A physiotherapeutic approach to shoulder instability in the competitive swimmer - PowerPoint Presentation

Slide1

A physiotherapeutic approach to shoulder instability in the competitive swimmer

Slide2

Sports Physiotherapist specialising in swimming

Founder and practice principal physiotherapist, Newcastle Physiotherapy

Former Senior GB International swimmer and British record holder for 200 and 400 I.M

Member of the GB Swimming Physiotherapy team, London 2012 Olympic Games

Darren

Wigg, Bsc (Hons) MCSPSM, HCPC Reg.

Introduction

Slide3

What is shoulder instability?

Inability to maintain HOH in glenoid

Can occur anteriorly (

est

98%), posteriorly or multidirectionallyAtraumatic instability occurs from repetitive overload or congenital joint featuresFocus today on atraumatic overload through swimming

Slide4

Ball and socket joint

Head of

humerus

and Glenoid

Very small shallow glenoid – ‘golf ball on a tee’

Inherently unstableNecessary for huge multi-directional ROM required

Anatomy

Slide5

Static stability

Superior Glenohumeral

Ligament

Limits anterior and inferior translation of adducted humerusMedial Gleonohumeral LigamentLimits anterior translation in lower and middle range of abductionInferior Glenohumeral LigamentPrimary

static restraint against anterior and posterior and inferiortranslation when humerus is abducted beyond 45

degreesGlenoid LabrumIncreases depth of glenoid cavity and increases stability up to 50%Negative intra-articular pressureAssists in maximizing joint congruency.

Slide6

Dynamic stability

Dynamic stability is provided by the rotator

cuff

Innervated by C5-6

Originate from the scapularAll have a different function………

Slide7

Dynamic stability

Supraspinatus initiates abduction and continues through range with deltoid

Infraspinatus laterally rotates primarily with arm in neutral

Teres Minor laterally rotates and is more active when arm is in 90 degrees of abductionSubscapularis internally rotates, strongest rc muscle providing 53% of total cuff strength

Slide8

Mobilisers

Slide9

Mobility demands

Slide10

Mobility demands

Slide11

Swimming shoulders

Abnormally high number of shoulder rotations per arm, per year

How many…..

Slide12

………..1.32 million!!

Slide13

Swimming shoulders

Shoulder instability and joint

hypermobility

common in elite

level swimmers – why???Swimmer screening results show hypermobile = better swimmersBeighton’s Score - higherAppears to be advantage for the competitive swimmerInstability

can lead to shoulder pain and pathologySubtle

balance required between mobility, strength and motor control

Slide14

Presentation, common subjective findings

Constant/intermittent pain, deep ache

Often report

cluncking

or clickingOften insideous onsetAggravating activities: catch and recovery phase of FC,BF and BC, lying on it, overhead activitiesEasing activities: support, avoidance of aggs, NSAID’S, iceActivity dependent rather than diurnal patternOften report recent change in training load/type - overload

Slide15

Posture

Swimming predominantly uses the anterior muscles at the front of the shoulder and chest

This can cause those muscles to become overactive and short pulling the shoulder forwards. The muscles at the back become underactive, weak and long

Kyphotic thoracic spine, protracted shoulder girdle and anteriorly translated HOH can narrow sub-acromial space and predispose swimmers to pain

Slide16

Presentation, Common objective tests/findings

Scapula winging or

dyskinesis

Painful arc of elevation

Positive RC tests and resisted testsPositive instability tests…..

Slide17

Load and Shift test

One hand stabilising over acromion

Other hand gripping HOH

Compress and glide anteriorly and posteriorly

Grade laxity 1-3

Slide18

Apprehension Relocation

Anterior instability

Shoulder at 90 abduction

Take to full passive LR

Apprehension positive if pain and or apprehensionRepeat with AP force through HOHIf pain free – test positive

Slide19

Sulcus sign

Superior

glenohumeral

ligament

Multidirectional instabilityOne hand on acromianOther hand gripping shaft of humerus above the elbow

Positive if sulcus appears below acromian

of 2cm or above

Slide20

Hypermobility assessment

Beightons

Score for hypermobility

Score above 4

Research suggests 10% of populationReduced levels of collagen in connective tissue

Slide21

Beightons Score

Hypermobility

Slide22

Secondary problems

Shoulder instability

can

predispose the swimmer to shoulder pain due to:Rotator cuff impingement, tears or tendonopathiesSub-acromial bursitis

Labral tears

Shoulder laxity per se minimal association with impingement (Lay Sein et al 2009)

Slide23

Typical treatment plan

Advice and education

surrounding acute pain management and adaption of training - coach

Supportive tape

Manual therapy:Mobilisation of stiff joints (usually cervicothoracic region)Mobilisation of overactive muscles (usually posterior cuff and subscapularis, pecs, upper trapezius)Exercise therapy:Initially low level scapular stability and control, progressing to more complex sport specific workRotator cuff conditioning with good scapular control, progressing through larger ROM as ableProgressive upper limb weight bearing exercise to stimulate stability muscles Stretching and foam roller/ trigger point ball for tight overactive mobilisers………

Slide24

Stroke / program analysis

Stroke analysis and attentive coaching will help to avoid the common mistakes which contribute to shoulder

pain

The

common faults in technique that reduce efficiency also increase risk of injuryPoor frontcrawl technique can predispose a swimmer to shoulder painInsufficient trunk rotation with a pull that crosses the mid line of the body is the main causative factorPoor core stability in the water can also contribute to the problemManage training loads ? Most important – most often asked why now?

Slide25

Delicate balance

We can’t strengthen ligaments without surgery!

We must strengthen the rotator cuff and scapular musculature to compensate for ligamentous laxity

Reduce muscle imbalances

Work on improving motor control and upper limb proprioceptionImprove spinal and shoulder girdle postureImprove technical deficienciesManage training loads

Slide26

Conclusions:

 These data indicate: (1) supraspinatus tendinopathy is the major cause of shoulder pain in elite swimmers; (2) this tendinopathy is induced by large amounts of swimming training; and (3) shoulder laxity per se has only a minimal association with shoulder impingement in elite swimmers.

Br J Sports Med 

doi:10.1136/bjsm.2008.047282

Shoulder Pain in Elite Swimmers: Primarily Due to Swim-volume-induced Supraspinatus TendinopathyMya Lay Sein (mlsein@gmail.com)Orthopaedic Research Institute, AustraliaJudie Walton (j.walton@unsw.edu.au)Orthopaedic Research Institute, AustraliaJames Linklater

 (linklj@telstra.com)Castlereagh Imaging, AustraliaRichard AppleyardOrthopaedic Research Institute, Australia

Brent KirkbrideNew South Wales Institute of Sport, AustraliaDonald KuahNew South Wales Institute of Sport, AustraliaGeorge AC Murrell (murrell.g@ori.org.au)

Slide27

refs

Hayes K, Callanan M, Walton J. Shoulder instability: Management and rehabilitation. JOSPT 2002;23(10):497-509.