Once upon a time, a swimmer named Megan comes in to see me for a nagging shoulder problem. Megan is in an elite level swimmer, having qualified for nationals recently. She is an incredibly hard worker, which makes the fact that her best events were the 500 Free and 1650 not surprising. She trains at a high volume each week, averaging about 7,000 yards a practice, but often more when it’s a distance specific set. Her training has been going well, she even has been able to keep up with some of the faster guys at practice! She was really pumped with how good her shoulders were holding up, since like many swimmers, Megan is hyper-mobile in both shoulders. Megan has had shoulder issues in the past, but nothing like what she would soon feel.
All of a sudden at practice one day, Megans right shoulder started to “pop” and feel oddly loose. Megans shoulder started to pop more and more, and she was starting to get more concerned. Instead of just feeling loose, she now would have to do a weird arm motion to get her should to feel like it was in the right spot again. This only occurred during longer freestyle sets, which was frustrating to Megan since she was a distance swimmer. Instead of being excited for summer nationals, Megan was starting to become worried.
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What is Going On with Megan?
Megan is dealing with some form of instability in her right shoulder. After talking a little bit more and completing a through examination, Megan was dealing with posterior instability. While not the most common form of swimmers shoulder, it is more common in the hyper-mobile swimmer . Posterior instability of the shoulder is defined when your shoulder moves excessively posterior. This specifically occurs in arm motions that involve shoulder flexion, internal rotation, and horizontal adduction. This excessive movement posteriorly can lead to subluxation of the shoulder, which gives that popping feeling Megan was talking about.
The Relationship between Hyper-Mobility and Instability
Why are swimmers, like Megan, who are hypermobile more likely to develop instability? Because the ligaments and joint capsule are stretched out. Both the ligaments and joint capsule help provide stability to the shoulder by acting as a passive restraint. As a result of this, the muscles have to work overtime to help stabilize the shoulder. When the muscles become fatigued, especially during longer sets, it becomes hard to the control the shoulder. This can lead to excessive shoulder movement, potentially leading to subluxations of the shoulder.
It should be noted that swimmers who are hyper-mobile do not always have instability! Instability is classified by having subluxations or dislocations. There are plenty of swimmers who are hypermobile that do not have any instability throughout their swimming career.
In fact, swimmers having hyper-mobile shoulders is advantageous for performance. Hypermobility actually allows for an improved body position and a longer stroke! So at some level, swimmers want to have hyper-mobile shoulders. Of course, with great mobility comes great responsibility to maintain strength and control throughout the entire range of motion. More on this later!
Are There Other Types of Instability?
Yes! The most common form of instability is anterior instability, which can be broken down further into anterior-inferior or anterior-superior. Anterior instability is far more common. Simply put, anterior is stability is the opposite of posterior instability. Instead of your shoulder having increased posterior translation, your shoulder has increased anterior translation. This also changes which positions you will be unstable in. For anterior instability, you will be most unstable in 90 degrees of abduction and external rotation, as opposed to 90 degrees of flexion, internal rotation, and horizontal adduction.
When selecting exercises for anterior or posterior instability, you want to start in exercises that are not in the unstable position. After mastering stability in exercises where you are more stable, you can start doing exercises in unstable positions. For the unstable position with anterior instability, you would strengthen in 90 degrees of abduction and external rotation. For posterior instability, this is strengthening in 90 degrees of flexion.
What Causes You to Be Hyper-Mobile?
There are two known causes of hyper-mobility. One cause is acquired hyper-mobility and the other cause is congenitial hyper mobility. Acquired hyper mobility is from repetitive micro trauma. For swimmers, the repetitive micro trauma is from using your shoulders all the time! This is the more common cause of hyper mobility and all your other joints will have normal mobility.
Congenital hyper mobility is something you are born with and affects 4-13% of the population. Some people with congenital disorders have connective tissue disorders like Ehler-Danos Syndrome, Marfan syndrome, or osteogenesis imperfecta, although this is not as common. Those with congenital hyper mobility will have a positive score on the beighton test. To learn more about the beighton test, click here.
What Does Megan Need To Do?
In order to gain her stability back, Megan needs to begin a progressive strength program. By improving her muscular strength and endurance, her muscles around the shoulder will be able to provide the stability needed for optimal shoulder function. However, you can not just do any exercise in this scenario. You have to target the specific deficits Megan has.
It turned out Megans right serratus anterior and upper trapezius were significantly weaker compared to the left. The examination also reveled poor neuromuscular control with arm at 90 degrees of shoulder flexion. Therefore the exercise selection needed to target the serratus anterior and upper trapezius while improving the neuromuscular control of her shoulder.
For anyone with posterior instability, you want to initially do exercises that are not in 90 degrees of shoulder flexion. Why? Because at 90 degrees of flexion, you will be the most unstable with posterior instability. The goal is to progress exercises from positions of stability to positions of instability. Based on this, the initial exercises chosen for Megan were…..
#1 Chair Press Ups
Chair press ups are one of my go to beginning exercises. Why? Because its great at activating the serratus anterior, triceps, and pecs. All of these muscles happen to play a huge role in swimming, and getting them fired up again is critical to resume normal, pain free swimming.
#2 Wall Slides
After watching the video, you may think “didn’t he just say not to start at 90 degrees of flexion for exercises?” There is a couple of tiny changes in the wall slide that make it a great exercise in this scenario. First, the lever is shorted because your elbows are bent, making it easier to maintain shoulder stability. Second, your forearms are constantly pressing against something, which also helps increase stability around the shoulder. Third, it is a great exercise for the serratus anterior. The serratus anterior helps increase scapular upward rotation, which gives your shoulder a solid base to move from, increasing stability. For these reasons, the wall slide is an amazing exercise for Megan!
#3 Prone A/T/Y
Prone A/T/Y are a great exercise for working on scapular retraction, and more specifically for Megan, increasing trapezius strength on the right. The biggest mistake I see with this exercise is not lift your shoulders off the ground as you lift your arms up. Making sure you move through the shoulder blade during this exercise is key!
Important Note:
It should be noted, the last thing Megan needs to do is stretch her shoulders. There is no sense in stretching something that is already loose. This will only exacerbate the problem. If you want to see stretches swimmers should avoid, check out a blog on three stretches swimmers need to avoid.
What Do You Do From Here?
After strengthening in more stable positions, Megan was able to progress to exercises that were performed in her unstable positions. On top of this, using neuromuscular control drills like rthymic stabilization, med ball plyometrics, or using the body blade helped Megan establish shoulder stability throughout her full range of motion.
In under a month, Megan was able to get finish her distance sets, WITHOUT any shoulder popping. In just a month Megan went from being discouraged to feeling confident about her swimming again.
The Wrap up:
Just because you are a swimmer who is hyper-mobile, it does not mean you need to have swimmers shoulder. Completing a specific movement program will help you establish the shoulder strength and stability needed to prevent any shoulder instability and help optimize your swimming performance.