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00913847.1980.11710933

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The Physician and Sportsmedicine
ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20
Shoulder Pain in Swimmers
Richard H. Dominguez
To cite this article: Richard H. Dominguez (1980) Shoulder Pain in Swimmers, The Physician and
Sportsmedicine, 8:7, 35-42, DOI: 10.1080/00913847.1980.11710933
To link to this article: http://dx.doi.org/10.1080/00913847.1980.11710933
Published online: 11 Jul 2016.
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Date: 12 November 2017, At: 23:01
CME Credit Material
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Shoulder Pain in Swimmers
Introduction
any sports are associatcd
with a specifie overuse
syndrome such as tennis
elbow in tennis players
or shinsplints in runners. Swimming is
no exception: Of the 40 swimmcrs on the
1978 World Championship Team, 57%
rcportcd a history of shoulder pain,
commonly called swimmcr's shoulder.
It's no wonder. Age-group swimming
programs cnablc childrcn as young as 8
ycars old to competc for national
records. Along with starting to train at a
younger age, today's swimmers arc training with significantly longer distancesas many as 20,000 mctcrs a day. A
swimmcr training 10,000 mctcrs a day
puts cach arm through at least 10,800
frccstylc, backstrokc, and butterfly
strokcs a wcck.
Swimmcrs tend to be a tcnacious
group, and swimming is a major part of
thcir livcs.lftreatcd corrcctly, swimmcr's
shouldcr should not mean they have to
abandon thcir sport. In this month's
CME article, Dr. Dominguez tells the
physician how to obtain an accurate history for correct diagnosis and describcs
the conscrvativc trcatmcnts thal should
be used for swimmcr's shouldcr whencver possible.
This article and the test that follows
arc part of a continuing series that offcrs
physician-readcrs the opportunity to
earn continuing medical education credits. The test may be submitted for two
hours of prcscribcd credit in the American Academy of Family Physicians
CME program or for AMA catcgory 1
credits.
continued
35
36
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Shoulder Pain
inSwimmers
Richard H. Dominguez, MD
Even though more swlmmers are seelng
physlclans for shoulder pain, fewer
need to be consldered for surgery.
5
houlder pain is the most common
orthopedie complaint in competitive swimmers over 12 years old. In
the early 1970s Kennedy and Hawkins' reported an incidence of approximately
3% in Canadian swimmers. However, severa)
studies indicate that the incidence is now
closer to 50%, because the swimmers train
with increased intensity and distances. 2 In the
United States, Dominguez,l Hall,4 and Richardson5 report incidences between 40% and
60% in various levels of age-group and Olympie swimmers.
The upper extremities are the prime movers in the modern swimming strokes, and the
lower extremities add only a small percentage
to speed, or in sorne cases, keep the lower
body afloat. 6 Therefore, as the training distances increase, the stress on the shoulder
increases dramatically.
Anatomy and Causes
Kennedy and Hawkins' used sophisticated
microvascular injection techniques to demonstrate that circulation in the bicipital tendon
was significantly compromised in one phase
of stroke mechanics. They theorized that this
continued
Dr. Dominguez practices at Wheaton Orthopedies, LJd, in Wheaton/Carol Stream, Illinois.
Till IIIIYIICIAII AIID INII'nMIDICIMI • VOl 8 • No 7 • .liA 110
37
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Many swimmers
admit that they try to
get back into shape
too quickly.
have pain at the beginning and near the end of
every season, because they are either trying to
get into condition or are getting tired as the
intensity of the training sessions increases.
Many swimmers admit that they try to get
back into shape too quickly, and it makes
their shoulders sore, but they still begin each
season by training too vi"gorously. The obvious treatment is to resume conditioning and
swimming gradually.
If there is no his tory of shoulder pain and it
began suddenly, further questioning about
the activity that exacerbates it is important.
For example, swimmers frequently participate in other sports-especially softball or
baseball-during the summer. Shoulder pain
after throwing is common in swimmers and
can be severe. Obviously, the treatment is to
stop throwing if swimming is the sport of
choice. If the athlete insists on participating in
a throwing sport, graduai throwing practice
with appropria te warm-ups and good throwHlstory
The history is the most important part of ing techniques are mandatory. A fatigue fracthe evaluation of shoulder pain in swimmers. ture may develop from weight lifting, and
The physician should first ask what position adolescents may even develop pull-off fraccauses the pain and where the pain is located. tures from the repetitive or sudden strain of
In typical swimmer's shoulder, pain most weight-lifting and weight-training routines.
commonly occurs in internai rotation and Frequently only one specifie exercise causes
forward flexion between 60° and 90°, which pain, _and the treatment is to eliminate that
is straight overhead, and then pulling down exerc1se.
another 30°. l·l.8 The pain is localized to the
The physician should next ask what strokes
front of the shoulder along the coracoacro- the patient swims and which ones aggravate
mial ligament from the coracoid to the the pain. Distance freestyle events and the
acromion or possibly to the midlateral line butterfly are common offenders. Backstroka round the acromion. Pain in the back of the ers also frequently have pain, but it is uncomshoulder is much Jess typical. Pain in the mon in breaststrokers, even though they train
parascapular region and trapezius is usually mainly in freestyle. If only one stroke causes
pain and it is not the swimmer's main stroke,
caused by fatigue from the training routine.
Next, the physician should ask whether the the treatment may be to eliminate that stroke
shoulder goes in and out of joint. The straight from the training routine for awhile.
The next questions are how far the athlete
overhead position when a backstroker
swims
and whether or not he has suddenly
touches the wall often causes this. Because the
swimmer suspects it is starting togo out, this increased the distance, which is common at
inferior subluxation of the shoulder is called the beginning of a season and is almost more
"apprehension shoulder. "1 lt is also possible important than the actual distance. lt is
for swimmers to have anterior subluxation of common to note an increase in pain at the
beginning of the training season.
the shoulder.
Swimmers who only swim during the
Another question is whether the swimmer
has ever had shoulder pain 6efore. Shoulder three-month high school season and try to
pain tends to be a recurring problem in keep up the same training routine as swimswimmers, and many experienced swimmers mers who swim 9 to Il months a year often
repetitive stress would lead to swelling and
resulting bicipital tendinitis, further irritation,
and rotator cuff tendinitis. ln addition, sudden increased stress on the rotator cuff can
cause swelling or trauma to these tendons.
Because of the small clearance of the rota tor
cuff under the coracoacromial ligament and
the acromion (coracoacromial arch), any significant swelling will cause these tendons and
the overlying subacromial bursa to impinge
on the coracoacromial arch, which is quite
painful.
Impingement occurs in the normal shoulder
if abduction is attempted with the shoulder in
marked internai rotation. 7 lmproper stroke
mechanics, such as abduction with progressive internai rotation at the wrong time, may
lead to an impingement syndrome. AH three
of these mechanisms probably play a role in
the development of swimmer's shoulder.
38
Vol 8 • No 7 • ~ 110 •TM• PIIYIICWIAIID IPOIITIM.DICIII.
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develop pain. Three-month swimmers can
often swim 2,000 to 5,000 yards before developmg pam.
The physician should also ask what time of
the season it is. Treatment frequently depends
on the time of the year, because most swimmers attach varying degrees of importance to
the events that they swim. The most important events are usually in the late winter or
early spring and again in late summer. At the
state high schoollevel, however, there can be
a wide variety. Treatment will depend on
whether there will be rest from training after
important events.
The final questions relate to previous
treatments and if there is paresthesia, numbness, tingling, or discoloration in the arm.
Paresthesia or changes in coloration may
indicate a thoracic outlet syndrome, cervical
spine problem, or a vascular complication
from a thoracic outlet syndrome or stress
thrombosis. Fortunately, these conditions are
not common in swimmers.
An additional question should be whether
the swimmer is recovering from any illnesses
such as the flu or mononucleosis. Shoulder
pain, especially muscular back pain in the
parascapular region, is common during recovery from various viral illnesses and may
last for three to six weeks after recovery from
the acute febrile episode. There is no way to
speed up this recovery, but the swimmer
· should decrease the training until the pain
resolves.
Physlcal Examlnatlons
The physical examination is important but
frequently unremarkable. lt is common for
swimmers with complaints of pain in the back
of their shoulders or the trapezius and parascapular region to have a normal examination.
The typical area of tenderness in swimmer's
shoulder is along the coracoacromial ligament and also under the acromion itself. The
pain is most marked with the arm overhead
and internally rotated from about 60° to 90°,
such as when the swimmer would be pulling
through in either the butterfly or freestyle.
This motion frequently elicits a positive jerk
test8 or impingement sign that is extremely
painful and mimics the pain exactly. With
these findings the diagnosis of swimmer's
shoulder is almost assured, but if these tests
are negative, the diagnosis is in doubt.
If there is significant swelling, diffuse tenderness, loss of sensation, atrophy, or loss of
pulse, the problem is more severe. 1t is
uncommon to find any wasting or significant
loss of motion. Having the swimmer put his
arm in the offending position or do the
offending motion often helps the physician
palpate and confirm a subluxation or the
tensing from an impending subluxation.
X-rays
Under age 25, x-rays for evaluating
shoulder pain in competitive swimmers are
usually normal and are taken only to rule out
underlying osseous pathology. X-rays are
essential for diagnosing a pull-off fracture or
a stress fracture. However, a stress fracture
may only appear on x-rays after two weeks.
If the physician suspects subluxation of the
shoulder, cineradiographs may be necessary.
Having the patient do the motion that causes
pain allows the examiner to see the humeral
head riding to the edge of the glenoid and
then clic king back into place. Unless the physician suspects a rotator cuff tear, arthrography will probably not be helpful.
Treatment
Treatment of swimmer's shoulder is usually simple and basic, but at times it can be
complex, confusing, and difficult. There are
only a few basic treatment modalities: rest,
ice, proper training (including weight training), anti-inflammatory agents, transcutaneous electrical nerve stimulation (TNS), and in
rare cases, surgery.
Rest. Rest is the main treatment for swim-
mer's shoulder. The patient under age 12
should totally rest from swimming until the
symptoms have resolved. ln this age-group
virtually ali lesions should heal with rest
alone. Swimmers over age 12 may not necessarily need absolute rest, depending on the
situation. Modified rest and swimming within
pain tolerance or up to the point of pain may
be permissible. Swimmers are frequently able
to swim severa) thousand yards before their
continued
1111 PIIYIICWI AIID UOIITIIIIDICIIII • Vell• No 7 • .U 110
38
The aim is to permit
sorne swimming
and healing at the
same time.
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shoulders hurt. They are also permitted to
train by kicking without the use of their arms
if holding onto the kick board is not painful. If
the swimmer is recovering from a viral illness,
an understanding of its effects and modification of the training program are ali that is
necessary un til he recovers. If the pain develops near the end of the season, it is often
ad visa ble tolet the swimmer swim and ignore
it, because he will soon get four to eight weeks
of rest before starting to train again.
It is uncommon for swimmers under age 25
to have pain in nonswimming activities, so
rest is usually sufficient to treat most cases.
The aim, however, is to permit sorne swimming and healing at the same time, so the
physician must use judgment. Over age 25,
when degenerative processes, pericapsulitis,
and tendinitis are common, rest alone may
not be sufficient.
/ce. lee is the therapeutic agent of choice.
Experienced athletic trainers who have
treated swimmers recommend applications of
crushed ice in a bag or preferably in Styro-
foam or paper cups 10 to 15 minutes a session,
four or five times a day, if possible. lee massage can be applied by the athlete to the
tender area at least before and after swimming but preferably four or five times a day.
This can be alternated with heat, but ice
should be the prime treatinent besides rest.
Training Routine. Proper technique with
weight training is essential. Because most pain
occurs in the beginning or middle of the season, fatigue plays a significant role. Since the
almost universal acceptance of weight training, severe shoulder pain in swimmers seems
to be Jess of a problem. However, depending
on various anatomical and strengthening factors, sorne weight-lifting techniques are painfui for sorne swimmers and should be avoided.
This is especially true in the ex tremel y flexible
swimmer who has apprehension shoulder or
subluxations of the shoulder.
The degree of sophistication and training
distances necessary to be competitive on a
state-wide level in high school is such that it is
impossible to train only three or four months
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a year and not develop shoulder pain. Although 1 believe that swimmers should have
at !east one or two months off each year, 1
also believe that to be competitive on a state
and national leve! they must train at !east nine
or ten months a year to swim the training
distances required.
This is where the history is essential. Increasing numbers of swimmers train through
an age-group program until high school and
then drop out and swim only during the high
school season, which in most states is abbreviated. Most of these swimmers develop
shoulder pain because they are not in the
program long enough to swim the distances
demanded of them.
Anti-injlammatory Drugs. Aspirin is the
anti-inflammatory drug of choice in almost
ali persons. Gastrointestinal side effects are
documented, but most swimmers are aware
of whether or not they have ulcer disease,
susceptible stomachs, or an intolerance to
aspirin that contraindicates its use.
The problem with aspirin is that swimmers
and the ir parents don 't see it as a therapeutic
agent, so there is sorne question of patient
compliance. lt should be routinely administered after meals three or four times a day.
With an explanation of the anti-inflammatory and therapeutic benefits of aspirin, most
patients will accept it.
In swimmers under age 25 who fail to
respond to salicylates or who can't take
aspirin, ibuprofen is an effective agent. In the
late teens and middle 20s, indomethacin or
phenylbutazone (Butazolidin) are helpful.
Over age 25 the drug of choice after aspirin is
either indomethacin, phenylbutazone, or
sulindac, which seems to offer sorne promise.
In the past severa! years, because of better
understanding and increased competence in
treating this condition, 1 have not found it
necessary to inject shoulders of young swimmers with steroids. Also, because steroids
weaken tendons for three to six weeks, 1
believe that informed consent from the
swimmer, coach, and parents is necessary
before the injection. They should be warned
that vigorous use may predispose the swimmer to further long-term injury, even though
Ttll IIIIYSICIAII AIID IPOIIITSIIIDICIMI • Vol 8 • No 7 • Jlj 110
the injection may relieve the pain on a short- Steroids do not
term basis. Knowing this, few people cons id er affect the natural history
an injection in spite of severe pain. 1am con- of swimmer's shoulder.
vinced that steroids do not affect the natural
history of this condition. Over the long run in
the under-25 pppulation they have had no
long-term beneficiai effects.
However, over age 25 the use of steroids is
a different issue because of calcifie deposits.
The warning still applies, but the use in severe
shoulder bursitis and tendinitis can be defended because of the reduced healing capabilities and tissue properties in this age-group.
TNS. TNS is an effective means of obtaining relief of pain for patients who have not
responded to the first three treatment modalities and are still having pain. 1know of no side
effects from its use other than tape allergies.
Although its efficacy may only last for 30 days
orso, it is helpful near the end of a season to
carry a swimmer through finals. The best
chance of success with this modality is with a
therapist or trainer who has experience or
training in TNS. If the therapist or trainer is
unfamiliar with TNS, he should either find
one who is or take additional training in this
modality.
Surgery. These treatments may not be
appropriate if the re is evidence of cervical rib
or thoracic outlet syndrome'-specifically,
paresthesia, discoloration, or swelling. Cardiovascular, thoracic, or neurosurgery consultation may be necessary in these situations.
The value of the sport must be weighed
against major surgical procedures, which may
have results that still preclude vigorous swimming. 1 know of no significant studies on
swimmers who have successfully returned to
swimming after such surgery, but 1 have
heard of individuals who have tried with
sorne success but also with significant
symptomatology.
For swimmers who have had disabling
swimmer's shoulder or a coracoacromial arch
impingement syndrome for 12 months in
spite of good treatment and who strongly
desire to continue swimming, 1 recommend
consultation with an orthopedie physician
familiar with shoulder surgery for this condicontinued
41
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Surgery should be
done only if the
disabiUty is severe and
justifies correction.
tion. Coracoacromialligament resection alone
or combined with acromioplasty can be beneficiai in properly selected patients.u.Q However, this procedure may have little or no
benefit for swimmers with subluxations of the
shoulders, so the diagnosis must be firmly
established before surgery.
Surgery may be a plausible treatment for
swimmers who are disabled with recurrent
subluxations or dislocations of the shoulder
confirmed by cineradiographyY If they are
unable to swim because of the disability and
they feel that swimming is worth it, or if the
subluxations occur in activities other than
swimming, surgical repair by an orthopedie
surgeon familiar with the demands of swimming is necessary.
Conclusion
Using this sequential approach to treatment, almost ali cases of swimmer's shoulder
can be successfully managed. However, at
times the complaints do not correlate with the
findings or the response seems inappropriate.
ln those instances 1 recommend a phone cali
to the coach and a frank discussion about
how he sees the problem. Coaches often present a different picture and are usually more
objective than the parents about the swimmer's problem and tolerances. At times it is
helpful to have the parent, coach, and swimmer together for a discussion, but in difficult
cases 1recommend a priva te consultation with
the coach. The coach may realize that a
swimmer is not as disa bled as he daims to be.
Other significant factors in shoulder pain
include the inability of sorne swimmers to face
failure such as losing a re lay spot, or they can 't
face a new competition, parental pressure, or
the demands of swimming. The swimmer
may not be complying with therapy. This part
of the history is frequently ignored but can
be vital to understanding the problem.
Swimmers who don't respond to treatment
must be carefully reevaluated at frequent
intervals. What may have appeared to be a
sore shoulder on an initial visit may, with
careful inspection and questioning on followup examination, turn out to be repeated luxations of the shoulder in an extremely flexible
person. These individuals commonly are
unable to swim the breaststroke or they have
trouble with patellar subluxations in that
event. ln these cases the physician may suspect that they have loose shoulders as weil,
although frequently the two do not correlate.
Obviously, treatment for recurrent subluxations of the shoulder is different.
If the disability is merely a nuisance and a
swimmer is able to cope and swim, it is safe to
ignore it. Surgery should be done only if the
disability is severe and justifies correction.
Almost ali swimmers respond to basic conservative treatment. Even though my practice
includes more and more swimmers, 1 see
fewer swimmers who need to be considered
for surgery . . _
Address correspondcnce to Richard H. Dominguez, MD,
Mona Kea Professional Park, 501 Thornhill Dr, Wheaton/
Carol Stream, IL 60187.
References
1. Kennedy JC, Hawkins RJ: Swimmer's shoulder.
Phys Sportsmed 2:34-38, April 1974
2. Dominguez RH: Swimmer's Shoulder. A Preliminary Report and Report of a Case. Presented to the
American Orthopedie Academy for Sports Medicine, New Orleans, 1976
3. Dominguez RH: Shoulder pain in age-group swimmers, in Eriksson B, Furberg B (Eds): Swimming
Medicine IV, vol 6. Baltimore, University Park
Press, 1978, pp 105-109
4. Hall G: Shoulder Pain in Swimmers. University of
Cincinnati, 1978, persona[ communication
5. Richardson AB: Shoulder Pain in Swimmers. Study
of Patients at an Olympie Training Center, Pre-
42
6.
7.
8.
9.
sented to the Competitive Swimming Sports Medicine Committee, Colorado Springs, CO, February
1979
Counsilman JE: The Science of Swimming. Englewood Cliffs, NJ, Prentice-Hall, lnc, 1968
De Palma AF: Surgery of the Shoulder, 2nd edition.
Philadelphia, J.P. Lippincott Co, 1973
Kennedy JC: Orthopedie manifestations, in Eriksson B. Furberg B (Eds): Swimming Medicine IV,
vol 6. Baltimore, University Park Press, 1978,
pp 93-100
Dominguez RH: Coracoacromial ligament resection for severe swimmer's shoulder, in Eriksson B,
Furberg B (Eds): Swimming Medicine IV, vol 6.
Baltimore. University Park Press, 1978, pp 110-114
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