Swimmer’s shoulder treatment | subacromial shoulder pain

Swimmer's shoulder treatment

Ross Hauser, MD

I have personally experienced the success of Prolotherapy for a number of sports injuries I sustained over the years. I have completed five Ironman triathlons. An Ironman race is a marathon in three sports – 2.4 mile swim, 112 mile bike, and a 26.2 mile marathon run all in the same day. The training for this is rigorous to say the least.

Subacromial shoulder pain, in search of a diagnosis

The difficulties in understanding subacromial shoulder pain is described by doctors from the Department of Orthopedics, Brigham and Women’s Hospital and Tufts University School of Medicine writing in The Journal of the American Academy of Orthopaedic Surgeons:1

Swimmer’s shoulder is a broad term often used to diagnose shoulder injury in swimmers. However, research has shed light on several specific shoulder injuries that often are incurred by the competitive swimmer.

  • Hyperlaxity
  • scapular dyskinesis (Scapular dyskinesis or SICK scapula syndrome is considered an overuse injury in which there is abnormal movement and resting location of the scapula).
  • subacromial impingement syndrome,
  • shoulder labral damage,
  • os acromiale, (Doctors in France describe os acromiale as a failure of fusion of the acromial process. It is usually asymptomatic and discovered by chance. When it is painful a differential diagnosis must be made in relation to the subacromial impingement syndrome.2
  • suprascapular nerve entrapment,
  • and glenohumeral rotational imbalances all may be included within a differential diagnosis for shoulder pain in the competitive swimmer.

An understanding of the mechanics of the swim stroke, in combination with the complex static and dynamic properties of the shoulder, is essential to the comprehension and identification of the painful swimmer’s shoulder. It is important for the athlete, coach, and clinician to be aware of the discerning characteristics among these different injuries to ensure a proper diagnosis and treatment plan to aid the swimmer in his or her return to competition.1

shoulder impingement

Swimmer’s shoulder has been a problem for a long time. In 1980 Famed orthopedic surgeon Frank Jobe, the same surgeon who invented the Tommy John Surgeryjoined with Dr. Allen Richardson and Dr. H. Royer Collins from the National Athletic Health Institute, Inglewood, California to write in the American Journal of Sports Medicine of the problem of swimmer’s shoulder in America’s best competitive swimmers:

Shoulder pain is the most common orthopaedic problem in competitive swimming. In a group of 137 of this country’s best swimmers, 58 had had symptoms of “swimmer’s shoulder.”

Population characteristics of this group indicated that symptoms increased with the caliber of the athlete, were slightly more common in men, and were related to sprint rather than distance swimming. The use of hand-paddle training exacerbated symptoms, which were more common during the early and middle season.

Treatment included stretching, rest, ice therapy, oral anti-inflammatory agents, judicious use of injectable steroids, and surgery as a last resort.3

Thirty-five years later in 2015, these treatment options did not seem to have helped nearly two generation of swimmers.

Writing in the American Journal of Sports Medicine, doctors from the Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California wrote of applying The Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score to define functional and performance measures of the upper extremity in overhead athletes. To date, no study has investigated the baseline functional scores for swimmers actively competing in the sport. What the doctors were doing was to use the The Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score to come up with baseline measurement. They were surprised by what they found:

  • Baseline scores for swimmers, which were lower than expected, were lower than baseline scores seen in studies of other overhead sports athletes.
  • The data corroborate previous studies identifying swimmers as having a high level of shoulder trouble.
  • Further research is indicated for improving shoulder symptoms and performance in competitive swimmers.4

In 2010 Klaus Bak of the Parken’s Private Hospital, Copenhagen, Denmark wrote in the Clinical journal of sport medicine:

  • Balanced strength training of the rotator cuff, improvement of core stability, and correction of scapular dysfunction is central in treatment and prevention.
  • Technical and training mistakes are still a major cause of shoulder pain
  • Imaging modalities (MRI) rarely help clarify the diagnosis, their main role being exclusion of other pathology.
  • If nonoperative treatment fails, an arthroscopy with debridement, repair, or reduction of capsular hyperlaxity is indicated.
    • The return rate and performance after surgery is low, except in cases where minor glenohumeral instability is predominant.
  • Overall, the evidence for clinical presentation and management of swimmer’s shoulder pain is sparse.5

The surgical option called into question, criticism from surgeons.

In November 2017, one of the leading medical journals in the world, The Lancet, reported the findings of 51 surgeons operating at 32 hospitals around the United Kingdom.

In this study, 313 patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were considered eligible for arthroscopic surgery. These same patients had previously completed a non-operative management program that included exercise therapy and at least one steroid injection.

The 313 patients were then divided into three groups:

  1. Arthroscopic subacromial decompression surgery group (106 patients),
  2. investigational arthroscopy surgery only (103 patients),
  3. or no treatment (104 patients)

Here are the results of the researchers:

  • Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. (Not enough evidence to warrant surgery).
  • Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. (The more invasive and complicated surgery offered no further benefit).
  • The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. (The success of the surgery may not have been the surgery itself).
  • The findings question the value of this operation for these indications, and this should be communicated to patients during the shared treatment decision-making process. (Doctors should tell the patient that if they get the more invasive surgery, the less invasive surgery, or no treatment, their outcomes will be about the same).

And finally, in the study recap: “During the past three decades, clinicians and patients with subacromial shoulder pain have accepted minimally invasive arthroscopic subacromial decompression surgery in the belief that it provides reliable relief of symptoms at low risk of adverse events and complications. However, the findings from our study suggest that surgery might not provide clinically significant benefit over no treatment.”6

In an accompanying article in The Lancet, Netherland University researchers Berend W Schreurs and Stephanie L van der Pas, wrote:

“The findings send a strong message that the burden of proof now rests on those who wish to defend the standpoint that shoulder arthroscopy is more effective than non-surgical interventions. Hopefully, these findings from a well respected shoulder research group will change daily practice. The costs of surgery are high, and although the low occurrence of complications might suggest that the surgery is benign, there is no indication for surgery without possible gain.”7

In other words, don’t have a surgery that does not help.

Prolotherapy and Platelet Rich Plasma Therapy for Shoulder Instability and Pain

Research on Platelet Rich Plasma Therapy, an injection treatment which re-introduces your own concentrated blood platelets into areas of chronic joint and spine deterioration, more commonly referred to as PRP is also inconclusive in regard subacromial shoulder pain. The problem? Single shots of PRP is not Comprehensive PRP Prolotherapy. Comprehensive PRP Prolotherapy, as demonstrated in the videos below give dozens of injections into the shoulder at a single treatment. This treats the entire shoulder joint complex and does not isolate on one specific problem. Doctors are increasingly recognizing that injury to any part of the shoulder is a problem of whole shoulder instability and a condition of degenerative shoulder disease.

Let’s illustrate this is a newly published study. In the May 2017 issue of the Orthopaedic journal of sports medicine, doctors compare PRP Injections to exercise as non-surgical treatments of subacromial shoulder pain. Here are the learning points of this research.

  • The doctors went into the study with an expectation that Platelet-rich plasma (PRP) would be an effective method in treating subacromial impingement.
  • This was a single-blinded randomized clinical trial with 1-, 3-, and 6-month follow-up.
  • Sixty-two patients were randomly placed into 2 groups, receiving either PRP or exercise therapy.
    • The outcome parameters were pain, shoulder range of motion (ROM), muscle force, functionality, and magnetic resonance imaging findings.
  • Results: Both treatment options significantly reduced pain and increased shoulder ROM compared with baseline measurements.
  • Both treatments also significantly improved functionality.
  • Both PRP injection and exercise therapy were effective in reducing pain and disability in patients with SAIS, with exercise therapy proving more effective.8

Two injections do not make comprehensive treatment

Doctors are eager to reduce the number of injections needed to help a patient, we are too, however, why get PRP injections if they are not going to help a patient achieve their treatment goals, pain-free shoulder movement?

Back to the research, what did the Platelet-Rich Plasma Group get?

  • Patients in the PRP group were injected twice: once at the beginning of the study and again 1 month after the first visit.
  • 5 mL of PRP was prepared. One milliliter of this PRP was sent to a laboratory for platelet counting.
  • The remainder of the obtained PRP (4 mL) was injected into the injured tendons. More specifically, 3 mL of PRP was injected into the partial tear in the tendon or, in the case of patients with tendinopathy, into hypoechogenic (documented damaged areas through ultrasound). The other 1 mL was injected into the subacromial space from the lateral posterior side of the arm at an angle of 45° to the horizon without ultrasound guidance.8

Before we compare this PRP treatment and our PRP treatment, it should be pointed out that even a non-comprehensive PRP treatment showed benefits. Now compare treatments:

In the athletic patient, shoulder injuries can cause damage both to the joint itself and the surrounding structures (i.e. ligaments and tendons). In our treatments as described in the videos we demonstrate on treating the whole shoulder.

If you have questions about subacromial shoulder pain and swimmer’s shoulder treatment, Get help and information from our Caring Medical staff

1. Matzkin E, Suslavich K, Wes D. Swimmer’s shoulder: Painful shoulder in the competitive swimmer. Journal of the American Academy of Orthopaedic Surgeons. 2016 Aug 1;24(8):527-36. [Google Scholar]

2. Barbier O, Block D, Dezaly C, Sirveaux F, Mole D. Os acromiale, a cause of shoulder pain, not to be overlooked. Orthopaedics & Traumatology: Surgery & Research. 2013 Jun 30;99(4):465-72 [Google Scholar]

3. Richardson AB, Jobe FW, Collins HR. The shoulder in competitive swimming. The American Journal of Sports Medicine. 1980 Jun;8(3):159-63. [Google Scholar]

4. Wymore L, Fronek J. Shoulder functional performance status of national collegiate athletic association swimmers: baseline Kerlan-Jobe orthopedic clinic scores. The American journal of sports medicine. 2015 Jun;43(6):1513-7. [Google Scholar]

5. Bak K. The practical management of swimmer’s painful shoulder: etiology, diagnosis, and treatment. Clinical Journal of Sport Medicine. 2010 Sep 1;20(5):386-90. [Google Scholar]

6 Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, Shirkey BA, Donovan JL, Gwilym S, Savulescu J, Moser J. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet. 2017 Nov 20. [Google Scholar]

7 Schreurs BW, van der Pas SL. No benefit of arthroscopy in subacromial shoulder pain. The Lancet. 2017 Nov 20. [Google Scholar]

8. Nejati P, Ghahremaninia A, Naderi F, Gharibzadeh S, Mazaherinezhad A. Treatment of Subacromial Impingement Syndrome: Platelet-Rich Plasma or Exercise Therapy? A Randomized Controlled Trial. Orthopaedic Journal of Sports Medicine. 2017 May 19;5(5):2325967117702366. [Google Scholar]

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