SWIMMER’S / SURFER’S SHOULDER

Swimmer's or Surfer's Shoulder is a common condition affecting both competitive and recreational swimmers and surfers. It is basically an overuse injury which results in the patient presenting with impingement or rotator cuff type symptoms during or after performing the aggravating activity.
 
The primary pathology is muscular imbalance. The freestyle and surfer’s strokes result in overdevelopment of both the shoulders internal rotators (subscapularis), compared to external rotators (infraspinatus) and the anterior chest wall musculature (pectoralis major and minor ) relative to the posterior wall scapular stabilisers ( rhomboids, levator scapulae, serratus anterior and parts of the trapezius).
 
The end result is that scapula assumes a protracted abducted position with associated reduction in the subacromial space. This, combined with the relative weakness of the infraspinatus, leads to impingement of the supraspinatus tendon on the under surface of the acromion. The swelling associated with repeated impingement leads to further reduction of the subacromial space.
 
With time the abnormal scapula position becomes relatively fixed secondary to tight anterior structures.
 
Left untreated the patient suffers continuing disability and risks the development of supraspinatus tendinosis or tear.

Diagnosis
 
The diagnosis is usually straight forward. The patient complains of anterior shoulder pain during or after the activity.
 
During swimming the freestyle the swimmer may demonstrate a wide flattened stroke, the so called “dropped elbow”, this may be present at the start of the swim or develop during the swim as the scapula stabilizers (especially serratus anterior) fatigue.
 
On examination they often have bilateral abnormal scapula malpositioning resulting in a round shouldered appearance and slight winging, tenderness over the supraspinatus insertion into the greater tuberosity is common, a painful arc is often present in forward flexion and abduction, impingement tests are positive.
 
Shoulder stability should also be assessed as subtle instability is common in swimmers and may contribute to impingement.

Treatment
 
Treatment involves correction of the muscle imbalance and anterior shoulder stretches.
 
Initially a thera-band programme focused in external rotation (infraspinatus) strengthening and scapular stabilization exercises, progressing to weight machines and free weights as tolerated, combined with appropriate stretches.
This approach is usually successful; it may need to be augmented with judicial use of subacromial corticosteroid to settle acute symptoms in florid cases.
 
Ideally these exercises shoulder be part of the swimmers or surfers training so as to prevent the condition in the first place.