Mike Allen PT, ATC, CSCS

Director of Rehabilitation Services

Steadman Hawkins Clinic – Denver

What is swimmer’s shoulder?

Swimming is a unique sport that primarily involves heavy repetitive use of the upper extremity.  It is reported that over 80% of elite level swimmers will have shoulder pain at some point in their career.  The shoulder is a complexed joint involving three bones (clavicle, scapula and humerus), three joints (gleno-humeral, scapular thoracic and acromio-clavicular) and well over 20 muscular attachments.  It’s felt that repetitive concentric loading through a large range of motion creates laxity (looseness) in the shoulder joint causing the ball (gleno-humeral head) to move excessively in the socket (glenoid).  In time, this can cause inflammation at the rotator cuff tendons as they contact boney shelf (acromion) above that ordinarily protects these tendons.

What are the common symptoms?

Pain in the shoulder area may extend up into the trapezius and neck.  Initially, the pain may be isolated during activity only; as the symptoms progress pain occurs during both activity and rest.

Is the pain getting worse?

There is a distinct progression of symptoms that can be followed.  Early intervention may prevent a minor condition for becoming significantly worse:

Stage I: Pain at the beginning of practice that resolves after warm-up

Stage II: Pain at the beginning of practice that increases during practice

Stage III: Pain during practice that last after practice and affects daily function

*Once an athlete begins to have increased pain during practice that affects daily function it is time to have a medical professional evaluate.

What are some of the causes?

May be one or a combination of the following:

• Sharp increase in training volume
• Increased volume with a  particular stroke
• Breakdown in stroke mechanics
• Addition of training implements (paddles/kick boards) with increase volume
• Breathing from one side only
• Inadequate strengthening program

What can we do for treatment?

Swimmer’s shoulder can be one of the more challenging diagnoses to treat due to the instability in the shoulder joint.  Treatment will vary depending on the severity of symptoms:

Class I

• Minor reduction in volume or adjustment of a particular stroke
• Adjustment of mechanics
• Icing after practice; anti-inflammatory medication as needed
• Pre/post practice CP rotator cuff and scapular strengthening program modified based on symptoms
• May take 1-2 weeks to completely resolve

Class II

• Medical consultation with physician, physical therapist or athletic trainer
• X-ray and MRI likely
• Significant reduction in volume or short period of complete rest
• Comprehensive CP rotator cuff and scapular strengthening program
• Ice and anti-inflammatory medication as needed
• May take 4-6 weeks to resolve

Class III

• Same treatment as class II
• X-ray and MRI likely
• May take 6-12 weeks to resolve
• Potentially a surgical candidate if no improvement with physical therapy after 3-6 months.

© Copyright 2011 Cuff Performance all rights reserved

Steadman Hawkins Clinic – Denver

What are common shoulder injuries in MMA?

Shoulder injuries present one of the most common and debilitating orthopedic conditions facing an MMA fighter.  If left untreated, a mild problem can quickly become chronic, leading to lost training time and potentially missed fight opportunities.  The purpose of this article is to describe the most common shoulder injuries and to provide a treatment algorithm in the event an injury occurs.

Anatomy

The shoulder is the most mobile joint in the human body involving:

• Three bones – clavicle, scapula and humerus
• Three joints – Gleno-humeral (GHJ), scapular thoracic  (ST) and acromio-clavicular (ACJ)
• Well over 20 muscular attachments.

Stability in the shoulder is provided by capsule, ligament and muscular attachments.  These  structures are placed under tremendous stress by the extreme ranges of motion and high compressive forces encountered by MMA fighters.

Three most common shoulder injuries/treatment:

• Gleno-humeral dislocation: The shoulder joint is a ball and socket joint and can become injured when overpressure is applied to the arm when it is place in the “throwing motion” or “goal post” position.

Treatment:  GHJ dislocations require medical attention.  Occasionally the shoulder self reduces but often needs a trained medical professional to put the joint back in place.  X-rays are required to evaluate injury to the bony structures for possible fracture and an MRI may be ordered to look at the joint capsule and labrum (cushion that supports the joint).  A sling will be used for comfort and a course of physical therapy consisting of progressive range of motion and gradual strengthening will begin.  The sling is usually discontinued within a week and return to normal daily activities is allowed as comfort dictates.  During this time the fighter can continue with core and lower extremity strengthening along with cardiovascular work as tolerated to maintain fitness levels.  Return to light bag work will begin around 4-6 weeks and full striking, likely after the 6 week mark.  Wrestling/ground work needs to be light until the 6-8 week mark with protection from the “throwing motion” or “goal post” position.  The likelihood of re-dislocation is fairly high (>80%) so progression back to full activity needs to be controlled and monitored.  If repeated dislocation occurs, then surgical stabilization may be the only alternative to get the fighter back to prior level of competition.  A fighter can expect a 4-6 month time frame back to full activity after surgical reconstruction.

• AC separation: This occurs when a fighter lands directly on the point of the shoulder without and outstretched arm.  Typically the fighter’s body weight plus the weight of his opponent drives the shoulder into the mat causing injury to the joint that connects the clavicle (collar bone) and the scapula (shoulder blade).  AC separations are classified as grade I, II and III.  Grades I and II are mild to moderate sprains, they are painful but do not require surgery.  Grade III injuries are complete dislocations that may require surgery if pain, function and cosmetic appearance continue to adversely affect the athlete.

Treatment:  X-rays are commonly taken to rule out a clavicle fracture and to evaluate the elevation of a clavicle with grade III injuries.  In all three classifications a sling is recommended for comfort only.  Range of motion exercise and progressive rotator cuff and scapular strengthening begin immediately.  Training will need to be reduced significantly for 2-4 weeks with a gradual return to unrestricted activity.  These injuries can linger; it’s not uncommon to have pain 6-8 weeks after an injury.  If pain persists, an injection of cortisone can help reduce inflammation and assist in returning back to full training quicker.

• Rotator Cuff Impingement: Repetitive striking combine compressive and distraction forces on the ground can cause inflammation of the rotator cuff tendons and the bursa (cushion) that underlie the bony shelf of the scapula called the acromion.  Ordinarily there is about 1cm of space for the tendons to move; the chronically forward head and rounded shoulder position fighters maintain can reduce this space and cause or aggravate an already inflamed shoulder.

Treatment:  Initially ice and anti-inflammatory medication in combination with a slight adjustment in training intensity may be enough to get fighter on track.  Typically a comprehensive course of soft tissue work, rotator cuff/scapular strengthening, postural training and selective stretching is needed to completely heal the shoulder and prevent recurrence.   The degree of inflammation is easily rated on the following scale:

Stage I: Pain at the beginning of practice that resolves after warm-up

Stage II: Pain at the beginning of practice that increases during practice

Stage III: Pain during practice that last after practice and affects daily function

Early intervention is key and may prevent a minor condition from becoming significantly worse.  Once an athlete begins to have increased pain during practice that affects daily function it is time to have a medical professional evaluate.

Is there something I can do to Prevent injury?

Absolutely!  Increasing postural awareness by avoiding the forward head and rounded shoulder position outside of the gym will immediately take pressure off your neck and shoulders reducing the chances of getting rotator cuff impingement.  With respect to traumatic injuries, the stronger, more stable and flexible the shoulder joint; the less likely it will become injured even in extreme loading patterns.  I strongly recommend the following pre-workout dynamic shoulder warm-up each day:

Pre-workout

• 2x 12-15 external/internal rotation at 0° abduction
• 2x 12-15 external rotation at 90° abduction – W’s
• 2x 12-15 reverse flys – T’s

Post-workout (1-2x/week): 2×12 each exercise

• External/external rotation at 0° and 90°
• Rows
• Shoulder extensions – I’s
• Reverse flys – T’s
• Y’s
• Push-ups

This pre-post routine is intended to complement a comprehensive upper and total body strengthening program.  It activates the smaller muscle groups in the shoulder which in turn provides greater stability and ultimately greater loading capacity to the shoulder complex.

© Copyright 2011 Cuff Performance all rights reserved

Does posture influence shoulder function and performance?
The answer to this question is a definitive yes. Car tires wear abnormally when the front end alignment is off; our bodies are no different, abnormal stress is placed on joints when strength and flexibility get out of balance. We live in a culture where prolonged periods of sitting is common; working on computers, driving, texting, and playing computer games all create forward flexed posture.

So what is really happening with rounded shoulders?

Looking at a person from a side view, there should be a nice plumb line that runs from the ear lobe to the shoulder and straight down though the hip, knee and ankle. If the head is forward, this can put excessive stress on the lower cervical (neck) spine and is often the cause of chronic neck pain. Quite often the shoulders are rounded forward as well due to shortening of the pectoralis (chest) muscles. This in Turn elongates the muscles that stabilize the shoulder blades, making them less mechanically efficient to contract while decreasing their strength. From this postural position, tightness is often seen in the back of the shoulder joint moving the ball (humeral head) forward in the shoulder socket, creating pressure on the front of the shoulder capsule, labrum, rotator cuff and biceps tendon.

Tipping point – Many of us are guilty of poor posture but we all don’t have shoulder problems. Typically there is an episode that causes the shoulder to suddenly become painful:

• Increased time at the computer – followed by a weekend in the yard raking or shoveling snow
• Increasing a throwing program too quickly after a winter without throwing
• A fall on an outstretched arm – weekend warrior playing football or mountain biking
• Sedentary worker that suddenly ramps up golf after a winter of inactivity

In all four examples, poor posture coupled with inadequate strengthening, flexibility and pre-season preparation resulted in injury.

What can be done to prevent shoulder injuries?

Increasing postural awareness in all settings offers a good starting point. Rather than trying to maintain a military posture, simply lift your sternum (breast bone) up and slightly draw your chin in towards your neck. Remember the imaginary plumb line running from your ear to your ankle, do your best to maintain that relationship when standing. Be aware of your sitting posture and try and get up and move every 20-30 minutes if you are on a long project.

Most importantly engage in a well designed shoulder strength and flexibility program 2-3x/week. Cuff Performance offers a comprehensive strengthening system that will target the entire shoulder complex to optimize performance and to prevent injury regardless of your sport or activity.

© Copyright 2011 Cuff Performance all rights reserved

This is a frequently asked question by parents and athletes and becomes more of an issue with athletes playing year round and at times in multiple leagues. Many youth league players are playing over 100 games over a 6+ month period; comparable to a professional season. New research indicates arm pain among young athletes is on the rise, with one study showing a five-fold increase in serious shoulder and elbow injuries among youth baseball and softball players since 2000. Early specialization may contribute to the problem by reducing overall recovery from fatigued shoulders and arms. Not only does participating in other sports enable the athlete to recover but helps him develop overall athleticism that may ultimately enhance performance in baseball. The American Sports Medicine Institute provided the following recommendations on pitch count and pitch selection:

ASMI Recommendations

Pitches/game

Recovery Times

Survey – Age Recommendation for Learning Various Pitches

Other Considerations

• Proper technique is a major factor in preventing injury.
• A well designed rotator cuff and total body strengthening program can reduce a young pitcher’s risk of injury.
• Players should gradually increase arm strength with a combination of long toss and intermittent mound work 6 weeks prior to the start of the season.
• Players should be encouraged to play multiple positions.
• Arm soreness is common early in the season as athletes condition their arm. If pain, altered mechanics or reduced velocity occurs more rest or medical evaluation may be warranted.

More information can be found at the complete ASMI research.

© Copyright 2011 Cuff Performance all rights reserved