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

By G. John Mullen of and, Swimming World correspondent

SANTA CLARA, California, January 9. THERE is a gap between coaches and health care professionals. This guide is to bridge the gap between these parties, to optimize swimming by getting swimmers healthier and faster, without missing time in the water.

These simple guidelines must be followed strictly ensuring shoulder recovery, while maintaining "feel" and strength in the water.

A typical health care approach includes numerous blank periods, as they wait to be seen by the next professional. Then, after treatment, they expect the swimmer to return to the pool after symptoms are alleviated. This is considered a successful treatment; unfortunately time away from the pool causes an athlete to lose "feel" and time from the water.

This is the best-case scenario; sometimes the symptoms are never improved and the swimmer fights through the symptoms; or they return to practice, hop in the pool going full throttle, and the symptoms return, likely re-injuring their shoulder.

This unfortunate occurrence is the fault of everyone involved and is easily prevented if all parties work in harmony. Unfortunately, many health care providers view coaches as masochists, gaining power by watching swimmers endure pain. Swim coaches often view health care professionals as germaphobes, participation-trophy endorsers, and bubble-wrap-society promoters as they encourage long times away from the pool.

Follow these guidelines to bridge the gap and create harmony between all parties involved.

Many health care professionals don't know how to safely return a swimmer to the pool with guidelines to benefit recovery. Applying continual, gradual swimming stress is essential to see if the swimmer's shoulder pain is improving. Therefore, it is important to know their current pain level and have them progressively return to the pool, with limitations to follow ensuring improvement, but maintaining neural feel. Knowing their current level of pain will help monitor if their symptoms are improving, as it is unlikely for the athlete to go from 8/10 to 0/10 pain after a few sessions with the rehabilitation specialist, especially if these symptoms are long-standing. Helping them progress with milder and fewer symptoms allows the swimmer to see progress, keep their sanity, and stay positive as they return to the pool.

After working with hundreds of swimmers, I began piecing together simple tricks to speed recovery while maintaining feel, thereby preparing the athlete for a full return to practice.

First and Foremost
Proper technique for injury prevention is essential. I'm sure not all of the readers will agree with these biomechanical corrections for swimming propulsive reasons, but these will put less stress on the shoulder joint and muscles, the primary correction for those with shoulder pain.

The most common biomechanical causes of shoulder pain in swimmers are:

Crossing Over
Crossing over occurs with the athlete initiates their catch and brings their arm across their body. When the arm crosses the body, it closes the space on the anterior shoulder. The anterior shoulder contains the supraspinatus, an over worked and often times irritated rotator cuff muscle.

Solution: Stabilize the shoulder during the initial catch by performing the "compact position". The compact position is achieved by depressing and retracting the shoulder blade, providing a stable base for movement. In the compact position, it is nearly impossible to cross over and impinge the anterior rotator cuff muscles.

Thumb-First Entry
If an athlete enters with his/her thumb, the whole hand can enter through a smaller hole, decreasing drag. However, many athletes achieve a thumbs-first entry through shoulder internal rotation. This orientation can stress the anterior structures of the shoulder and increase the risk for shoulder impingement.

Luckily, the thumb-first entry can be achieved with no movement at the shoulder. Instead, instruct your athletes to use forearm pronation (rotating the forearm inwards) instead of shoulder internal rotation to get their thumbs to enter first, decreasing the amount of drag on the entry.

Solution: Either instruct your swimmers to enter fingers first or thumb first with only forearm pronation, a difficult but beneficial difference. Consider performing finer tip drag drills or hesitation drills just prior to entry.

Head-Up Position
Head position is another controversial topic. In the olden days, athletes were instructed to look up towards the other end of the pool. Unfortunately, this leads to athletes curling their neck upwards, putting many shoulder and neck muscles in improper positions. This will impair strength and put shoulder muscles at risk for injury.

Solution: Invest in a snorkel and practice having the swimmer have the water line just above their hair line.

Armpit Breathing
Every coach knows the armpit breather. This indentured swimmer has difficulties controlling and timing their neck rotation. These swimmers will often look back when they breathe or breathe late. This can irritate the shoulder by stretching and putting the shoulder muscles at the wrong muscle length.

Solution: Instruct the swimmer to initiate their breath prior to their arm entering the water. For example, if you are breathing to your right, initiate your breath just prior to your left arm entering the water. Performing six kick rotational drills while carefully adding arm strokes can help the swimmer learn how far and in what direction to turn their head.

"Normal" Freestyle Catch
There is no such thing as normal, but safe biomechanical strokes contain certain items. Review the hand entry series on Swimming World.

Once swimming biomechanics are improved, it is necessary to have guidelines for return. Here are the nuts and bolts to returning to swimming in no time, allowing the athlete to maintain "feel" and not be thrown into the gutter lane to swim breaststroke or kick.

Rules and Regulations
No more than 3
If the swimmer has had 8/10 symptoms, have them swim the next practice with proper form unless they have 3/10 pain. At a 3/10, it is likely irritation and further damage may occur. If high pain levels occur the athlete continually enters the inflammatory stage of a musculoskeletal injury, restarting the whole injury, or worse, lead to sympathetic or affective pain.

If the swimmer has a 3/10 pain at rest, it is best to have them stay out of the water as either inflammation or sympathetic pain is the cause. Have them immediately seek treatment for these conditions.

This approach is effective when the athlete is seeing a health care professional on a regular basis and their symptoms are continually improving. If the symptoms are not improving with a rehabilitative specialist, either find a new one or consider taking a break from doing the activity which causes the symptoms (likely pulling). As much as I realize maintaining "feel" is important, keeping a swimmer's shoulder away from the knife is even more important.

Solution: Have the swimmer swim workout until their symptoms reach 3/10. Once a 3/10 occurs, have them kick with their arms at their side or in streamline (if their symptoms don't increase with streamline) with fins. This allows them to stay in the water and keep feel. Moreover, most swimmers can do main sets and intervals with fins, keeping them involved in practice and their face in the water. If they have 3/10 symptoms prior to practice, discontinue for the day and have them seek treatment for inflammation or sympathetic pain.

No Kickboards
If someone has shoulder pain, this is a big one. Most cases of shoulder pain occur due to repeated overhead motions, leading to musculoskeletal pain. Holding a kickboard for a stagnant period is locking the arm in an overhead position and irritating the shoulder repeatedly. Does this sound smart to you?

Moreover, athletes commonly push their shoulders down on the board, leading to overpressure on the joint, which is a hazardous move.

This will perpetuate the pain and is easily replaced with kicking on the back. In fact, to prevent this dangerous position and prevent re-injury, I will have swimmers kick without a board for an extended period after the symptoms resolve (approximately one month).

Solution: Kick on your back in streamline if symptoms are less than 3/10; if symptoms are greater than 3/10, have them kick on their side or with their arms next to their side.

No Paddles
This is a tough one for some programs, but paddles place higher stress on the shoulder by allowing the swimmer to grab more water. This obvious statement supports the fact that moving more water requires more arm strength and use of shoulder muscles. Even with perfect technique, paddles will increase shoulder stress, a bad thought for shoulder pain. Removing paddles will give the shoulder time to recover, getting them back to paddles sooner.

Solution: Swimming with a pull buoy only or kicking if 3/10 symptoms have occurred.

Bottom Hand
Off a flip turn athletes should initiate their pull with their bottom hand. This is biomechically advantageous to rapidly rotate and spiral the athlete to the surface. Unfortunately, this powerful stroke is always performed by the same arm as swimmers are robotic and ambiturners. For athletes with shoulder pain, it is necessary to give the overworked shoulder a break. In almost all overuse injuries the bottom hand off the turn is the injured shoulder.

Solution: Reverse your rotations off the wall and start your stroke with your opposite arm. This will feel like writing with your opposite hand, but will distribute shoulder stress and allow adequate shoulder healing.

These guidelines help bridge coaches and health care professionals. The next part of this series will discuss a simple pre-swimming prevention program to improve tight muscles.

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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