Dr. Detective
Courtesy of: Swimming World
By Dr. G. John Mullen, PT, DPT, CSCS of Swimming Science, Center of Optimal Restoration , and Mullen Physical Therapy, Creator of Swimmer's Shoulder System, Swimming Science Research Review Swimming World correspondent

SANTA CLARA, California, August 26. SHOULDER pain can sometimes be due to the rotator cuff muscles. However, there are numerous passive and active structures in the shoulder which cause pain and dysfunction. Luckily, surgery isn't also required. This case of Dr. Detective takes the case of an age-group swimmer and water polo player with a history of shoulder pain, but luckily, resolves without surgery.

"Take a break" is a common response from physicians and rehabilitation specialists when they run into an athlete with shoulder pain. However, swimmers know stopping isn't an option when taper meets are around the corner. Also, simply "taking a break" doesn't always resolve pain in swimming, as stroke biomechanics often plays a role in the presentation of pain. This means you could "take a break" and have an awesome rehabilitation program, but if you don't modify the swimmer's stroke, then pain may persist.


Whenever I run into a swimmer who has tried to "take a break" and has received a rehabilitation program, it is important to take a look at the swimmer's stroke. This makes it imperative to find someone with a knowledge base of the sport, or a comprehensive knowledge of biomechanics and is willing to work with the coaching staff.

The Patient
15-year-old Monica's shoulder was not getting better with rest and chiropractic care.

Yet, this wasn't any chiropractor, but a chiropractor for a top university and was referred by a renowned shoulder orthopedic surgeon. Monica was diagnosed with "shoulder pain," which later turned into "labrum defect" noted in a magnetic resonance image (MRI).

The shoulder labrum acts to deepen the area for the humerus (upper arm) to lie. In swimming and water polo, the labrum is continually rubbed during the high volume of rotations. Unfortunately, a tear to her labrum explains the potential source of her pain, but not the root cause. This is a big distinction, as many overhead athletes have labrum defects without pain. Instead, a labrum defect is likely painful if there is an unnecessary painful stimulus causing further irritation (and perhaps inflammation) to this area. This labrum defect may also be an old condition, and without a previous MRI, there is no way to determine if this defect occurred when the pain began. This requires a search for the painful stimulus.




The Patient's Signs and Symptoms
Monica was a sprint swimmer and water polo player who stood at 5'11" and around 175 pounds. She was in great shape, but was clearly endomorphic (likely necessary to handle the contact in water polo).



She notes pain during the initial catch of her freestyle and water polo stroke. This pain typically started after 1,000 yards and remained at a level of 4 -- 5 out of 10. She also told me the pain was not worse in the morning or continuously throughout the day, only during practice. The pain started about six months ago during water polo practice, but worsened until she saw the other medical professionals. She didn't have anyone look at it until four months ago, because she thought it would just "go away." With the other medical professionals, the pain improved, but she also took a four-week break from the water. Upon returning, the pain was still at a 4 -- 5 out of 10. She said the chiropractor did a lot of myofascial releases and strengthening of the scapular stabilizers.

Overall, the rehabilitation program and notes from the chiropractor looked comprehensive, leaving some detective work ahead.

The Tests and Assessments
Since the chiropractor did a comprehensive strengthening program, I was particularly interested to see how Monica swam. Before the swimming assessment, I knew she didn't rotate much on her freestyle. Being a sprinter and water polo player, flat-shoulder paddling is common.

Visual Assessment
Monica presented a typical swimmer's posture, with rounded shoulders and kyphotic thoracic spine. This position moves the head of the humerus in a position where the labrum is likely more susceptible.




Movement Assessment
During all shoulder motions, Monica demonstrated excessive shoulder elevation and frequent flexing at her elbows. This is a sign for an overactive biceps brachii, a muscle which attaches directly at the superior labrum. She also had pain with standing overhead internal rotation (similar to the initial catch in freestyle), when the infraspinatus (a posterior rotator cuff muscle) is stretched and pulls on the joint capsule, which pulls on the labrum.

Swimming Assessment
In the water (as anticipated), Monica had a short, choppy freestyle lacking shoulder and hip rotation. Though sprint swimming does require less hip rotation, it is important for the shoulders to rotate to distribute the stress at the shoulder. She also demonstrated a late breath during her freestyle, likely adding stress to her shoulder. Lastly, she swam a bit "uphill," allowing her to remain in kyphosis, with her shoulders rounded.




Treatment
This case required a unique combination of resolving the overactive biceps brachii and infraspinatus which were tugging on the labrum and stroke biomechanical improvement. For this, manual myofascial releases were performed to these muscles, resolving her pain during her internal rotation test. In the pool, a systematic approach of fixing one swimming flaw at a time was utilized. In the following order, the swimmer and her coach were instructed to focus on each criterion:

1) Body position: Having the back of the ears align with the top of the hips. If the swimmer is not in a straight line in the water, the shoulders will sit too far forward and cause excess stress.

2) Body rotation: Rotating the shoulders approximately 45 degrees to allow the anterior and posterior shoulder muscles to contribute to the catch (opposed to only allowing the anterior muscles).

3) Breathing: Initiating axial head rotation (breathing) briefly before the opposite arm entered the water. Delayed breathing can cause the neck muscles to contract when the shoulder muscles are meant to fire. This combination can tug the shoulder in different directions, likely increasing the stress at the joint.

These manual therapy techniques were combined with self myofascial releases (SMR) to the previously-mentioned muscles each day.



The Outcome
After five weeks, Monica reported no pain with water polo or swimming. She noted she was still working on her body rotation and breathing, but was able to swim the whole practice with no pain for the past week.

Summary and Recommendation
Shoulder pain has many presentations and even more causes. It is important to find the root cause of pain, instead of providing a general rehabilitation program. Luckily, once the root cause was discovered, the symptoms resolved rather quickly. This allowed a streamlined treatment, removing the focus from excessive, unnecessary strengthening exercises.

Main Take-Home Points:
If you have shoulder pain, check it out earlier than later! Waiting for it to resolve, or "taking a break" may not alleviate your symptoms.

Stroke biomechanics don't just improve swimming velocity, but often protect the body. Make sure you consider stroke biomechanics if you have pain.

Don't be content with finding a structural abnormality; instead seek the root cause of your symptoms!

By Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University. He is the founder of the Mullen Physical Therapy, the Center of Optimal Restoration, head strength coach at Santa Clara Swim Club, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.