Swimmer's Shoulder Clinical Presentation

Updated: Feb 03, 2017
  • Author: Sherwin SW Ho, MD; Chief Editor: Craig C Young, MD  more...
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Presentation

History

Taking a careful and detailed history greatly aids the physician in the diagnosis of swimmer's shoulder.

  • The adolescent or teenaged swimmer often presents with a history of a recent growth spurt, an increase in the level of training and competition, or both.

  • Pain associated with the condition

    • Initially, the pain is only noted during or immediately after swimming.

    • As the athlete tries to swim "through the pain," it may worsen to the point where it affects nonswimming shoulder activities and might eventually be noted at rest or at night.

    • When the athlete finally stops swimming because of the pain, the condition often improves but recurs with a return to swimming if the rotator cuff has not been specifically restrengthened.

    • The character of the pain in swimmer's shoulder is similar to that of rotator cuff pain. The pain is often poorly localized and felt to be deep within the shoulder.

    • On occasion, the pain can be associated with a particular position or phase of the stroke.

    • A reproducible click or painful catch should alert the examiner to the possibility of a glenoid labral tear.

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Physical

Ask the patient to localize the area of pain. They may describe the pain as being deep, localized to the posterior aspect of the shoulder. Less commonly, they occasionally localize the pain anteriorly or at the deltoid insertion area of the upper arm. Pain characterized as such is consistent with rotator cuff tendinitis, the most common underlying cause of pain in swimmer's shoulder.

Observe both shoulders for any asymmetry, particularly in scapular position, or rotator cuff muscle mass (atrophy).

  • Range of motion

    • Check the ROM of both shoulders, comparing one side to the other.

    • The author typically measures the following:

      • Forward flexion and/or abduction (>180°, combined glenohumeral joint and scapulothoracic motion)

      • Glenohumeral joint abduction (>90°, measured by stabilizing the scapula with one hand, while abducting the glenohumeral joint alone)

      • Abducted external rotation (>90°, measured with the shoulder in 90° of abduction, with the elbow flexed)

      • Abducted internal rotation (>90°, same technique as abducted external rotation)

      • Maximum internal rotation (thoracic vertebrae T4-T6, measuring combined glenohumeral joint and scapulothoracic motion by having the patient reach up his/her spine with the thumb)

    • In most swimmers, both internal rotation (IR) and external rotation (ER) are increased as compared to the general population.

  • Check shoulder strength

    • Assess the strength of the rotator cuff by resisting internal rotation (subscapularis) and external rotation (infraspinatus, teres minor) with the shoulder in the neutral position (at the side) and the elbow flexed to 90°.

    • Assess the strength of supraspinatus using the Jobe test position, with resisted shoulder elevation with the arms extended, internally rotated, and positioned in the scapular plane (approximately 30-45° anterior to the coronal plane). If weakness is apparent, retest the supraspinatus in the same arm position except with the arms externally rotated (ie, thumbs pointing upwards).

    • Assess the strength of the subscapularis with the subscapularis lift-off test. Perform this test by placing the shoulder in internal rotation with the back of the patient's hand against the small of the back. The patient attempts to lift hand away from back against the examiner's resistance.

    • Early on, the above tests may only produce pain; however, in advanced cases, weakness in the involved muscle, most commonly the supraspinatus, may be noted.

  • Check shoulder stability

    • Perform a shoulder apprehension test by placing the shoulder in maximum abduction and external rotation (90-90 position) while applying an anteriorly directed force to the shoulder from behind in an attempt to elicit a feeling of apprehension or instability. This test typically elicits some discomfort but no apprehension or sense of instability in most swimmers.

    • Perform anterior and posterior drawer tests of the humerus both in neutral with the patient sitting, and supine with the arm abducted 90°, while axially loading the glenohumeral joint (load and shift test). Compare to the opposite shoulder.

    • In most swimmers' shoulders, a mild-to-moderate increase in laxity is noted, indicating multidirectional laxity. Occasionally, this can lead to symptomatic instability in which the swimmer complains of the shoulder subluxing or shifting with use.

  • Check joint laxity

    • Assess inferior laxity by identifying the presence of a sulcus sign. This is completed by pulling the arm inferiorly, while checking for a gap or sulcus between the humeral head and lateral edge of the acromion, indicating inferior subluxation of the humeral head.

      • Grade 1 - Less than 1 finger breadth (< 1 cm)

      • Grade 2 - One finger breadth (1-2 cm)

      • Grade 3 - Greater than 1 finger breadth (> 2 cm)

    • Compare to the opposite shoulder (should be similar, except following unilateral traumatic injury).

    • Check for generalized ligamentous laxity (GLL) in other joints (eg, hyperextension at elbows and knees, thumb to forearm test, middle finger hyperextension to forearm). Generalized ligamentous laxity indicates a significant amount of inherent joint laxity related to the individual's collagen composition and is more commonly found in females than males. Multidirectional instability (MDI) is more difficult to manage in the presence of GLL.

  • Check for labral tear

    • A labral tear is suggested when a painful click is noted during the recovery phase of the any overhand stroke. Often, the swimmer can reproduce this click during the exam.

    • The O'Brien test can suggest a superior labral tear, or the so-called SLAP lesion. Have the athlete resist a downward force with the arm extended in the forward flexed position, adducted 15° toward the midline, with the shoulder in maximal internal rotation (thumb pointing down). Pain produced with this maneuver and relieved with the arm externally rotated suggests a SLAP lesion.

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Causes

See the list below:

  • As the shoulder is pushed to its limits in terms of strength and endurance, the rotator cuff muscles generally fatigue before the power muscles, allowing micromotion and subluxation of the humeral head. This, in turn, decreases stroke efficiency, while leading to injuries of the rotator cuff, biceps tendon, and glenoid labrum.

  • Superior subluxation of the humeral head is particularly problematic as it can impinge the rotator cuff tendons against the acromion above, leading to tendinitis and/or tears. The overlying subacromial bursa (also referred to as the subdeltoid bursa) often becomes inflamed, leading to painful bursitis.

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