Shoulder Pain in Swimmers

Shoulder pain is one of the most common injuries reported by swimmers, with most studies focusing on its incidence in younger, more competitive swimmers, which is estimated to be around 40-65%. Understanding the nature of the sport helps explain the reasoning behind this. Previous studies suggest that the arms generate approximately 80-90% of the propulsion force during freestyle swimming. Additionally, the repetitive nature of the sport—specifically the overhead movements against the water—forces swimmers to use similar motions repeatedly, which can stress the same tissues over time, eventually leading to overuse injuries. The most commonly observed type of shoulder pain in swimmers is related to the rotator cuff.

For more information about rotator cuff-related shoulder pain, click here.

Specificity of Swimming:

Understanding the movement during the propulsion phase can provide insight into which muscles are responsible for most of the pushing motion, which in turn can help us understand the potential overload or overuse mechanisms that lead to swimming-related injuries. The propulsion phase of the freestyle stroke involves a pulling movement that can be divided into two stages: early pull-through and late pull-through.

Early Pull-Through: This phase begins when the hand enters the water and ends when the arm is perpendicular to the torso.

Muscular activity: During this phase, studies show that the pectoralis major is predominantly active, helping to adduct and internally rotate the arm. The opposite muscular activity of the teres minor (rotator cuff) is also noted to control the strong pull of the pectoralis major.

Late Pull-Through: This phase starts at the end of the early pull-through and ends when the hand exits the water.

Muscular activity: The main muscle involved in this phase is the latissimus dorsi, along with activation of the subscapularis (rotator cuff) and serratus anterior, which helps maintain proper scapular positioning during arm movement.

In general, the study by Kerrigan et al. (1991) found that the serratus anterior and subscapularis were consistently active throughout the entire swim cycle, which may expose these muscles to fatigue.

Combining Biomechanics with Knowledge of Rotator Cuff-Related Shoulder Pain:

By examining muscular activity, we see that two primary muscles participate in force generation during the swimming stroke: the pectoralis major and the latissimus dorsi. Although these muscles are separate and function as prime movers in different phases of propulsion, they share two key characteristics: they both act as adductors (bringing the arm close to the body) and internal rotators of the shoulder. The repetitive nature of swimming and the overuse of similar muscle groups can alter the dynamics of the shoulder joint and/or overload specific tissues.

Although there is no clear evidence linking scapular dyskinesis (abnormal movement of the scapula) directly to shoulder pain, it may be a contributing factor in certain cases. In a study by Candela et al. (2018), they found that around 10% of swimmers may experience scapular dyskinesis, while other studies report a range of 10-70%.

In another study, Linklater et al. (2010) examined swimmers with symptomatic shoulder pain due to rotator cuff-related pain and found that the incidence of tendinopathy was associated with the amount of time spent in training (hours swum per week) and the distance swum per week. In simple terms, they discovered that inappropriate training variables may be a key factor in tendon-related injuries.

Prevention of Shoulder Pain in Swimmers:

Studies have attempted to explore whether adding land-based strengthening exercises can help prevent shoulder pain in swimmers. However, these studies have failed to show that additional strength training in a swimmer’s program can prevent injuries, even though some swimmers did show improvement in strength. Therefore, a more consistent and well-structured training program, along with appropriately adjusted training variables, should be the main prevention strategy. It is important to balance the stress placed on tissues with adequate recovery to avoid overuse injuries. If you are experiencing shoulder pain, seeking a professional examination by a physical therapist can help you understand how to manage the condition effectively.

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Reference:

Pink M, Perry J, Browne A, Scovazzo ML, Kerrigan J. The normal shoulder during freestyle swimming. An electromyographic and cinematographic analysis of twelve muscles. Am J Sports Med. 1991;19(6):569-576. doi:10.1177/036354659101900603

Preziosi Standoli J, Fratalocchi F, Candela V, et al. Scapular Dyskinesis in Young, Asymptomatic Elite Swimmers. Orthop J Sports Med. 2018;6(1):2325967117750814. Published 2018 Jan 23. doi:10.1177/2325967117750814

Sein ML, Walton J, Linklater J, et al. Shoulder pain in elite swimmers: primarily due to swim-volume-induced supraspinatus tendinopathy. Br J Sports Med. 2010;44(2):105-113. doi:10.1136/bjsm.2008.047282

Feijen S, Tate A, Kuppens K, Claes A, Struyf F. Swim-Training Volume and Shoulder Pain Across the Life Span of the Competitive Swimmer: A Systematic Review. J Athl Train. 2020;55(1):32-41. doi:10.4085/1062-6050-439-18