Returning from injury and prevention article

By G. John Mullen of SwimmingScience.netand CenterofOptimalRestoration.com, Swimming World correspondent

Dr. G. John Mullen is a Doctor of Physical Therapy and a Certified Strength and Conditioning Specialist. At USC, he was a clinical research assistant at USC performing research on adolescent diabetes, lung adaptations to swimming, and swimming biomechanics. G. John has been featured in Swimming World Magazine, Swimmer Magazine, and the International Society of Swim Coaches Journal. He is currently the strength and conditioning coach at Santa Clara Swim Club, owner of the Center of Optimal Restoration and creator of Swimming Science.

"DR. John, my shoulder feels like someone left a fork inside it." It's not every day I hear such a descriptive term applied to shoulder symptoms, especially from an athlete whose primary language is not English.

I looked in the pool to see one of the Norwegian National Team members rubbing her shoulder; I had her hop out to take a quick look. A few questions were racing through my mind as she hopped out, does she always have shoulder symptoms during kick sets? What strokes cause her symptoms? What phase of these strokes cause her symptoms? How long has she had these symptoms? Will getting out of the pool hurt her shoulder? Why does she wear her cap like a helmet...must be a Norway thing?

She climbed out of the water, favoring her uninjured shoulder, then walked over to me on the frigid pool deck of Santa Clara Swim Club. I asked her a plethora of questions ranging from frequency of her symptoms, to what strokes and phases of her strokes are most symptomatic. Following my inquiry, I had her perform precise shoulder movements to discover what was causing her symptoms and obtained a clear picture of weak shoulder blade stabilizers and posterior rotator cuff muscles. She told me she has had symptoms for the past four months and they were more pronounced during the "catch" of her freestyle.

We immediately moved from the pool to the weight room and performed a session to improve muscle tone, immediately leading to improved strength. After 15 minutes, she was asymptomatic with the same movements. It is all fine and dandy that her symptoms improved, but the cause is not resolved and her symptoms will return in the pool. Therefore, specific guidelines are mandatory to ensure proper shoulder health and injury prevention. Unfortunately, swimming is a unique sport where missed time in the water impedes success, especially during crucial moments before big competitions. This series will address why missing a few days in the pool greatly alters your "feel" in the water, making you feel like a wet noodle, the health care professionals' and coaches' view on shoulder symptoms and realistic guidelines to return to swimming.

Wet Noodle
Swimming is a unique sport requiring forward movement through an atypical medium, water. This unnatural movement requires countless hours of training to achieve proper biomechanics and to gain awareness in the pool. If a track star misses a few days, they are able to hop on the starting blocks and perform best times...sounds nice! If a swimmer misses a few days, they will hit the water like a wet noodle and be light years off their best times. This difference is due to high neural input required in swimming.

Neural input is why "feel" is essential and discussed on every pool deck. One obvious reason swimming requires high neural input is because swimming is a foreign activity. People cannot swim without lessons; if you throw a toddler in the pool, they will drown. Many other sports utilize natural motions: turning, cutting and jumping performed by toddlers many times during the day. These motions aren't only in childhood, I haven't run a 5k in a few years, but I guarantee if I left on a 5k run I'd feel fine at the beginning, then I'd die. Think about it, even if you don't jog or run, you walk around each day of your life. Swimming is nearly the opposite as you never swim unless you do a practice or race your bathtub toys. If you're in adequate cardiovascular shape, but miss a few workouts, you walk around on deck mentally tackling the water, standing on the block, flexing down, and attempting to perform a front flip off the block...finally in the water it feels like water is rushing off your hand, karate chopping the water. After feeling like Shawn Bradley on Little People, Big World, the neural system improves as your body adapts to water, diminishing this awkward sensation.

Unlike running, where force production is the main component for velocity, drag is the most important variable in swimming. Obtaining an optimal hydrodynamic position is essential and "feel" can control this positioning. Having "feel" controls body position, decreases drag and leads to elite swimming. Unfortunately, missing a few days decreases one's ability to control water and correct body position, leading to swimming like a brick wall.

In running, air is a relatively static medium. Wind occurs, but is less noticed unless high amounts occur. In the water, even slight currents are felt, completely changing body orientation. This is due to the higher density of water. The dense water will alter your movements, leading to a less hydrodynamic position if you miss only a few days of practice. Controlling water is essential and missing a few days will let water and waves control you. Don't miss time in the water, control the water, don't let it control you!

Time Away From the Pool
After an injury, many health care professionals recommend taking time away from the activity contributing to symptoms. This approach isn't only with swimming, but as discussed, time away from swimming is more disruptive for progress than other sports. When college scholarships, advertisements and Olympic dreams are on the line, any unnecessary vacations from the pool impede progress, impairing "feel" and a hydrodynamic position in the pool.

The series' next installment will tackle the reasoning behind taking time off from the pool from a health care professionals' perspective and coaches' perspective. Hopefully, you recognize the importance of feel in the water, even during an injury. Unfortunately, many health care professionals do not understand this concept and if you see anyone about a bum shoulder the first line of treatment includes rest for 2-3 weeks. If during a main training phase, this can greatly impede swimming potential and frankly ruin your season. Coaches are often on the other spectrum, calling all shoulder pain as "muscle pain" having the swimmers get back to their 10x200 butterfly with paddles. This approach can perpetuate shoulder symptoms and lead to a longer recovery. Part II will discuss why these camps take each stand and provide a methodical method to return to the pool to maintain "feel", while improving shoulder symptoms.

Also, if you closely followed part I, you're expecting a piece on health care professionals and coaches approach and view on shoulder injuries. This piece will be later in the multi-part series, but understanding the injury process comes first.

Every active individual will be injured in their life. The more activity you perform, the more likely you will endure a musculoskeletal injury. This may scare or shock some of you, but look on the bright side, a musculoskeletal injury is better than a heart attack, stroke, or diabetes! Also, when I say musculoskeletal injury, I'm not talking about a hangnail, a stubbed toe at the post 2008 Olympic Trials after party, or the thought of doing 10x200's butterfly – I'm talking about an injury requiring more than 20 seconds of whining.

If you are a swimmer, it is likely this injury will occur to your shoulders. It is estimated 80 percent of swimmers will experience shoulder pain during their career. This incidence increases as you age, Masters swimmer beware! If you stave off shoulder injury, it is likely you will injure another body part. No matter the site of injury, there is a physiological process the body goes through depending on the type of injury. This article will discuss the types of injury and their associated physiology process. We are going to go deep on this article, so it's important to focus!

Types of Injury
There are two main types of injuries, macrotraumas and microtraumas.

Macrotraumas are the big, bad uglies; you'll know when they occur. Think of Willis McGahee's knee bending like a flamingo or a swimmer breaking their hand on a relay after going 22.0 SCY...yes I've seen this before. That is a macrotrauma, more specifically: fractures, dislocations, sprains (injuries to ligaments), strains (injuries on muscles and tendons), tears (ligaments), lacerations (deep cuts) and large contusions (bruises).

Microtraumas are typically chronic, overuse injuries. These injuries can start as soreness and progress to certain macrotruamas (sprains, strains). These are sometimes thought as less serious injuries, but can transform into ugly, stubborn injuries. These injuries include tendinitis and stress fractures.

Many athletes ignore microtraumas, trying to push through the pain. Whether this view is self-aided or provided by an overzealous coach, it will perpetuate the injury. However, rest won't necessarily heal the microtrauma either. Nothing worse than getting the courage to allow your coach to take a few days off of workouts to recover and upon returning realizing that, 1) you feel like a wet noodle and 2), your microtrauma hasn't improved. This has pushed swimmers to quitting physically and mentally for years.

Physiological Steps
After any injury (again no hangnails), the body goes through specific steps to repair itself. This linear process takes time and the body goes through each step, never pulling on the lane line to finish earlier.

Step 1 – Inflammation
Everyone is familiar with inflammation. I mean, who doesn't pop a few Non-steroidal Anti-Inflammatory Drugs (NSAIDS like Advil, Aleve) from time to time? This process occurs within minutes of every injury, but can linger for weeks or months with bad injuries or treatment. Inflammation is stemmed by infiltration of cells entitled neutrophils the first 6-24 hours; they are replaced by other cells (monocytes) in 24-48 hours. These cells will try to attack the inflammation and remove injurious agents. Phagocytosis and the release of enzymes of neutrophils and macrophages are responsible for eliminating the injurious agents and thus constitute two major benefits derived by the accumulation of leukocytes at the inflammatory site. Chronic inflammation is a different warrior. The key player is another type of cell, the macrophage. Macrophages are large cells which can remain for weeks to months, perpetuating injuries.

The classic signs and symptoms of inflammation are swelling, redness, throbbing, radiating heat and constant pain, especially when you wake up (not for 5 seconds, I'm talking pain for 30-60 minutes upon waking). Understand, just because you had the initial injury 4 months ago, doesn't mean inflammation has resolved or hasn't returned. Pay closer attention to the signs and symptoms than the duration.

Step 2 – Repair
Once inflammation resolves (remember, this is not a constant variable), the body attempts to repair itself. Humans and animals amazing machine, living in an open system with minimal tune ups required. Think of your dog, if it hurts it leg it will lay around allowing the body to repair itself. The body uses collagen, the body's gum, to repair injured structures. Unfortunately, it doesn't always repair itself properly. The body lays collagen in an erratic, inefficient fashion.

Remember, the body is repairing in this phase, not repaired. Just because the injury feels better, doesn't necessarily mean it is fixed!

Step 3 – Remodeling
The last step is remodeling, lasting anywhere from 2-4 months. This lengthy process attempts to return the body to a "pre-injury" state, which takes time to do properly. The body is now able to lay collagen in an orderly fashion, optimal for recovery and success. In this phase the body will begin to return to full strength and function. However, the body is still more susceptible for a re-injury during this time. It is essential to play close attention to any aches and pains.

Summary
If you are active, injuries are unavoidable. Once injured, it is essential to know which steps and precautions to take to maximize recovery and minimize time away from the pool, wet noodle syndrome (WNS). The next installment in this series will tackle the view of injury from the side of health care professionals and coaches. Stay healthy in the meantime...

Shoulder pain is extremely common is swimmers. It is estimated 80 percent of swimmers will experience shoulder pain during their career. Shoulder pain incidence increases with age, Masters swimmer beware! Unfortunately the common route of improvement after an injury is lengthy. For example, if you have shoulder pain, you swim through it for 2-3 weeks trying be Mr/Mrs Tough Guy, digging deep reiterating the 'no pain no gain' mantra. Most often, these symptoms dissipate, but if they continue the next step is a visit to an orthopaedic surgeon or primary care physician (typically taking one week to schedule). At this time, one of three things occur: 1) you receive referral for imaging (x-rays, MRI, etc.), 2) you schedule a cortisone shot, 3) you schedule an evaluation with a rehabilitative specialist (physical therapist, osteopath, chiropractor, massage therapist, trainers, supplement provider, Bushman in San Francisco). Let's look at these three options in more detail:

* MRI's: Unfortunately, imaging for shoulders is practically worthless. Dr. James Andrews (orthopedic surgeon to every MLB pitcher) recently said "after scanning 31 healthy pitchers shoulders: The pitchers were not injured and had no pain. But the MRI's found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. If you want an excuse to operate on a pitcher's throwing shoulder, just get an MRI,".

This is a scary reality! I don't think Dr. Andrews (a surgeon, keep in mind) is suggesting MRI's are worthless or no one needs shoulder surgery, they just aren't the be-all end-all for shoulders.

Consider this, you've been swimming for 10 years, constantly using your shoulder causing microdamage over the years. This microdamage is likely causing structural abnormalities: edema, rotator cuff tendinitis, labrum tears, etc. These structural abnormalities are normal in overhead athletes just like Dr. Andrews said. Now imagine, suddenly you start having shoulder pain, go to your primary care physician and receive an MRI. This imaging will show the structural abnormalities you've had for years due to swimming! If these structural abnormalities aren't new, they are unlikely causing your new symptoms.

* Cortisone Injections: Cortisone injections are extremely beneficial in treating inflammation. Unfortunately, by the time many clients get to a physician's office (in 2-3 weeks) the inflammation has dissipated! If the inflammation has resolved, why get a cortisone injection? Maybe we should only utilize cortisone injections if severe inflammation is present.

* Rehabilitative Specialist: These specialists commonly take a few weeks to schedule an appointment and when they see you they will work on your symptoms. If handled "properly", you will see this professional for 2-3 weeks and have full symptom alleviation. Unfortunately, many rehab clinics, no matter their specialty, rely heavily on modalities (electrical stimulation, ice, ultrasound) and exercises instructed by an assistant with the best intentions, but sometimes lack of knowledge base. These modalities are mildly beneficial if used during the right phase of the injury, but are over prescribed modalities with high insurance payment returns. Is medical reimbursement the reason you want a modality...I hope not?

This process is lengthy resulting in long periods from the pool with hopeful improvements. Unfortunately, this long drought doesn't always improve symptoms or function, here are the common routes after a shoulder injury, all consider a "successful" approach to shoulder injury:

1) Brief Improvement: Upon return, your shoulder is feeling great, you tell your coach you are feeling amazing and are ready to make up for lost time. Unfortunately, you dive in the pool, activating different muscles (a good thing, since the normal muscle pattern lead to injury). After feeling good for the first hour, fatigue occurs and old movement patterns return with accompanying symptoms, likely causing a re-injury.

2) Full Improvement? Another commonality is having full symptom alleviation after seeing a rehabilitation specialist for 4-6 weeks, then returning to the pool feeling like a wet noodle. Do you think this is the best course of action? If you have lost all of your neural feel in the water and have to start back to pre-season form necessary? Imagine if there was a systematic approach which maintains "feel" with symptom alleviation?

3) No Improvement: Hop in the water after your four weeks of simultaneous TENS, ice, ultrasound and tape to find your symptoms unchanged with swimming. Total symptom alleviation is great on land and the first step towards success, but many health care professionals do not understand the demands of swimming, recklessly throwing swimmers back in the pool with improper guidelines. I've witnessed this process hundreds of times, this broken record needs to be upgraded to a 3-D system immediately!

If you read part I like a good student, you now understand swimming isn't football where the huge off-season is utilized to build strength and speed, then the season consisting of games, while maintaining off-season gains and preventing injuries. Once discharged from 2-3 weeks of rehabilitation sessions without practice, these players hop on the field play up to their full skill level (if symptoms are fully alleviated) without any decrease in performance. This is due to the natural movements of football and their gains achieved during the off-season. Everyone may not be good at it, but each one of you can run, jump, tackle, not everyone can swim. Think about it, everyone can run, jump or tackle, it may be embarrassing, but you can do it. Not everyone can swim, this is one large difference.

Concurrent System
Swim training performed concurrently with the competitive season is essential. If a swimmer had a shoulder injury, returns to the pool and tries to compete after not touching the water for 3 weeks, they'd belly flop off the block and be swimming like they had machetes for arms! I'd be shocked if anyone perform their maximal potential and even if they did then two options exist:
1. They aren't good at swimming and their best times compete with glaciers.
2. They are Superman Swimmers, who don't require training. If you are or know one of these swimmers, please have them e-mail me immediately for further testing.

Once again, staying in the water is mandatory, unfortunately many health care professionals just don't understand this necessity. However, many coaches are too aggressive, perpetuating an injury, or aggravating the injury upon return.

Health Care Professionals
The goal of any health care professional is complete resolution of symptoms and accomplishment of goals. Unfortunately, these goals may conflict, impeding progress during process at essential times potentially impairing a season or career, if performed during a high period of motor learning. Motor learning is more active during specific developmental stages. If a young swimmer tragically has shoulder pain, removing them from the pool may impair motor learning, taking countless hours in the pool to regain.
Health care professionals view surrounds the injury process. Under any injury the body incurs inflammation. Inflammation leads to excess fluid in the joint, which causes aberrant movements and pain. The goal of the health care professional is to alleviate this inflammation.

Unfortunately in their eyes, any pain is viewed as feeding into inflammation and the injury process. This unrealistic approach is their reasoning behind long absences from the pool.

Remember, any absence from the pool impedes feel and impairs performance, an area many health care professionals do not comprehend or frankly care about, since their main job is resolution of symptoms, not optimizing performance.

Swim Coach
The other end of the spectrum are swim coaches. These folks try to build the best swimmer possible. This process takes long hours in the pool, often causing re-injury if return to swimming is not increased systematically.

From what I've seen, coaches have two approaches to shoulder injury:
1. Swim through the pain to toughen up: Swimming through the pain oftentimes make an injury worse. This method is effective in some situations as many swimmers do not know the difference between pain and injury, especially in the Nerf ball society today. However, making an injury worse can perpetuate the inflammatory process described earlier. If you swim through a shoulder injury, it likely causes areas of your shoulder to continually rub against another, worsening the situation. This will make the injury worse and lead to even longer periods away from the pool.
2. Stop swimming to heal the injury: This is similar to the health care professional view. These coaches have a swimmer immediately discontinue swimming and all activities. This approach commonly improves inflammation and symptoms out of the water, but impair swimming and oftentimes doesn't prevent re-injury.

Wrap-up
From my perspective, health care professionals and coaches hold one key to the optimal rehabilitation system. The next installment will address the proper method to handle a new shoulder injury. This system consists of activities to heal the shoulder while allowing the athlete to maintain feel in the water.
 

THERE is a gap between coaches and health care professionals. This guide is to bridge the gap between these parties, to optimize swimming by getting swimmers healthier and faster, without missing time in the water.

These simple guidelines must be followed strictly ensuring shoulder recovery, while maintaining "feel" and strength in the water.

A typical health care approach includes numerous blank periods, as they wait to be seen by the next professional. Then, after treatment, they expect the swimmer to return to the pool after symptoms are alleviated. This is considered a successful treatment; unfortunately time away from the pool causes an athlete to lose "feel" and time from the water.

This is the best-case scenario; sometimes the symptoms are never improved and the swimmer fights through the symptoms; or they return to practice, hop in the pool going full throttle, and the symptoms return, likely re-injuring their shoulder.

This unfortunate occurrence is the fault of everyone involved and is easily prevented if all parties work in harmony. Unfortunately, many health care providers view coaches as masochists, gaining power by watching swimmers endure pain. Swim coaches often view health care professionals as germaphobes, participation-trophy endorsers, and bubble-wrap-society promoters as they encourage long times away from the pool.

Follow these guidelines to bridge the gap and create harmony between all parties involved.

Many health care professionals don't know how to safely return a swimmer to the pool with guidelines to benefit recovery. Applying continual, gradual swimming stress is essential to see if the swimmer's shoulder pain is improving. Therefore, it is important to know their current pain level and have them progressively return to the pool, with limitations to follow ensuring improvement, but maintaining neural feel. Knowing their current level of pain will help monitor if their symptoms are improving, as it is unlikely for the athlete to go from 8/10 to 0/10 pain after a few sessions with the rehabilitation specialist, especially if these symptoms are long-standing. Helping them progress with milder and fewer symptoms allows the swimmer to see progress, keep their sanity, and stay positive as they return to the pool.

After working with hundreds of swimmers, I began piecing together simple tricks to speed recovery while maintaining feel, thereby preparing the athlete for a full return to practice.

First and Foremost
Proper technique for injury prevention is essential. I'm sure not all of the readers will agree with these biomechanical corrections for swimming propulsive reasons, but these will put less stress on the shoulder joint and muscles, the primary correction for those with shoulder pain.

The most common biomechanical causes of shoulder pain in swimmers are:

Crossing Over
Crossing over occurs with the athlete initiates their catch and brings their arm across their body. When the arm crosses the body, it closes the space on the anterior shoulder. The anterior shoulder contains the supraspinatus, an over worked and often times irritated rotator cuff muscle.

Solution: Stabilize the shoulder during the initial catch by performing the "compact position". The compact position is achieved by depressing and retracting the shoulder blade, providing a stable base for movement. In the compact position, it is nearly impossible to cross over and impinge the anterior rotator cuff muscles.

Thumb-First Entry
If an athlete enters with his/her thumb, the whole hand can enter through a smaller hole, decreasing drag. However, many athletes achieve a thumbs-first entry through shoulder internal rotation. This orientation can stress the anterior structures of the shoulder and increase the risk for shoulder impingement.

Luckily, the thumb-first entry can be achieved with no movement at the shoulder. Instead, instruct your athletes to use forearm pronation (rotating the forearm inwards) instead of shoulder internal rotation to get their thumbs to enter first, decreasing the amount of drag on the entry.

Solution: Either instruct your swimmers to enter fingers first or thumb first with only forearm pronation, a difficult but beneficial difference. Consider performing finer tip drag drills or hesitation drills just prior to entry.

Head-Up Position
Head position is another controversial topic. In the olden days, athletes were instructed to look up towards the other end of the pool. Unfortunately, this leads to athletes curling their neck upwards, putting many shoulder and neck muscles in improper positions. This will impair strength and put shoulder muscles at risk for injury.

Solution: Invest in a snorkel and practice having the swimmer have the water line just above their hair line.

Armpit Breathing
Every coach knows the armpit breather. This indentured swimmer has difficulties controlling and timing their neck rotation. These swimmers will often look back when they breathe or breathe late. This can irritate the shoulder by stretching and putting the shoulder muscles at the wrong muscle length.

Solution: Instruct the swimmer to initiate their breath prior to their arm entering the water. For example, if you are breathing to your right, initiate your breath just prior to your left arm entering the water. Performing six kick rotational drills while carefully adding arm strokes can help the swimmer learn how far and in what direction to turn their head.

"Normal" Freestyle Catch
There is no such thing as normal, but safe biomechanical strokes contain certain items. Review the hand entry serieson Swimming World.

Once swimming biomechanics are improved, it is necessary to have guidelines for return. Here are the nuts and bolts to returning to swimming in no time, allowing the athlete to maintain "feel" and not be thrown into the gutter lane to swim breaststroke or kick.

Rules and Regulations
No more than 3
If the swimmer has had 8/10 symptoms, have them swim the next practice with proper form unless they have 3/10 pain. At a 3/10, it is likely irritation and further damage may occur. If high pain levels occur the athlete continually enters the inflammatory stage of a musculoskeletal injury, restarting the whole injury, or worse, lead to sympathetic or affective pain.

If the swimmer has a 3/10 pain at rest, it is best to have them stay out of the water as either inflammation or sympathetic pain is the cause. Have them immediately seek treatment for these conditions.

This approach is effective when the athlete is seeing a health care professional on a regular basis and their symptoms are continually improving. If the symptoms are not improving with a rehabilitative specialist, either find a new one or consider taking a break from doing the activity which causes the symptoms (likely pulling). As much as I realize maintaining "feel" is important, keeping a swimmer's shoulder away from the knife is even more important.

Solution: Have the swimmer swim workout until their symptoms reach 3/10. Once a 3/10 occurs, have them kick with their arms at their side or in streamline (if their symptoms don't increase with streamline) with fins. This allows them to stay in the water and keep feel. Moreover, most swimmers can do main sets and intervals with fins, keeping them involved in practice and their face in the water. If they have 3/10 symptoms prior to practice, discontinue for the day and have them seek treatment for inflammation or sympathetic pain.

No Kickboards
If someone has shoulder pain, this is a big one. Most cases of shoulder pain occur due to repeated overhead motions, leading to musculoskeletal pain. Holding a kickboard for a stagnant period is locking the arm in an overhead position and irritating the shoulder repeatedly. Does this sound smart to you?

Moreover, athletes commonly push their shoulders down on the board, leading to overpressure on the joint, which is a hazardous move.

This will perpetuate the pain and is easily replaced with kicking on the back. In fact, to prevent this dangerous position and prevent re-injury, I will have swimmers kick without a board for an extended period after the symptoms resolve (approximately one month).

Solution: Kick on your back in streamline if symptoms are less than 3/10; if symptoms are greater than 3/10, have them kick on their side or with their arms next to their side.

Bottom Hand
Off a flip turn athletes should initiate their pull with their bottom hand. This is biomechically advantageous to rapidly rotate and spiral the athlete to the surface. Unfortunately, this powerful stroke is always performed by the same arm as swimmers are robotic and ambiturners. For athletes with shoulder pain, it is necessary to give the overworked shoulder a break. In almost all overuse injuries the bottom hand off the turn is the injured shoulder.

Solution: Reverse your rotations off the wall and start your stroke with your opposite arm. This will feel like writing with your opposite hand, but will distribute shoulder stress and allow adequate shoulder healing.

Wrap-up
These guidelines help bridge coaches and health care professionals. The next part of this series will discuss a simple pre-swimming prevention program to improve tight muscles.