The Tommy John of Swimming

The amount of adolescent elbow injuries in little league pitchers is considered an epidemic in the respective sport. It has become a major issue of debate in the world of little league baseball, with several recent injury prevention protocols being put into place to cut down on adolescent Tommy John surgery. Several policies now exist to prevent this invasive procedure, including pitch counts for games played as a pitcher and the amount of rest required after said pitch counts. However, for every advance that has been made on reducing elbow injuries in adolescent pitchers, little-to-no attention has been put to the epidemic of swimmer’s shoulder injuries in adolescent and young adult swimmers. We need to take an in-depth look as to why the swimmer’ shoulder is just as big of an issue in the swim world as elbow injury in the baseball world, and why similar precautions need to be put in place. 

Little league pitchers are playing now more than ever, with grade school and high school ball, as well as traveling teams that take their season from the fall to the following summer. With all this play time, repetitive strain is put on the structures of the arm, especially those of the ulnar collateral ligament (ucl), aka the medial elbow. Among adolescent baseball players aged 11 to 22, nonsurgical ucl injuries increased 9 fold from 2009-2016 compared to years past (Zaramski 2017). Approximately 74% of youth baseball players have reported elbow pain at some point in their career (Fleisig 2012). With elbow injuries becoming more and more common in the younger generation of baseball players, drastic interventions needed to take place. Organizations such as USA Baseball, Little League Baseball, Baseball Canada, and the American Orthopaedic Society for Sports Medicine all began to create guidelines and protocols to prevent injuries in adolescent pitchers. Pitch counts were created, where younger pitchers could only throw a certain amount of pitches per game, depending on the age, and a subsequent amount of rest time based on the number of pitches. For example, if a 15 year-old pitcher throws 95 pitches in a game, he has at least a four day resting period before pitching in another game. 

Similar to the Tommy John injury in baseball players, swimmer's shoulder is a non-contact sport injury that develops from repetitive strain. It was once thought of as simply subacromial impingement, inflammation of the tendons and bursal sacs of the rotator cuff. But diagnosis of swimmer’s shoulder is much more global than the local structures of the rotator cuff. It involves structural shoulder laxity and strain of the dynamic stabilizers of the shoulder and scapula, as well as other pathologies such as bicep tendinitis and scapular dyskinesis. Structural laxity of the shoulder, particularly the glenoid labrum, is normal to an extent for the swimmer’s shoulder. It allows more range of motion and makes it easier for the swimmer to put the shoulder in positions while swimming to reduce drag and increase speed. But shoulder laxity leads to reliance on the dynamic stabilizers of the shoulder and scapula to make up for the lack of structural stability. This leads to muscle fatigue, especially in the muscle used during the catch or pull-through portion of swimming such as serratus anterior and the subscapularis. 

In addition, biomechanical factors play a huge role in the development of swimmer’s shoulder. Typically most of these shoulder injuries occur during freestyle (aka front crawl), which is the most common form of swimming used in training and in competition. Three of the most common compensations that stress the shoulder in freestyle are as follows: crossing the midline with hand entry at the beginning of the stroke, early body rotation during the catch portion of the stroke, and dropping the elbow during recovery out of the water. Crossing the midline with hand entry already puts the shoulder in a position for impingement and starting to catch the water in this position furthers the impingement of the shoulder. Early body rotation during the catch-phase of freestyle creates a dissociation between the core and the upper extremity. This causes a break in the kinetic chain which forces the body to put more torque on the shoulder to perform the catch. Lastly, dropping the elbow during recovery may be a sign that the swimmer is already suffering from shoulder pain. Dropping elbow decreases the amount of internal rotation during freestyle, which decreases impingement symptoms during the recovery phase. 

Unlike baseball pitchers, though, who are developing elbow injuries during games, swimmers are more likely to develop shoulder issues in practice. A swimmer can average 40 miles per week in training which equates to about 23,000 rotations per shoulder (Cajedo 2019). The problem with all this amount of stress to the shoulder is that it happens year round. Outside of holidays, most amateur swimmers compete throughout the entire year. But considering how long swimming has been around and how much technique has changed, injuries should be dropping right? Unfortunately, shoulder injuries for age-group swimmers have only increased in the last 10 years, with as high as 90% of swimmers saying they developed shoulder pain or pathology at some point in their career.  Repetitive strain is constantly being added to the rotator cuff muscles and without injury prevention, pathology is likely to develop within the shoulder complex.

Image by Rod Havriluk via Swimming Technology Research

Furthermore, though shoulder pain for swimmer’s itself has become a global diagnosis and taking into account that many healthcare professionals consider it an epidemic in the sport, few guidelines or protocols developed by the major competitive swimming organizations exist. Neither the Sports Medicine Committee of FINA (the international governing body of swimming),  nor USA Swimming or the American Swim Coaches Association have created guidelines or restrictions to the amount of yards swam per week for amateur to elite swimmers that suffer from shoulder pain. Without shoulder injury prevention protocols in place, swimmers and coaches alike may not know how to properly rest and recover. 

Comparing the two adolescent epidemic sport injuries, one of them has injury prevention rules put in place that aims at decreasing the rate of injuries. The other has no set rules in place and the injury rate is only getting worse. Having a set guideline created can decrease shoulder injuries developed during training and increase the longevity of the swimmer’s career. As prevalent as swimmer’s shoulder injury is within the swim community, amateur to professional, we need to intervene to create an injury free culture in our pools. This means properly resting swimmers with shoulder injuries, especially young adult swimmers. A set amount of yards for swimmers, based on age and experience in the pool, with existing or prior shoulder injuries can help the swimmer heal faster thereby increasing the longevity of his or her career. It can also be used as a time to implement better biomechanics and prehab exercises to prevent future shoulder injuries. This will create a stronger, more efficient, and lasting career for swimmers for years to come. 

Alec Domjan, DC

Do you have shoulder pain? What have you done to decrease your symptoms? If you continue to have issues, please give us a call! We at Indy Muscle & Joint want to keep our athletes competing and give them the tools to manage their symptoms! We’re here to help! Book an appointment online now! 

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