Acute Phase
Treatment of swimmer's shoulder in the acute phase is primarily with physical therapy. Working with a physical therapist can be helpful, particularly one with expertise in treating shoulder injuries and swimmers, who can oversee a rehabilitation program that helps the athlete transition from dry land exercises to swimming. Surgical intervention may be considered in athletes with persistent pain.
Rehabilitation program
Pain relief, which is the first goal of treatment, involves resting the shoulder. In most cases, the athlete should stop or significantly decrease his or her swimming activities. A physical therapist can help modify shoulder and activities to help avoid re-aggravation of the rotator cuff. Anti-inflammatory treatment in the form of regular icing and nonsteroidal anti-inflammatory medications should also be instituted until the athlete is pain free.
The second goal of treatment is to restore normal strength in the rotator cuff. Regaining strength can be accomplished with a supervised exercise program for the rotator cuff using relatively light weights (2-3 lb, up to a maximum of 5 lb) and high repetitions (12-20 reps per set). These exercises can be performed on a daily basis or every other day.
The addition of therapist-administered therapeutic modalities can help further reduce pain and inflammation during the acute phase of injury. These may include the following:
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Ultrasound
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Phonophoresis
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Iontophoresis
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Electrical stimulation
Surgical Intervention
Surgical intervention is considered in athletes who continue to have shoulder pain after a minimum of 6 months of guided rest and rehabilitation.
The surgical procedure should include an examination under anesthesia to determine the degree of laxity, a diagnostic arthroscopy (to look for labral or rotator cuff tears and capsular laxity), and, when indicated, a surgical tightening of the lax capsule (capsulorrhaphy). In the older athlete, a subacromial decompression is typically performed if there is arthroscopic evidence of impingement.
The athlete should be cautioned about the postsurgical trade-off of increased shoulder stability for some loss of flexibility, resulting in difficulty in returning to swimming at the same level as before the injury.
Baker et al determined that arthroscopic management of symptomatic multidirectional instability can return athletes to sports with a high rate of success. [9] In their study of 40 athletes (mean age 19.1 y; 24 males; 16 females), at a mean of 33.5 months follow-up, the mean American Shoulder and Elbow Surgeons score was 91.4 of 100 (range, 59.9-100), and the mean Western Ontario Shoulder Instability postoperative percentage score was 91.1 of 100 (range, 72.9-100). [9] Full or satisfactory range of motion was reported in 91% of the patients, normal or slightly decreased strength was noted in 98%, and 86% of the athletes had little or no limitation on returning to their sport.
Using electromyography, Illyes et al compared the muscle activity in patients who received conservative therapy (n = 34) and those who underwent capsular shift with postoperative rehabilitation (n = 31) with the muscle activity of individuals with stable shoulder joints (n = 50) before and after treatment during pull, push, and elevation of upper extremities and during overhead throw. [10] The investigators found that the post-therapy muscle patterns of both treatment groups were similar to those of the healthy control group. However, whereas conservative therapy restored muscular control, the open capsular shift treatment combined with postoperative conservative rehabilitation resolved the patients' labrous ligamentous abnormalities and restored muscular control. [10]
Kiss et al compared the kinematic parameters and the on-off muscle patterns of patients with multidirectional instability treated by physiotherapy (n = 32) or by capsular shift and postoperative physiotherapy (n = 19) before and after treatment during elevation in the scapular plane. Both treatment groups' results were compared with those of 25 healthy individuals. [11] Patients with multidirectional instability had different scapulothoracic and glenohumeral rhythms as well as increased relative displacement between the scapular and humeral rotation centers relative to the healthy subjects.
Although physiotherapy strengthened the rotator cuff, biceps brachii, triceps brachii, and deltoid muscles, as well as increased the neuromuscular control of the shoulder joints in patients with multidirectional instability, it did not restore the alteration in shoulder kinematics in these patients. [11] However, capsular shift and postoperative physiotherapy angulation at 60º of scapulothoracic and glenohumeral rhythms restored the relative displacement between the scapular and humeral rotation centers as well as the duration of muscular activity.
Consultations
In cases unresponsive to rest and rehabilitation, consultation with an orthopedic surgeon is recommended.
Other Treatment
A corticosteroid injection may be considered in older patients but is rarely used in adolescents and almost never in skeletally immature patients.
Recovery Phase
A capsulorrhaphy usually requires immobilization in an arm sling or immobilizer for 4-6 weeks to allow the capsule to heal in the surgically-tightened position. This is then followed by a rotator cuff strengthening program in physical therapy. Passive range of motion (PROM) is typically restricted during this time so as not to stretch out the capsule. ROM commonly returns on its own with exercise and normal shoulder use. One can expect about 50-75% of the normal shoulder motion to return by 3 months and 100% of motion by 6 months following successful surgery. Modified stroke work can begin once the athlete achieved a minimum of 80% of normal motion and strength in the shoulder. Return to competitive swimming is anticipated between 6 and 12 months following surgery.
Maintenance Phase
The maintenance phase is the final phase of rehabilitation. The athlete should be independent with a strengthening program as instructed by his or her athletic trainer or physical therapist. The therapist and coach should both be involved in re-assessment of swimming mechanics and stroke technique, addressing any errors to prevent recurrence of injury.
