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Swimmer’s shoulder in young athlete: Rehabilitation with emphasis on manual therapy and stabilization of shoulder complex
Manual Therapy 16 (2011) 510e515
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Case report
Swimmer’s shoulder in young athlete: Rehabilitation with emphasis on manual therapy and stabilization of shoulder complex Gabriel Peixoto Leão Almeida a, *, Vivian Lima De Souza a, Gisele Barbosa a, Marcelo Bannwart Santos a, Michele Forgiarini Saccol a, b, Moisés Cohen a a
Centro de Traumatologia do Esporte (CETE), Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Escola Paulista de Medicina, Rua Embaú, n 73, Vila Clementino, Cep: 04039-060, São Paulo, SP, Brazil Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brazil
b
a r t i c l e i n f o Article history: Received 19 October 2010 Received in revised form 21 December 2010 Accepted 22 December 2010 Keywords: Swimming Musculoskeletal disorders Manual therapy Exercise
1. Introduction Competitive swimmers swim 10e14 km per day six to seven days per week, which corresponds to 2500 rotations of the shoulder per day. The combination of these repetitive movements with a large range of motion of the joint makes the shoulder more prone to injury in this sport (Stocker et al.,1995; Pink and Tibone, 2000; Weldon and Richardson, 2001; Lynch et al., 2010). Wolf et al. (2009) investigated a university swim team over five seasons and found that 71% of the athletes became injured in this period, with the shoulder accounting for 35.4% of all injuries. Another study involving young highperformance athletes reports that 91% of the 80 athletes analyzed had shoulder pain (Sein et al., 2010). “Swimmer’s shoulder” was first described by Kennedy and Hawkins (1974), who defined the condition as a painful presentation due to repetitive impingement of the shoulder in swimmers. Swimmer’s shoulder does not have an established clinical diagnosis, but rather is a syndrome that may be due to subacromial impingement, tendinopathy of the rotator cuff and long portion of the biceps brachii, shoulder instability, labral tear or acromion-clavicle injury * Corresponding author. Rua Onofre Sampaio Cavalcante, n 381, Cidade dos Funcionários, Cep: 60834-450; Fortaleza, CE, Brazil. Tel.: þ55 11 87708340/55 11 55395090; fax: þ55 11 55395090. E-mail address: [email protected] (G.P. Leão Almeida). 1356-689X/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2010.12.012
(Bak and Fauno, 1997; Jones, 1999; Sein et al., 2010). Treatment for swimmer’s shoulder is generally conservative (Allegrucci et al., 1994; Russ, 1998) and the main goals are to reduce the pain, control the inflammatory process, strengthen, stretch and improve the stability of the glenohumeral joint, correct posture and return the athlete to the sport at the pre-injury level (Kenal and Knapp, 1996; Weldon and Richardson, 2001). This paper describes a rehabilitation protocol with an emphasis on manual therapy and strengthening of the stabilizing muscles of the shoulder complex in a young competitive swimmer. 2. History A 10-year-old female competitive swimmer with a training frequency of six times a week 3 h a day and three years experience practicing the sport reported feeling strong pain in the anterior region of the left (dominant) shoulder during a practice session, but was able to finish the session. However, she was unable to practice the following day due to debilitating pain in the shoulder (Fig. 1). The physician solicited radiographs of the shoulder, which were normal. Magnetic resonance imaging revealed Bigliani type 1 acromion (Mayerhoefer et al., 2009) and a T2 hypersignal in the supraspinatus tendon, leading to the diagnosis of supraspinatus tendinopathy.
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trapezius, levator scapula, sternocleido-mastoid, scalene, rhomboid, coracobrachial, subscapular, supraspinal, pectoralis minor, biceps (long portion) and suboccipital muscles. 3.3. Range of motion and muscle strength of shoulder The range of motion (ROM) was determined using a universal goniometer for the movements of flexion, extension, abduction and medial and lateral rotation with 90 of shoulder abduction, which were all preserved in comparison to the contralateral limb, but the patient reported pain at the end of each movement (Hayes et al., 2001). The muscle strength test was executed based on Kendall et al. (2005). The injured shoulder (left) exhibited muscle strength deficit in comparison to the right shoulder for the movements of flexion, extension, abduction and lateral rotation (grade 4/5), whereas the movements of adduction and internal rotation exhibited normal muscle strength (grade 5/5). 3.4. Specific tests
Fig. 1. Body chart illustrating pain presentation.
3. Examination 3.1. Pain level and functional capacity The score on the visual analog pain scale (VAPS) was 9.5 (0 ¼ absence of pain; 10 ¼ maximal pain). The result of the initial Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was 26.6 points and 68.75 points on the sports and music activities module (0 ¼ no pain and disability; 100 ¼ worst pain and disability) (Orfale et al., 2005). 3.2. Inspection and palpation The head leaned forward and the shoulders were protracted (Kendall et al., 2005), with a Kibler type III scapula, in which excessive migration of the upper angle of the scapula occurs during movement with greater than 90 of flexion (Kibler and Sciascia, 2010). Bone palpation revealed pain in the acromioclavicular joint, coracoid process, greater tuberosity of the humerus, upper and lower angle of the scapula and cervical spine at C5eC6eC7. Palpation of the musculature revealed pain in the upper and mid
The patient reported pain during the Neer impingement test (Neer, 1983) and HawkinseKennedy test (Hawkins and Kennedy, 1980). The tests used to evaluate stability were anterior apprehension (anterior instability) (Rowe and Zarins, 1981), Jerk test (posteroinferior instability) (Blasier et al., 1997) and sulcus sign (inferior instability) (Neer and Foster, 1980), all of which were negative. The Upper Limb Tension Test 1 (ULTT1) specific for the median nerve was used to test neural tension (Elvey, 1985; Butler, 2000). The test is considered positive if it reproduces pain, a bilateral difference greater than 10 of extension of the elbow and an increase in symptoms with the contralateral inclination of the cervical spine (Wainner et al., 2003). In the present case, the test reproduced the anterior pain in the patient’s shoulder and a worsening during contralateral inclination. 4. Intervention and results The rehabilitation protocol was divided into four phases, totaling 24 sessions of physical therapy with a frequency of three times a week (Allegrucci et al., 1994). The initial goal was to reduce the symptoms, thus manual therapy techniques at cervical and thoracic spine, glenohumeral joint and neural tissue were performed. After this phase, exercises to increase strength, stability and functional capacity were performed, followed a gradual return to sport. At the end of each session the patient was reassessed in all the initial examination criteria and the level of pain was reviewed (Graph 1). Also, at the end of each week the Dash questionnaire and the optional module (Graph 2) were re-checked.
Visual Analog Pain Scale
8 7 6 5 4 3 2 1 0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Session Graph 1. Visual analog pain scale over the sessions.
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60 50
Scores
40 30 20 10 0 1
2
3
4
5
6
7
8
Weeks DASH
Optional Module
Graph 2. Disabilities of the arm, shoulder and hand questionnaire and sports/music activities module over the weeks.
4.1. Phase I (1st to 4th session) Initially, myofascial release and trigger point inhibition were performed (Vernon and Schneider, 2009). The shoulder mobilization techniques were executed obeying Maitland’s principles (Hengeveld and Banks, 2005), with Grade II anterior, posterior and inferior mobilization of the shoulder, progressing to Grade III in the second session. At levels C5eC6eC7 of the cervical spine, Grade II posteroanterior mobilization was performed. All Maitland mobilizations were executed in three 30-s sets. For the mobilization of the upper thoracic spine (T2eT5), the technique of natural apophyseal glides (NAGS) reverse of the Mulligan concept was executed in three 1-min sets (Exelby, 2002; Vicenzino et al., 2007). Neural mobilization was performed in the same position as that of the evaluation, but within a range that did not exacerbate the pain. Oscillatory movements of the wrist were performed in flexioneextension in
three 1-min sets (Butler, 2000). In the second session, isometric strengthening work was begun for the rotator cuff and posterior depression of the scapula, strengthening increased according to the capacity to perform the exercise without pain (Table 1). As criteria for the progress of Phase II, the patient reported the absence of pain in the anterior region of the shoulder, the absence of pain upon bone palpation, complete ROM with pain in the upper trapezius only at the end of the range from flexion to abduction and a score of 5 points on the VAPS. 4.2. Phase II (5th to 13th session) Exercises for the strengthening of the dynamic stabilizers of the scapulothoracic and glenohumeral joints, stretching, core stability exercises (Fig. 2), proprioception and aerobic conditioning were emphasized. The sessions began with contraction techniques,
Table 1 Exercise program based on progress phases. Sets Repetitions Phase I Isometric exercises Shoulder Internal rotation External rotation Scapula Posterior depression Exercises with elastics Internal rotation External rotation Elevation of shoulder to scapula plane Scapular muscle exercises Prone Extension Horizontal abduction with external rotation Push-upplus PNF Functional diagonal Primitive diagonal Device oscillatory (bodyblade) Flexion Abduction Rhythmic stabilization 90 of shoulder flexion Position from 90 to 90 Core stability exercises Elbow-Toe Back bridge Side bridge Plyometrics Trampoline Thera-band (rotations)
Phase II
Phase III
Phase IV
3 12 3 12 3 12 0.5 kg
3 15 3 15 3 15 0.5 kg
3 25 3 25 3 15 1 kg
3 30s 0.5 kg 3 30s 0.5 kg 3 10 (cot)
3 40s 0.5 kg 3 40s 0.5 kg 3 12 (floor)
3 40s 1 kg 3 40s 1 kg 3 15 (floor)
3 12 0.5 kg 3 12 0.5 kg
3 15 0.5 kg 3 15 0.5 kg
3 10 3 10
3 12 3 12
3 15 s 3 15 s
3 30 s 3 30 s
2 30 s 2 30 s 2 30 s
3 40 s 3 40 s 3 40 s
3 30 s 3 30 s
3 40 s 3 40 s
3 10 8 s 3 10 8 s 3 10 8 s
2 20 s 2 20 s
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Fig. 2. Exercises performed for this case report: (A) back bridge, (B) side bridge, (C) elbow-toe, (D) prone extension, (E) horizontal abduction with external rotation, (F) position from 90 e90 with bodyblade, (G) abduction with bodyblade, (H) flexion with bodyblade.
followed by stretching (contractionerelaxation) (Sharman et al., 2006), with three sets of four repetitions for the sternocleidomastoid, scalene and pectoralis minor muscles (Kluemper et al., 2006). This was followed by stretching of the anterior and posterior capsule of the shoulder (Weldon and Richardson, 2001). This phase began with strengthening of the musculature of the scapula, shoulder and stabilizers of the hip and trunk (Table 1) (Weldon and Richardson, 2001; Cools et al., 2007). In this phase, the athlete was allowed only to train the lower limbs for swimming. When necessary, manual therapy techniques described above (Phase I) were employed to reduce the pain symptoms which the patient presented with. To progress to Phase III, the patient exhibited a complete painfree ROM, a score of 3 points on the VAPS, normal muscle strength for all movements (Grade 5/5) and a negative ULTT1.
4.3. Phase III (14th to 20th session) There was progression in the strengthening exercises and plyometric exercises were added (Table 1) on a trampoline and with thera-band exercise bands, diagonal exercises of proprioceptive neuromuscular facilitation (PNF) (Allegrucci et al., 1994; Carson, 1999) and exercises using an oscillatory device commonly known as a Bodyblade (Fig. 2). Stretching was maintained with the same sets and repetitions. Functional swim movement training was performed, in which the patient was positioned in ventral decubitus on the exercise ball and an elastic band attached to a back rest placed in front of her and was instructed to execute upper arm movements in four swimming styles (Allegrucci et al., 1994). The patient was allowed to perform half of her swimming training routine, but instructed not to perform specific exercises that required only the use of the upper limbs. At the end of this phase and as criteria for the progress of Phase IV, the patient reported no shoulder pain, but a sensation of discomfort with sporadic nonspecific movements, impingement tests (Neer and HawkinseKennedy) did not generate any pain and score of 0 points on the VAPS.
4.4. Phase IV (21st to 24th session) This phase involved the return to the sport, for which communication with the coach and/or physical trainer was fundamental in order to draft a specific program for the athlete’s gradual return. The stretching, plyometric, sensory-motor and functional exercises remained in this phase. Information was provided for the prevention for future injuries, such as stretching of the anterior and posterior capsule of the shoulder and strengthening of the rotator cuff and stabilizers of the scapula. At the end of rehabilitation, the athlete was able to return to her sport activities at the pre-injury level. In the follow-up evaluation, she exhibited complete ROM with an absence of pain in all shoulder movements, an absence of pain during bone and muscle palpation and normal muscle strength for all movements (Grade 5/5). The impingement tests (Neer and HawkinseKennedy) and ULTT1 did not generate any pain and there was significant improvement regarding the scores of the overall DASH questionnaire, the sport and musical activities module and the VAPS (Table 2). 5. Discussion The results in this case report demonstrate improvement in pain and disability following a manual therapy management and exercise program addressing strengthening of the stabilizing muscles of the shoulder complex. The treatment strategy was based on normalizing impairments of the cervical and thoracic spine, glenohumeral
Table 2 Pain and functional capacity of shoulder before and after rehabilitation protocol.
DASH questionnaire (0e100) Sports and music activities module (0e100) VAPS (0e10)
Initial
Final
26.6 68.75 9.5
5 6.25 0
DASH ¼ Disabilities of the arm, shoulder and hand; VAPS ¼ Visual Analog Pain Scale.
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joint and upper limb neural tissue. However, due to the multimodal intervention, a direct relationship between the intervention and the improvements cannot be conclusively established by this type of report. The positive results achieved in the present case are consistent with those reported in other studies demonstrating the benefits of manual therapy for shoulder disorders (Bang and Deyle, 2000; Bergman et al., 2010). Bang and Deyle (2000) found that manual therapy combined with specific exercises for patients with shoulder impingement syndrome achieved better results in comparison to a group submitted to specific exercises alone. Bergman et al. (2010) compared a group submitted to standard conservative treatment involving orientation, anti-inflammatory agents, analgesics, exercise and massage to a group who received both standard conservative treatment and manual therapy and found lesser pain severity and better mobility of the shoulder and neck in the latter group. In the initial evaluation, the neural tension test indicated substantial mechanosensitivity of the neural tissue, which may be an important factor of shoulder pain, regardless of sport and daily activities (Coppieters et al., 2003). Manual therapy techniques were performed to address the neural tissue mechanosensitivity believed to contribute to the patient’s symptoms. Manual therapy techniques were also used to treat the articular component thus creating a multimodal approach. Allison et al. (2002) didn’t find any difference in the level of pain and functional capacity on patients that presented with cervico-brachial pain syndrome treated with neural or articular techniques. In a case study, Haddick (2007) report an improvement in functional capacity and ROM of the shoulder following manual therapy performed on a patient with shoulder pain due to problems with the cervical spine and neural tissue. A number of hypotheses have been raised to explain the reduced pain and improved function achieved with manual therapy, such as inhibition of the afferent pathway of pain through the stimulation of mechanoreceptors, activation of the descending pain inhibitory system, possible corrections of joint position problems, excitation of the sympathetic system and non-opioid hypalgesia (Coppieters et al., 2003; Vicenzino et al., 2007; Bergman et al., 2010; Jowsey and Perry, 2010). Shoulder strengthening exercises for swimmers are mainly directed at the stabilizers of this joint, as muscle imbalance in the scapulo-humeral musculature is believed to be an important contributing factor to injuries among swimmers (Allegrucci et al., 1994; Johnson et al., 2003; O’Donnell et al., 2005). A number of studies report the effects of exercise on postural correction in swimmers. Kluemper et al. (2006) and Lynch et al. (2010) demonstrated that strengthening exercises combined with stretching are capable of improving posture in swimmers with regard to the forward lean of the head and protraction of the shoulders. Manual therapy is mainly based on the individuality and overall status of the patient and does not merely consider the pathological condition. Thus, the favorable results are limited to the case study described and cannot be considered a pattern for swimmer’s shoulder. Further studies are needed to clarify the effects of manual therapy on shoulder pain and disability more consistently. 6. Conclusion Manual therapy techniques for the shoulder, lower cervical spine and upper thoracic spine in combination with specific exercises for the stabilizers of the shoulder were effective in improving pain and functional capacity in the present case, allowing the patient’s return to competitive swimming at the pre-injury level.
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Journal of Manipulative and Physiological Therapeutics 2010;33(2):96e101. Blasier RB, Soslowsky LJ, Malicky DM, Palmer ML. Posterior glenohumeral subluxation: active and passive stabilization in a biomechanical model. Journal of Bone and Joint Surgery 1997;79(3):433e40. Butler DS. The sensitive nervous system. Unley, South Australia: NoiGroup Publications; 2000. Carson PA. The rehabilitation of a competitive swimmer with an asymmetrical breaststroke movement pattern. Manual Therapy 1999;4(2):100e6. Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B, et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? American Journal of Sports Medicine 2007;35(10):1744e51. Coppieters MW, Stappaerts KH, Wouters LL, Janssens K. The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain. Journal of Orthopaedic & Sports Physical Therapy 2003;33:369e78. Elvey R. Brachial plexus tension tests and the pathoanatomical origin of arm pain. In: Glasgow E, Twomey L, Scull E, Idczak R, editors. Aspects of manipulative therapy. Melbourne: Churchill Livingstone; 1985. p. 116e22. Exelby L. The Mulligan concept: its application in the management of spinal conditions. Manual Therapy 2002;7(2):64e70. Haddick E. Management of a patient with shoulder pain and disability: a manual therapy approach addressing impairments of the cervical spine and upper limb neural tissue. Journal of Orthopaedic & Sports Physical Therapy 2007;37(6):342e50. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. American Journal of Sports Medicine 1980;8:151e8. Hayes KW, Walton JR, Szomor ZR, Murral GA. Reliability of five methods for assessing shoulder range of motion. Australian Journal of Physiotherapy 2001;47:289e94. Hengeveld E, Banks K. Maitland’s peripheral manipulation. London, UK: Butterworth-Heinmann Ltd; 2005. Johnson JN, Gauvin J, Fredericson M. Swimming biomechanics and injury prevention: new stroke techniques and medical considerations. The Physician and Sportsmedicine 2003;31(1):41e6. Jones JH. Swimming overuse injuries. Physical Medicine and Rehabilitation Clinics of North American 1999;10(1):77e94. Jowsey P, Perry J. Sympathetic nervous system effects in the hands following a grade III postero-anterior rotator mobilization technique applied to T4: a randomized, placebo-controlled trial. Manual Therapy 2010;15(3):248e53. Kenal KA, Knapp LD. Rehabilitation of injuries in competitive swimmers. Sports Medicine 1996;22(5):337e47. Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles: testing and function, with posture and pain. Baltimore, MD: Williams & Wilkins; 2005. Kennedy JC, Hawkins R. Swimmers shoulder. The Physician and Sportsmedicine 1974;2:34e8. Kibler WB, Sciascia A. Current concepts: scapular dyskinesis. British Journal of Sports Medicine 2010;44(5):300e5. Kluemper M, Uhl T, Hazelrigg H. Effect of stretching and strengthening shoulder muscles on forward shoulder posture in competitive swimmers. Journal of Sport Rehabilitation 2006;15:58e70. Lynch SS, Thigpen CA, Mihalik JP, Prentice WE, Padua D. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. British Journal of Sports Medicine 2010;44(5):376e81. Mayerhoefer ME, Breitenseher MJ, Wurnig C, Roposch A. Shoulder impingement: relationship of clinical symptoms and imaging criteria. Clinical Journal of Sport Medicine 2009;19(2):83e9. Neer II CS, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. Journal of Bone and Joint Surgery 1980;62(6):897e908. Neer II CS. Impingement lesions. Clinical Orthopaedics and Related Research 1983;183:70e7. O’Donnell CJ, Bowen J, Fossati J. Identifying and managing shoulder pain in competitive swimmers: how to minimize training flaws and other risks. The Physician and Sportsmedicine 2005;33(9):27e35. Orfale AG, Araújo PM, Ferraz MB, Natour J. Translation into Brazilian Portuguese, cultural adaptation and evaluation of the reliability of the disabilities of the arm, shoulder and hand questionnaire. Brazilian Journal of Medical and Biological Research 2005;38(2):293e302.
G.P. Leão Almeida et al. / Manual Therapy 16 (2011) 510e515 Pink M, Tibone JE. The painful shoulder in the swimming athlete. Orthopedic Clinics of North America 2000;31(2):247e61. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder. Journal of Bone and Joint Surgery 1981;63(6):863e72. Russ DW. In-season management of shoulder pain in a collegiate swimmer: a team approach. Journal of Orthoppaedic & Sports Physical Therapy 1998;27(5):371e6. Sein ML, Walton J, Linklater J, Appleyard R, Kirkbride B, Kuah D, et al. Shoulder pain in elite swimmers: primarily due to swim-volume-induced supraspinatus tendinopathy. British Journal of Sports Medicine 2010;44(2):105e13. Sharman MJ, Cresswell AG, Riek S. Proprioceptive neuromuscular facilitation stretching: mechanisms and clinical implications. Sports Medicine 2006;36(11):929e39. Stocker D, Pink M, Jobe FW. Comparison of shoulder injury in collegiate- and master’s-level swimmers. Clinical Journal of Sport Medicine 1995;5(1):4e8.
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Vernon H, Schneider M. Chiropractic management of myofascial trigger points and myofascial pain syndrome: a systematic review of the literature. Journal of Manipulative and Physiological Therapeutics 2009;32(1):14e24. Vicenzino B, Paungmali A, Teys P. Mulligan’s mobilization-with-movement, positional faults and pain relef: current concepts from a critical review of literature. Manual Therapy 2007;12(2):98e108. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine 2003;28(1):52e62. Weldon III EJ, Richardson AB. Upper extremity overuse injuries in swimming: a discussion of swimmers’s shoulder. Clinics in Sports Medicine 2001;20(3):423e38. Wolf BR, Ebinger AE, Lawler MP, Britton CL. Injury patterns in division I collegiate swimming. American Journal of Sports Medicine 2009;37(10):2037e42.
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Case report
Swimmer’s shoulder in young athlete: Rehabilitation with emphasis on manual therapy and stabilization of shoulder complex Gabriel Peixoto Leão Almeida a, *, Vivian Lima De Souza a, Gisele Barbosa a, Marcelo Bannwart Santos a, Michele Forgiarini Saccol a, b, Moisés Cohen a a
Centro de Traumatologia do Esporte (CETE), Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Escola Paulista de Medicina, Rua Embaú, n 73, Vila Clementino, Cep: 04039-060, São Paulo, SP, Brazil Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brazil
b
a r t i c l e i n f o Article history: Received 19 October 2010 Received in revised form 21 December 2010 Accepted 22 December 2010 Keywords: Swimming Musculoskeletal disorders Manual therapy Exercise
1. Introduction Competitive swimmers swim 10e14 km per day six to seven days per week, which corresponds to 2500 rotations of the shoulder per day. The combination of these repetitive movements with a large range of motion of the joint makes the shoulder more prone to injury in this sport (Stocker et al.,1995; Pink and Tibone, 2000; Weldon and Richardson, 2001; Lynch et al., 2010). Wolf et al. (2009) investigated a university swim team over five seasons and found that 71% of the athletes became injured in this period, with the shoulder accounting for 35.4% of all injuries. Another study involving young highperformance athletes reports that 91% of the 80 athletes analyzed had shoulder pain (Sein et al., 2010). “Swimmer’s shoulder” was first described by Kennedy and Hawkins (1974), who defined the condition as a painful presentation due to repetitive impingement of the shoulder in swimmers. Swimmer’s shoulder does not have an established clinical diagnosis, but rather is a syndrome that may be due to subacromial impingement, tendinopathy of the rotator cuff and long portion of the biceps brachii, shoulder instability, labral tear or acromion-clavicle injury * Corresponding author. Rua Onofre Sampaio Cavalcante, n 381, Cidade dos Funcionários, Cep: 60834-450; Fortaleza, CE, Brazil. Tel.: þ55 11 87708340/55 11 55395090; fax: þ55 11 55395090. E-mail address: [email protected] (G.P. Leão Almeida). 1356-689X/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2010.12.012
(Bak and Fauno, 1997; Jones, 1999; Sein et al., 2010). Treatment for swimmer’s shoulder is generally conservative (Allegrucci et al., 1994; Russ, 1998) and the main goals are to reduce the pain, control the inflammatory process, strengthen, stretch and improve the stability of the glenohumeral joint, correct posture and return the athlete to the sport at the pre-injury level (Kenal and Knapp, 1996; Weldon and Richardson, 2001). This paper describes a rehabilitation protocol with an emphasis on manual therapy and strengthening of the stabilizing muscles of the shoulder complex in a young competitive swimmer. 2. History A 10-year-old female competitive swimmer with a training frequency of six times a week 3 h a day and three years experience practicing the sport reported feeling strong pain in the anterior region of the left (dominant) shoulder during a practice session, but was able to finish the session. However, she was unable to practice the following day due to debilitating pain in the shoulder (Fig. 1). The physician solicited radiographs of the shoulder, which were normal. Magnetic resonance imaging revealed Bigliani type 1 acromion (Mayerhoefer et al., 2009) and a T2 hypersignal in the supraspinatus tendon, leading to the diagnosis of supraspinatus tendinopathy.
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trapezius, levator scapula, sternocleido-mastoid, scalene, rhomboid, coracobrachial, subscapular, supraspinal, pectoralis minor, biceps (long portion) and suboccipital muscles. 3.3. Range of motion and muscle strength of shoulder The range of motion (ROM) was determined using a universal goniometer for the movements of flexion, extension, abduction and medial and lateral rotation with 90 of shoulder abduction, which were all preserved in comparison to the contralateral limb, but the patient reported pain at the end of each movement (Hayes et al., 2001). The muscle strength test was executed based on Kendall et al. (2005). The injured shoulder (left) exhibited muscle strength deficit in comparison to the right shoulder for the movements of flexion, extension, abduction and lateral rotation (grade 4/5), whereas the movements of adduction and internal rotation exhibited normal muscle strength (grade 5/5). 3.4. Specific tests
Fig. 1. Body chart illustrating pain presentation.
3. Examination 3.1. Pain level and functional capacity The score on the visual analog pain scale (VAPS) was 9.5 (0 ¼ absence of pain; 10 ¼ maximal pain). The result of the initial Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was 26.6 points and 68.75 points on the sports and music activities module (0 ¼ no pain and disability; 100 ¼ worst pain and disability) (Orfale et al., 2005). 3.2. Inspection and palpation The head leaned forward and the shoulders were protracted (Kendall et al., 2005), with a Kibler type III scapula, in which excessive migration of the upper angle of the scapula occurs during movement with greater than 90 of flexion (Kibler and Sciascia, 2010). Bone palpation revealed pain in the acromioclavicular joint, coracoid process, greater tuberosity of the humerus, upper and lower angle of the scapula and cervical spine at C5eC6eC7. Palpation of the musculature revealed pain in the upper and mid
The patient reported pain during the Neer impingement test (Neer, 1983) and HawkinseKennedy test (Hawkins and Kennedy, 1980). The tests used to evaluate stability were anterior apprehension (anterior instability) (Rowe and Zarins, 1981), Jerk test (posteroinferior instability) (Blasier et al., 1997) and sulcus sign (inferior instability) (Neer and Foster, 1980), all of which were negative. The Upper Limb Tension Test 1 (ULTT1) specific for the median nerve was used to test neural tension (Elvey, 1985; Butler, 2000). The test is considered positive if it reproduces pain, a bilateral difference greater than 10 of extension of the elbow and an increase in symptoms with the contralateral inclination of the cervical spine (Wainner et al., 2003). In the present case, the test reproduced the anterior pain in the patient’s shoulder and a worsening during contralateral inclination. 4. Intervention and results The rehabilitation protocol was divided into four phases, totaling 24 sessions of physical therapy with a frequency of three times a week (Allegrucci et al., 1994). The initial goal was to reduce the symptoms, thus manual therapy techniques at cervical and thoracic spine, glenohumeral joint and neural tissue were performed. After this phase, exercises to increase strength, stability and functional capacity were performed, followed a gradual return to sport. At the end of each session the patient was reassessed in all the initial examination criteria and the level of pain was reviewed (Graph 1). Also, at the end of each week the Dash questionnaire and the optional module (Graph 2) were re-checked.
Visual Analog Pain Scale
8 7 6 5 4 3 2 1 0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Session Graph 1. Visual analog pain scale over the sessions.
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60 50
Scores
40 30 20 10 0 1
2
3
4
5
6
7
8
Weeks DASH
Optional Module
Graph 2. Disabilities of the arm, shoulder and hand questionnaire and sports/music activities module over the weeks.
4.1. Phase I (1st to 4th session) Initially, myofascial release and trigger point inhibition were performed (Vernon and Schneider, 2009). The shoulder mobilization techniques were executed obeying Maitland’s principles (Hengeveld and Banks, 2005), with Grade II anterior, posterior and inferior mobilization of the shoulder, progressing to Grade III in the second session. At levels C5eC6eC7 of the cervical spine, Grade II posteroanterior mobilization was performed. All Maitland mobilizations were executed in three 30-s sets. For the mobilization of the upper thoracic spine (T2eT5), the technique of natural apophyseal glides (NAGS) reverse of the Mulligan concept was executed in three 1-min sets (Exelby, 2002; Vicenzino et al., 2007). Neural mobilization was performed in the same position as that of the evaluation, but within a range that did not exacerbate the pain. Oscillatory movements of the wrist were performed in flexioneextension in
three 1-min sets (Butler, 2000). In the second session, isometric strengthening work was begun for the rotator cuff and posterior depression of the scapula, strengthening increased according to the capacity to perform the exercise without pain (Table 1). As criteria for the progress of Phase II, the patient reported the absence of pain in the anterior region of the shoulder, the absence of pain upon bone palpation, complete ROM with pain in the upper trapezius only at the end of the range from flexion to abduction and a score of 5 points on the VAPS. 4.2. Phase II (5th to 13th session) Exercises for the strengthening of the dynamic stabilizers of the scapulothoracic and glenohumeral joints, stretching, core stability exercises (Fig. 2), proprioception and aerobic conditioning were emphasized. The sessions began with contraction techniques,
Table 1 Exercise program based on progress phases. Sets Repetitions Phase I Isometric exercises Shoulder Internal rotation External rotation Scapula Posterior depression Exercises with elastics Internal rotation External rotation Elevation of shoulder to scapula plane Scapular muscle exercises Prone Extension Horizontal abduction with external rotation Push-upplus PNF Functional diagonal Primitive diagonal Device oscillatory (bodyblade) Flexion Abduction Rhythmic stabilization 90 of shoulder flexion Position from 90 to 90 Core stability exercises Elbow-Toe Back bridge Side bridge Plyometrics Trampoline Thera-band (rotations)
Phase II
Phase III
Phase IV
3 12 3 12 3 12 0.5 kg
3 15 3 15 3 15 0.5 kg
3 25 3 25 3 15 1 kg
3 30s 0.5 kg 3 30s 0.5 kg 3 10 (cot)
3 40s 0.5 kg 3 40s 0.5 kg 3 12 (floor)
3 40s 1 kg 3 40s 1 kg 3 15 (floor)
3 12 0.5 kg 3 12 0.5 kg
3 15 0.5 kg 3 15 0.5 kg
3 10 3 10
3 12 3 12
3 15 s 3 15 s
3 30 s 3 30 s
2 30 s 2 30 s 2 30 s
3 40 s 3 40 s 3 40 s
3 30 s 3 30 s
3 40 s 3 40 s
3 10 8 s 3 10 8 s 3 10 8 s
2 20 s 2 20 s
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513
Fig. 2. Exercises performed for this case report: (A) back bridge, (B) side bridge, (C) elbow-toe, (D) prone extension, (E) horizontal abduction with external rotation, (F) position from 90 e90 with bodyblade, (G) abduction with bodyblade, (H) flexion with bodyblade.
followed by stretching (contractionerelaxation) (Sharman et al., 2006), with three sets of four repetitions for the sternocleidomastoid, scalene and pectoralis minor muscles (Kluemper et al., 2006). This was followed by stretching of the anterior and posterior capsule of the shoulder (Weldon and Richardson, 2001). This phase began with strengthening of the musculature of the scapula, shoulder and stabilizers of the hip and trunk (Table 1) (Weldon and Richardson, 2001; Cools et al., 2007). In this phase, the athlete was allowed only to train the lower limbs for swimming. When necessary, manual therapy techniques described above (Phase I) were employed to reduce the pain symptoms which the patient presented with. To progress to Phase III, the patient exhibited a complete painfree ROM, a score of 3 points on the VAPS, normal muscle strength for all movements (Grade 5/5) and a negative ULTT1.
4.3. Phase III (14th to 20th session) There was progression in the strengthening exercises and plyometric exercises were added (Table 1) on a trampoline and with thera-band exercise bands, diagonal exercises of proprioceptive neuromuscular facilitation (PNF) (Allegrucci et al., 1994; Carson, 1999) and exercises using an oscillatory device commonly known as a Bodyblade (Fig. 2). Stretching was maintained with the same sets and repetitions. Functional swim movement training was performed, in which the patient was positioned in ventral decubitus on the exercise ball and an elastic band attached to a back rest placed in front of her and was instructed to execute upper arm movements in four swimming styles (Allegrucci et al., 1994). The patient was allowed to perform half of her swimming training routine, but instructed not to perform specific exercises that required only the use of the upper limbs. At the end of this phase and as criteria for the progress of Phase IV, the patient reported no shoulder pain, but a sensation of discomfort with sporadic nonspecific movements, impingement tests (Neer and HawkinseKennedy) did not generate any pain and score of 0 points on the VAPS.
4.4. Phase IV (21st to 24th session) This phase involved the return to the sport, for which communication with the coach and/or physical trainer was fundamental in order to draft a specific program for the athlete’s gradual return. The stretching, plyometric, sensory-motor and functional exercises remained in this phase. Information was provided for the prevention for future injuries, such as stretching of the anterior and posterior capsule of the shoulder and strengthening of the rotator cuff and stabilizers of the scapula. At the end of rehabilitation, the athlete was able to return to her sport activities at the pre-injury level. In the follow-up evaluation, she exhibited complete ROM with an absence of pain in all shoulder movements, an absence of pain during bone and muscle palpation and normal muscle strength for all movements (Grade 5/5). The impingement tests (Neer and HawkinseKennedy) and ULTT1 did not generate any pain and there was significant improvement regarding the scores of the overall DASH questionnaire, the sport and musical activities module and the VAPS (Table 2). 5. Discussion The results in this case report demonstrate improvement in pain and disability following a manual therapy management and exercise program addressing strengthening of the stabilizing muscles of the shoulder complex. The treatment strategy was based on normalizing impairments of the cervical and thoracic spine, glenohumeral
Table 2 Pain and functional capacity of shoulder before and after rehabilitation protocol.
DASH questionnaire (0e100) Sports and music activities module (0e100) VAPS (0e10)
Initial
Final
26.6 68.75 9.5
5 6.25 0
DASH ¼ Disabilities of the arm, shoulder and hand; VAPS ¼ Visual Analog Pain Scale.
514
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joint and upper limb neural tissue. However, due to the multimodal intervention, a direct relationship between the intervention and the improvements cannot be conclusively established by this type of report. The positive results achieved in the present case are consistent with those reported in other studies demonstrating the benefits of manual therapy for shoulder disorders (Bang and Deyle, 2000; Bergman et al., 2010). Bang and Deyle (2000) found that manual therapy combined with specific exercises for patients with shoulder impingement syndrome achieved better results in comparison to a group submitted to specific exercises alone. Bergman et al. (2010) compared a group submitted to standard conservative treatment involving orientation, anti-inflammatory agents, analgesics, exercise and massage to a group who received both standard conservative treatment and manual therapy and found lesser pain severity and better mobility of the shoulder and neck in the latter group. In the initial evaluation, the neural tension test indicated substantial mechanosensitivity of the neural tissue, which may be an important factor of shoulder pain, regardless of sport and daily activities (Coppieters et al., 2003). Manual therapy techniques were performed to address the neural tissue mechanosensitivity believed to contribute to the patient’s symptoms. Manual therapy techniques were also used to treat the articular component thus creating a multimodal approach. Allison et al. (2002) didn’t find any difference in the level of pain and functional capacity on patients that presented with cervico-brachial pain syndrome treated with neural or articular techniques. In a case study, Haddick (2007) report an improvement in functional capacity and ROM of the shoulder following manual therapy performed on a patient with shoulder pain due to problems with the cervical spine and neural tissue. A number of hypotheses have been raised to explain the reduced pain and improved function achieved with manual therapy, such as inhibition of the afferent pathway of pain through the stimulation of mechanoreceptors, activation of the descending pain inhibitory system, possible corrections of joint position problems, excitation of the sympathetic system and non-opioid hypalgesia (Coppieters et al., 2003; Vicenzino et al., 2007; Bergman et al., 2010; Jowsey and Perry, 2010). Shoulder strengthening exercises for swimmers are mainly directed at the stabilizers of this joint, as muscle imbalance in the scapulo-humeral musculature is believed to be an important contributing factor to injuries among swimmers (Allegrucci et al., 1994; Johnson et al., 2003; O’Donnell et al., 2005). A number of studies report the effects of exercise on postural correction in swimmers. Kluemper et al. (2006) and Lynch et al. (2010) demonstrated that strengthening exercises combined with stretching are capable of improving posture in swimmers with regard to the forward lean of the head and protraction of the shoulders. Manual therapy is mainly based on the individuality and overall status of the patient and does not merely consider the pathological condition. Thus, the favorable results are limited to the case study described and cannot be considered a pattern for swimmer’s shoulder. Further studies are needed to clarify the effects of manual therapy on shoulder pain and disability more consistently. 6. Conclusion Manual therapy techniques for the shoulder, lower cervical spine and upper thoracic spine in combination with specific exercises for the stabilizers of the shoulder were effective in improving pain and functional capacity in the present case, allowing the patient’s return to competitive swimming at the pre-injury level.
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