing physical recovery from a swimming injury. Put a tennis ball here or a baseball there and — poof! — you can improve your shoulder pain. However, injury rehabilitation is never this easy, especially if you’ve been dealing with shoulder pain for a while.

However, pain and structural abnormalities are not always clear-cut. One study took diagnostic images of asymptomatic triathletes’ shoulders and noted that 71 percent had abnormalities. They also looked at symptomatic triathletes’ shoulders and found that 62 percent had abnormalities (Reuter, 2008). These abnormalities ranged from inflammation to rotator cuff tears, suggesting that there is little correlation between structural abnormalities and the triathlete’s symptoms.

One can have a structural abnormality but not feel symptoms. Another study found that 79 percent of asymptomatic professional baseball pitchers had abnormal labrums (Miniaci, 2002). None of this directly pertained to swimmers, but it is hard to believe that running or biking caused the structural abnormalities in the triathletes’ shoulders; and as stated, pitchers perform only a fraction of the overhead movements as swimmers perform, so imagine the volume of shoulder abnormalities in swimmers.

This may surprise some of you, but sometimes stuff breaks/tears/inflames and you don’t feel it. Conversely, sometimes you hurt, but nothing is wrong structurally. A proper system of prevention and rehabilitation respects the complex interaction of pain, dysfunction, and pathology.

Our medical system defaults to surgery far too often, simply because most people don’t know what else to do when something keeps hurting. Surgery is sometimes needed, but should only be an option after other means have been exhausted in an effort to rebuild an otherwise robust ship. Sometimes surgery is indicated and will correct the cause of a swimming injury, but symptoms, signs, imaging, and other factors need to be assessed first.

The current typical evaluation and rehabilitation process after an injury is often lengthy and inefficient. When shoulder pain occurs, most swimmers try to swim through it for two or three weeks, do an extra kick set, or skip the pulling set. Sometimes these alterations are from your coach’s advice; other times you dig deep, reiterating the “no pain, no gain” mantra. Hopefully, the symptoms will go away with these alterations. But, if they continue, an orthopedic surgeon or primary care physician is the next stop (typically taking one week to schedule an appointment). At this time, diagnostic imaging (x-rays, MRI, etc.), a cortisone shot, or a referral to a rehabilitative specialist (physical therapist, osteopath, chiropractor, massage therapist, trainer, or supplement provider) are the typical courses of action.

Let’s look at three options in detail:

  1. MRIs (Magnetic Resonance Imaging): Dr. James Andrews (a world-renowned orthopedic surgeon for Major League Baseball pitchers) recently said, “After scanning 31 healthy pitchers’ shoulders: The pitchers were not injured and had no pain. But the MRIs found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI (Kolata, 2011).”  This is a scary reality, and I’m not suggesting that MRIs are worthless. I don’t think Dr. Andrews is suggesting that no one needs shoulder surgery; they just aren’t the be-all, end-all for shoulder injuries. Often, repeated overhead motions cause microdamage, which accumulates over time without correlated symptoms. This accumulated damage isn’t the typical cause of shoulder pain in swimmers, as they’ve become accustomed to these abnormalities.
  2. Cortisone Injections: Cortisone injections are extremely beneficial in treating inflammation. By the time many clients get to a physician’s office (in two to three weeks) the inflammation has dissipated! If the inflammation has resolved, why get a cortisone injection? Cortisone should only be utilized if severe inflammation is present. Cortisone also has long-term deteriorative effects on muscle. Cortisone is a typical stop on the route to surgery when a physician or therapist is not sure what the cause of the symptoms is.
  3. Rehabilitative Specialist: These specialists commonly take a few weeks to schedule an appointment, and when they see you they will work on your symptoms. If handled “properly,” you will see this professional for two to three weeks and have full symptom alleviation. Unfortunately, many rehab clinics, no matter their specialty, rely heavily on modalities (electrical stimulation, ice, and ultrasound) and exercises instructed by an assistant. These modalities are mildly beneficial if used during the right phase of the injury, but are over prescribed with high insurance payment returns.

Choosing one of these three options often results in long periods from the pool. Worst of all, during this long drought, symptoms and joint function don’t always improve. Here are the common routes after a shoulder injury, all of which are considered “successful” approaches by a health care specialist:

  1. Brief Improvement: Upon return, many swimmers are asymptomatic and begin to push themselves to make up for lost time. The body is activating different muscles (a good thing, since the normal muscle pattern leads to injury). Sadly, after feeling good for the first hour, fatigue occurs and old movement patterns return along with the accompanying symptoms, which will likely cause a re-injury.
  2. Full Improvement: Another commonality is having full symptom alleviation after seeing a rehabilitation specialist for four to six weeks, then returning to the pool feeling like a wet noodle, having lost all neural feel that was developed throughout the season. This puts the swimmer back to pre-season form, often making best times unlikely.
  3. No Improvement: The last option is the worst of all. Upon return, after four weeks of simultaneous electrical stimulation, ice, ultrasound, and tape, the athlete finds their symptoms unchanged when swimming. Total symptom alleviation is great on land, which is a large step towards success. However, in this scenario the health care professionals do not take into consideration the demands of swimming, failing to consider continual preparation necessary to meet the demands of the sport.

Unlike other sports, swimming is a novel activity which doesn’t have an extended off-season. For example, in football there is a lengthy off-season that is utilized to build strength and speed. The season consists both of games and practice sessions, which allow time for maintaining off-season gains and preventing injuries. Once discharged from two to three weeks of rehabilitation sessions, football players are able to hop on the field and play (if symptoms are fully alleviated) without any decrease in performance. This is due to the natural movements of football and their gains achieved during the off-season.

Concurrent System

Unlike other sports, swim training is performed concurrently with the competitive season. If a swimmer had a shoulder injury, then returned to the pool after not swimming for three weeks, they’d belly flop off the block and be swimming like they had machetes for arms! Swimmers need the neural feel and repetitive swim training in order to perform optimally.

Once again, staying in the water is mandatory. Nonetheless, many health care professionals don’t understand this necessity. On the other hand, many coaches are too aggressive in trying to completely minimize time out of the pool, perpetuating an injury, or aggravating the injury upon return.

Health Care Professionals

The two primary goals of health care professionals are to resolve the symptoms associated with an injury and to regain the ability to perform all daily activities. Unfortunately, for an athlete these goals may be in conflict with each other. When a health care professional recommends to stop swimming to heal the injury, it impedes swimming during essential times of motor development. Motor learning is more active during specific developmental stages. If a young swimmer has shoulder pain, removing them from the pool may impair motor learning, which takes countless hours in the pool to potentially regain. Health care professionals approach the process of injury improvement by relying on their scientific understanding of the body’s anatomy and physiology.

In their eyes, any pain is viewed a sign of causing re-injury. This unrealistic approach is their reasoning behind long absences from the pool. Remember, any absence from the pool impedes “feel” and impairs performance. This is an area that many health care professionals do not comprehend, since their main goal is resolution of symptoms, not optimizing performance.

Swim Coach

At the other end of the spectrum are swim coaches. A swim coach’s’ goal is to build the best swimmer possible. This process takes long hours in the pool, which can often cause re-injury if the return to swimming is not increased systematically.

From what I’ve seen, coaches generally have three approaches to shoulder injury:

  1. Swim through the pain to toughen up: Swimming through the pain often makes an injury worse. This method is effective in some situations, like when mental strength is being overcome, but many swimmers do not know the difference between pain and injury. However, making an injury worse can perpetuate the inflammatory process. If you swim through a shoulder injury, it likely causes areas of your shoulder to continually rub against each other, feeding into poor muscle force generation. This will make the injury worse and lead to even longer periods away from the pool.
  2. Stop swimming to heal the injury: This is similar to the health care professional’s view. These coaches have a swimmer immediately discontinue swimming. This approach commonly improves inflammation and symptoms out of the water, but certainly impairs one’s swimming ability. Staying out of the water also does not guarantee that the injury won’t return, completely heal, or occur again.
  3. Grab a board and kick: Kicking is a great alternative to provide rest for the shoulder, but using a board puts the shoulder in an inappropriate position, potentially increasing shoulder symptoms and discomfort.

To reiterate, symptoms do not always correspond with structural abnormalities. Unfortunately, coaches and health care professionals often times look past or ignore the mental aspect of injuries, particularly the confidence of returning to the pool.

The Patient

I recently saw a 17-year-old male swimmer, Fabio, with shoulder pain for the past year. He had received physical therapy and multiple cortisone injections in both shoulders over the past year with minor improvement in his symptoms.

The Patient’s Signs and Symptoms

Fabio was a middle-distance swimmer with the hopes of swimming at a Division I university. Unfortunately, he was not able to compete at his championship meet last fall due to this injury. He stood at 6’1″ and weighs approximately 180 pounds.

Fabio noted pain during the recovery phase of his swimming stroke and was currently swimming 2,000 yards for three days a week. With this protocol, he was stopping at a pain level of 3/10, as he read this online. The pain was the same in the morning and at night.

Fabio was obviously frustrated with his shoulder, not sure how much yardage to increase and not sure if he will be able to swim in college, due to the injury.

The Tests and Assessments

During the testing, it was clear Fabio was hesitant of any shoulder movement. As he raised his arms overhead, he was cautious, moving extremely slow through standard shoulder range of motion. Despite this hesitation, he did not report pain with any movement. To find some comparable sign (a test which reproduces his pain to re-test), I performed a maximal resisted external rotation test. This test provoked a 2/10 pain upon release.

Swimming Assessment

On a video, the swimmer demonstrated a low shoulder stress stroke, entering shoulder width apart, with the hand diving down into the catch upon entry. Also, the recovery was relaxed, neither too narrow nor wide. Unfortunately, the video of him stroking was only at an easy speed, the only swimming video I obtained.

Treatment

The treatments first began with myofascial releases (MFR) on the posterior rotator cuff, infraspinatus and teres minor. Five minutes of MFR on the posterior cuff resolved his resisted external rotation pain in the first session. I taught him how to release these areas by himself and he demonstrated competency.

Self-Myofascial Release For Posterior Rotator Cuff Muscles

However, upon the second visit he reported the same symptoms and growing frustration. During this session, I performed MFR on the posterior rotator cuff and once again resolved him symptoms. During this MFR, I discussed the mental side of injury recovery. When most people hear about the mental side of injuries, they often think of people “faking” injuries or exaggerating symptoms, but recent research by Scharbrun (2015) suggests the cortex in the brain “smudges” after chronic low back pain. What this means is after an extended injury, the region of the brain associated with injury becomes altered. This altered representation may not seem like a big deal, but if the brain begins over-interpreting information, it is likely to interpret more information as pain or misinterpret a non-painful stimuli as painful. For example, if you have an injury, you constantly think about this injury. Always wondering, is this going to hurt? How does my shoulder feel? This constant mental chatter is potentially the reason for this smudging.

Luckily, mental skills and training are a cheap and easy method of potentially improving this smudging in the cortex. The mental skill I used with Fabio was an incantation. An incantation is a positive, repeated saying. This repeated saying can improve mental strength regarding an injury and prevent the mind from constantly analyzing the impaired area. In this example, I had Fabio repeat an incantation for five minutes upon waking and during the first five minutes of warm-up each day. One example incantation I used was: “My shoulder is strong, my shoulder is healthy, and I’m getting faster each day.”

This mental training was combined with continued MFR and posterior rotator cuff training for four sessions.

Three-point external rotation exercise

The Outcome

After implementing this soft-tissue and mental training, Fabio noted great improvement. Within a few weeks he was confidently performing the entire workout with his team, with minimal pain (reporting a 1/10 pain approximately once a workout).

Summary and Recommendation

Mental training and skills won’t always be the holy grail of recovery, but plays a role in many, especially those with long-standing pain. Moreover, this form of mental training has little to no negative effects. If you are recovering from an injury, consider performing incantations and improving your mental strength and recovery.

The Mental Side of Injury Recovery

Reference:

  1. Schabrun SM, Elgueta-Cancino EL, Hodges PW. Smudging of the Motor Cortex is related to the Severity of Low Back Pain. Spine (Phila Pa 1976). 2015 Apr 17. [Epub ahead of print]
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Beth Balletto-Celeste
8 years ago

Interesting

Yasmin Sandford
8 years ago

Paul Sandford

Stefano Balian
8 years ago

Bianca Thurm olha eu ai …

Bianca Thurm
8 years ago
Reply to  Stefano Balian

Obrigada por compartilhar eu vou ler e depois eu comento valeu

Stefano Balian
8 years ago

Priscila Picolin

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