Science of Performance: Return to Swimming After Injury, Part II

By G. John Mullen of SwimmingScience.net and CenterofOptimalRestoration.com, Swimming World correspondent

SANTA CLARA, California, December 27. IF you missed part I or part I.5 read them now!

Shoulder pain is extremely common is swimmers. It is estimated 80 percent of swimmers will experience shoulder pain during their career. Shoulder pain incidence increases with age, Masters swimmer beware! Unfortunately the common route of improvement after an injury is lengthy. For example, if you have shoulder pain, you swim through it for 2-3 weeks trying be Mr/Mrs Tough Guy, digging deep reiterating the 'no pain no gain' mantra. Most often, these symptoms dissipate, but if they continue the next step is a visit to an orthopaedic surgeon or primary care physician (typically taking one week to schedule). At this time, one of three things occur: 1) you receive referral for imaging (x-rays, MRI, etc.), 2) you schedule a cortisone shot, 3) you schedule an evaluation with a rehabilitative specialist (physical therapist, osteopath, chiropractor, massage therapist, trainers, supplement provider, Bushman in San Francisco). Let's look at these three options in more detail:

* MRI's: Unfortunately, imaging for shoulders is practically worthless. Dr. James Andrews (orthopedic surgeon to every MLB pitcher) recently said "after scanning 31 healthy pitchers shoulders: The pitchers were not injured and had no pain. But the MRI's 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,".

This is a scary reality! I don't think Dr. Andrews (a surgeon, keep in mind) is suggesting MRI's are worthless or no one needs shoulder surgery, they just aren't the be-all end-all for shoulders.

Consider this, you've been swimming for 10 years, constantly using your shoulder causing microdamage over the years. This microdamage is likely causing structural abnormalities: edema, rotator cuff tendinitis, labrum tears, etc. These structural abnormalities are normal in overhead athletes just like Dr. Andrews said. Now imagine, suddenly you start having shoulder pain, go to your primary care physician and receive an MRI. This imaging will show the structural abnormalities you've had for years due to swimming! If these structural abnormalities aren't new, they are unlikely causing your new symptoms.

* Cortisone Injections: Cortisone injections are extremely beneficial in treating inflammation. Unfortunately, by the time many clients get to a physician's office (in 2-3 weeks) the inflammation has dissipated! If the inflammation has resolved, why get a cortisone injection? Maybe we should only utilize cortisone injections if severe inflammation is present.

* 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 2-3 weeks and have full symptom alleviation. Unfortunately, many rehab clinics, no matter their specialty, rely heavily on modalities (electrical stimulation, ice, ultrasound) and exercises instructed by an assistant with the best intentions, but sometimes lack of knowledge base. These modalities are mildly beneficial if used during the right phase of the injury, but are over prescribed modalities with high insurance payment returns. Is medical reimbursement the reason you want a modality…I hope not?

This process is lengthy resulting in long periods from the pool with hopeful improvements. Unfortunately, this long drought doesn't always improve symptoms or function, here are the common routes after a shoulder injury, all consider a "successful" approach to shoulder injury:

1) Brief Improvement: Upon return, your shoulder is feeling great, you tell your coach you are feeling amazing and are ready to make up for lost time. Unfortunately, you dive in the pool, activating different muscles (a good thing, since the normal muscle pattern lead to injury). After feeling good for the first hour, fatigue occurs and old movement patterns return with accompanying symptoms, likely causing a re-injury.

2) Full Improvement? Another commonality is having full symptom alleviation after seeing a rehabilitation specialist for 4-6 weeks, then returning to the pool feeling like a wet noodle. Do you think this is the best course of action? If you have lost all of your neural feel in the water and have to start back to pre-season form necessary? Imagine if there was a systematic approach which maintains "feel" with symptom alleviation?

3) No Improvement: Hop in the water after your four weeks of simultaneous TENS, ice, ultrasound and tape to find your symptoms unchanged with swimming. Total symptom alleviation is great on land and the first step towards success, but many health care professionals do not understand the demands of swimming, recklessly throwing swimmers back in the pool with improper guidelines. I've witnessed this process hundreds of times, this broken record needs to be upgraded to a 3-D system immediately!

If you read part I like a good student, you now understand swimming isn't football where the huge off-season is utilized to build strength and speed, then the season consisting of games, while maintaining off-season gains and preventing injuries. Once discharged from 2-3 weeks of rehabilitation sessions without practice, these players hop on the field play up to their full skill level (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. Everyone may not be good at it, but each one of you can run, jump, tackle, not everyone can swim. Think about it, everyone can run, jump or tackle, it may be embarrassing, but you can do it. Not everyone can swim, this is one large difference.

Concurrent System
Swim training performed concurrently with the competitive season is essential. If a swimmer had a shoulder injury, returns to the pool and tries to compete after not touching the water for 3 weeks, they'd belly flop off the block and be swimming like they had machetes for arms! I'd be shocked if anyone perform their maximal potential and even if they did then two options exist:
1. They aren't good at swimming and their best times compete with glaciers.
2. They are Superman Swimmers, who don't require training. If you are or know one of these swimmers, please have them e-mail me immediately for further testing.

Once again, staying in the water is mandatory, unfortunately many health care professionals just don't understand this necessity. However, many coaches are too aggressive, perpetuating an injury, or aggravating the injury upon return.

Health Care Professionals
The goal of any health care professional is complete resolution of symptoms and accomplishment of goals. Unfortunately, these goals may conflict, impeding progress during process at essential times potentially impairing a season or career, if performed during a high period of motor learning. Motor learning is more active during specific developmental stages. If a young swimmer tragically has shoulder pain, removing them from the pool may impair motor learning, taking countless hours in the pool to regain.
Health care professionals view surrounds the injury process. Under any injury the body incurs inflammation. Inflammation leads to excess fluid in the joint, which causes aberrant movements and pain. The goal of the health care professional is to alleviate this inflammation.

Unfortunately in their eyes, any pain is viewed as feeding into inflammation and the injury process. This unrealistic approach is their reasoning behind long absences from the pool.

Remember, any absence from the pool impedes feel and impairs performance, an area many health care professionals do not comprehend or frankly care about, since their main job is resolution of symptoms, not optimizing performance.

Swim Coach
The other end of the spectrum are swim coaches. These folks try to build the best swimmer possible. This process takes long hours in the pool, often causing re-injury if return to swimming is not increased systematically.

From what I've seen, coaches have two approaches to shoulder injury:
1. Swim through the pain to toughen up: Swimming through the pain oftentimes make an injury worse. This method is effective in some situations as many swimmers do not know the difference between pain and injury, especially in the Nerf ball society today. However, making an injury worse can perpetuate the inflammatory process described earlier. If you swim through a shoulder injury, it likely causes areas of your shoulder to continually rub against another, worsening the situation. 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 view. These coaches have a swimmer immediately discontinue swimming and all activities. This approach commonly improves inflammation and symptoms out of the water, but impair swimming and oftentimes doesn't prevent re-injury.

Wrap-up
From my perspective, health care professionals and coaches hold one key to the optimal rehabilitation system. The next installment will address the proper method to handle a new shoulder injury. This system consists of activities to heal the shoulder while allowing the athlete to maintain feel in the water.

Dr. G. John Mullen is a Doctor of Physical Therapy and a Certified Strength and Conditioning Specialist. At USC, he was a clinical research assistant at USC performing research on adolescent diabetes, lung adaptations to swimming, and swimming biomechanics. G. John has been featured in Swimming World Magazine, Swimmer Magazine, and the International Society of Swim Coaches Journal. He is currently the strength and conditioning coach at Santa Clara Swim Club, owner of the Center of Optimal Restoration and creator of Swimming Science.

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