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The rehabilitation of a competitive swimmer with an asymmetrical breaststroke movement pattern
Manual Therapy (1999) 4(2), 100±106 # 1999 Harcourt Brace & Co. Ltd
Case report
The rehabilitation of a competitive swimmer with an asymmetrical breaststroke movement pattern P. A. Carson Private Practitioner, Bloemfontein, South Africa
SUMMARY. This case study describes the treatment and management of an 11-year-old competitive swimmer who was repeatedly disquali®ed from races because of an asymmetrical movement pattern, otherwise called stroke. The treatment was based on the impairments found during the physical examination that were considered relevant to the physical dysfunction resulting in the asymmetrical stroke. This gave rise to the hypothesis that muscle imbalances around the right shoulder and left hip, together with a relative restriction of motion in these joints, were resulting in the transmission of forces up and down the kinetic chain and that these were contributing factors to the asymmetrical breaststroke stroke. An eclectic approach was used in the analysis, and the subsequent treatment and management, of the problem. To achieve the goal of a symmetrical stroke, the muscle balance/imbalance approaches of Janda (1994), Sahrmann (1988) and Kendall et al. (1993) were used. The joint impairments were treated with techniques described by Maitland (1986) and Mulligan (1996), while the exercise programme included the core/stabilizing approach presented by Blanch (1997). The treatment period consisted of four phases of 3 weeks each. The result indicates that early identi®cation and treatment of muscle imbalance syndromes and relative joint restrictions by the physiotherapist and coach working together may be useful in establishing good movement patterns and technique for competitive swimmers.
kick. A scissors, ¯utter or downward dolphin kick is not permitted'. Briggs et al. (1995) in their analysis of the breaststroke kick describes the kick as follows: `the hips are ®rst abducted with the knee internally rotated. The hips are then actively internally rotated and the knees forcibly extended with the feet externally rotated during the propulsive phase'. Costill et al. (1992) describe the kick as the most intricate part of the stroke. Janda (1994) is of the opinion that the tendency for some muscles to develop tightness, and others inhibition or weakness, is not random and results in systematic dysfunction associated with muscle imbalance patterns. In the shoulder±neck complex, muscles prone to tightness are pectoralis major and minor, upper trapezius, levator scapulae and sternocleidomastoid. The small neck extensors, temporalis, digastric and masseter are also involved. Muscles that tend to develop weakness and inhibition are the lower stabilizers of the scapula (serratus anterior, rhomboids, middle and lower trapezius, deep neck ¯exors
INTRODUCTION AND BACKGROUND The ruling body of competitive swimming is Federation Internationale de Natation Amateur (FINA) (1996±1998). It is this body that lays down the rules for stroke techniques. Failure to comply with these rules results in disquali®cation. The subject was disquali®ed for a raised right shoulder and dropped left hip, or in swimming terms, a `screw kick'. A recent rule change allows shoulder asymmetry but as regards the kick, Rule SW 7.4 and 7.5 of the FINA handbook states that `all movements of the legs shall be simultaneous and in the same horizontal plane without alternating movement. The feet must be turned outwards during the propulsive part of the
Petro A. Carson, BSc (Physiotherapy) (Wits), BA (Unisa), PO Box 13685, Noordstad, 9302, Bloemfontein, South Africa. Physiotherapist in private practice. Presently studying for MPhil (Sports Physiotherapy) at the Sports Science Institute of University of Cape Town. This case study was submitted as part of the requirements for the MPhil. 100
The rehabilitation of a competitive swimmer 101
supra and mylohyoid). The nature of the breaststroke arm movement is conducive to reinforcing these patterns if attention is not paid to correct technique and appropriate stretching. The pelvic-hip complex is characterized by the imbalance between shortened and tight hip ¯exors and lumbar erector spinae and weakened gluteal and abdominal muscles. Poor posture and long hours of sitting on school benches as well as sitting in front of the television or computer may reinforce these patterns. Janda (1994) is of the opinion that muscle imbalance in children, in contrast to that of adults, usually starts in the upper part of the body. The reason for this is unknown, but it is presumed that comparatively weak neck muscles support the large and heavy head of the child. The fact that the centre of gravity of the child's head is located forward but is gradually shifted backwards into a well-balanced position during growth exacerbates the problem. Kendall et al. (1993) point out that while it is important to observe and recognize postural deviations in the growing individual, it is equally important to realize that children are not expected to conform to the adult standard of alignment. White & Sahrmann (1994), however, suggest that in accordance with Wolf's law, incorrect postural alignment and/or faulty force transmission through the musculoskeletal system lead to maladaptation of the components of that system. The correction of kinetics at an early age would contribute to the normal development of bones and joints. Their `Movement System Balance Theory' proposes that the relative length of soft tissues including antagonistic muscles, capsule, ligaments, tendons and nerves, determines the posture of joints. This theory suggests that the body will take the line of least resistance and that movement will occur in the more ¯exible areas. Blanch (1997) is of the opinion that to create a `perfect human machine' where major motions occur at the large joints (i.e. hip and shoulders) without compensating movements along the thoracic and lumbar spine requires core strength and/or stability. This stability would require optimum range of motion in the limbs and that the musculature of the trunk should be able to maintain the trunk position while applying and receiving force. The major force producing muscles originate from the trunk and insert on the limbs, e.g. latissimus dorsi and gluteus maximus. The subject of this case report was an all round sportsman who played hockey, golf and squash as well as swimming. He started swimming at 7 years of age and gained provincial colours holding six provincial records in his age group in the freestyle, backstroke and breaststroke events. Recently he had been disquali®ed in the breaststroke events as a result of an asymmetrical kick. As this had usually occurred # 1999 Harcourt Brace & Co. Ltd
after having won the event, it was extremely distressing for the subject and he no longer wished to swim breaststroke, which was previously his best stroke. His parents had been told that he had scoliosis. PHYSICAL EXAMINATION The subject was right hand dominant. Observation from posterior, anterior and lateral aspects revealed a slight thoraco lumbar scoliosis convex to the right, plus a slightly raised left shoulder. Both scapulae were abducted with winging and tipping evident. The shoulders were rounded, especially the right side. The pelvis was slightly tilted anteriorly. The gluteal folds were level with the bulk on the left appearing slightly smaller than the right. This was con®rmed on palpation. Both feet were slightly pronated (Fig. 1). Manual muscle testing with the muscles in the shortened position, as described by Kendall et al. (1993), revealed weakness/inhibition of the serratus anterior, as well as middle and lower ®bres of trapezius on the right side when compared with the
Fig. 1ÐPosterior view illustrating winging and tipping of scapulae. Manual Therapy (1999) 4(2), 100±106
102 Manual Therapy
left. When testing the upper ®bres of trapezius on the right, the subject rotated his shoulder forward when resistance was applied. This did not occur on the left side. Latissimus dorsi testing on the right elicited a strong contraction of the upper ®bres of trapezius on the right as well. There was a bilateral weakness of the rhomboids. Passive range of motion testing, as described by Kendall et al. (1993), revealed tightness in the pectoralis minor bilaterally with the subject lying supine with knees bent and arms at the side. This was recorded as marked on both sides but especially on the right. The right upper ®bres of trapezius and levator scapulae were tight. With the subject supine, it was possible to demonstrate anterior translation of the right humeral head but not the left with medial rotation of the shoulder while the arm was in 90 degrees of abduction. This was taken as a possible tightness of the joint capsule as well as the overlying muscles. Observation of the push up, as advocated by Janda (1994), revealed bilateral winging of the scapulae with a tendency of the right shoulder to rotate forward and elevate, indicating serratus anterior weakness. In the pelvic-hip complex the left gluteus medius, maximus and tensor fascia lata were all weaker than the right side. The left hip internal and external rotators were also weaker on the left side. When performing a squat the pelvis shifted laterally to distribute the weight over the right leg. This was accompanied by trunk lateral ¯exion to the left. Passive range of motion was measured with a goniometer and followed the procedure used by Blanch (1977) in his `Screening of Swimmers'. Hamstring and sciatic nerve ¯exibility was measured using the Straight Leg Raise (SLR), a good range being an angle with the horizontal of greater than 70 degrees. The subject had a range of 65 degrees on the left and 68 degrees on the right. Hip internal rotation was measured in prone lying with both knees ¯exed to 90 degrees and kept together in contact with the bench. The right side was normal at 45 degrees while the left side was restricted at 30 degrees. Tibial external rotation, the other important component of the stroke, was normal. A video of the subject swimming breaststroke was taken as a functional demonstration. This was also used as a baseline for re-evaluation at a functional level. It was also used in stroke analysis and helped in the process of relating the relevant impairments found to the dysfunction. TREATMENT Sahrmann (1988) advocates that, because a medical diagnosis is insucient, diagnostic categories should Manual Therapy (1999) 4(2), 100±106
be developed by physiotherapists. In her opinion the diagnosis by the physiotherapist is the term that names the primary dysfunction towards which treatment by the therapist is directed. This dysfunction is identi®ed by history taking, symptoms and signs, examination and tests the therapist performs or requests. Taking into account various views (Sahrmann 1988; Kendall et al. 1993; Janda 1994; White & Sahrmann 1994; Blanch 1997) and assessing the evidence of the examination as well as the videotape, the following hypothesis was formed: a muscle/soft tissue imbalance around the neck±shoulder complex was altering the instantaneous axis of rotation of this joint and was contributing to the shoulder dysfunction while the decreased range of internal rotation in the left hip and the associated muscle imbalance was resulting in the transmission of forces up the kinetic chain to the gluteal muscles and lumbar spine resulting in fatigue of these muscles and lumbar extension. All these factors were contributing to the abnormal movement pattern. This was explained to the subject and his mother, and a proposed treatment plan was outlined. They were told that the treatment would be time consuming and demanding, requiring active participation on behalf of both of them. The help of the swimming coach would also have to be enlisted. The proposed treatment plan was accepted by both, and treatment commenced. The long-term goal was to restore function enabling the subject to swim a breaststroke race without being disquali®ed. To achieve this, a time period of approximately 3 months was anticipated. The immediate goal was to work on the impairments that had been assessed as relevant and to gain the symmetry needed between left and right sides. Swimming demands that the swimmer is able to perform forceful repetitive motions at the extremes of range while maintaining a stable trunk and to achieve this the following treatment strategy was instituted: 1. Joint mobilizations of the right shoulder and left hip. The joint mobilizations for the shoulder consisted of antero-posterior pressures as described by Maitland (1986). These were performed as IV++ with the arm at the side as well as in 90 degrees of abduction and external rotation. The aim of this was to restore glide in the joint and possibly to stretch the posterior capsule and in an attempt to change the instantaneous axis of rotation of the joint, which is aected by the length and mobility of the soft tissues crossing the joint. Hip joint mobilizations were performed by using a belt and applying lateral traction to the hip joint while performing internal rotation as described by Mulligan (1996). As advocated by him, three sets of 10 pain free repetitions into resistance were performed. This did not quite result in # 1999 Harcourt Brace & Co. Ltd
The rehabilitation of a competitive swimmer 103
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7.
performing a `miracle' as described by Mulligan (1996) but the increase in range was remarkable. White & Sahrmann (1994) are of the opinion that manual therapy complements the movement system balance approach to patient management in particular the need to mobilize hypomobile joints that are contributing to hypermobility elsewhere or to a faulty movement pattern. Post isometric relaxation techniques for the tight muscles, namely upper ®bres of trapezius, levator scapulae and pectoralis minor. This was followed by active stretching. This involved stretching the scapula elevators by ¯exing the neck towards the chest and laterally to the onset of resistance in these muscles. Active depression and abduction of the ipsilateral scapula accompanied this by contraction of the lower ®bres of trapezius and serratus anterior. Active stretching was also given as part of the home programme. Closed chain and medicine ball exercises concentrating mainly on the shoulder, abdominal muscles (especially transversus abdominus) and hip muscles. The movement system balance theory emphasizes that powerful, rapid movements of the limbs should take place from a stable base, i.e. the scapulo-thoracic joint, cervical and thoracic spine for the upper limb, the lumbar spine and pelvis for the lower limb. The exercises described by Blanch (1997) are designed to achieve this. The sequence involves patterning to lay down an engram for stability, followed by mobility on stability and ®nally loaded mobility on stability. Postural correction and awareness. This was done in front of a mirror and initially taping was used as an aid to help brace weak muscles and increase proprioceptive awareness (Fig. 2). Appropriate postures during activities of daily living were stressed. According to Blanch (1997) being able to maintain good posture while not engaging in sport will reinforce the pattern of using the stabilizers correctly or, alternatively, if the stabilizers are not activated routinely (i.e. during everyday activities) it is usually more dicult to recruit them purely for athletic pursuits. Postero-anterior mobilizations to the cervical and thoracic and lumbar spine. These consisted mainly of large amplitude grade II and III movements to help maintain smooth movement of the spinal joints. Neurodynamic stretches. These were carried out for both upper and lower limbs to ensure that adverse neural tension would not interfere with the movement patterns. The home exercise programme was demonstrated to the mother who supervized it. This consisted of Theraband exercises for hip internal rotation in the functional position of prone lying and shoulder external rotation (loaded mobility on
# 1999 Harcourt Brace & Co. Ltd
Fig. 2ÐTaping to provide support and proprioception.
stability), plus closed chain hip, shoulder and abdominal exercises using a Physio Ball as described by Blanch (1997), passive stretching by sitting in the `frog position' required by breaststroke (initially this could only be accomplished by using two pillows between the legs), manual stretching of pectoralis minor by the subject's mother. Activities such as skipping and moving along in a wheelbarrow-type position whilst being held by the legs were encouraged. These were considered fun activities and were also used to aid co-ordination by encouraging reciprocal movements. This phase of treatment consisted of three sessions a week for 3 weeks. At the end of the period a session with the coach at the pool was held at which time a video was taken. Stroke assessment revealed that the shoulder position was much better and that the subject was able to perform one or two `correct' kicks but then lapsed back into the habitual pattern. On Manual Therapy (1999) 4(2), 100±106
104 Manual Therapy
advice from the coach the next phase of 2 weeks concentrated on the pelvic area. The subject watched the video and this helped in the visualization of the stroke movement. During phase two of the rehabilitation programme full range of internal rotation at the hip was achieved. Treatment was focussed on quality of movement in the pelvic area and the strengthening of the left gluteal muscle which on manual palpation had a much smaller bulk than on the right side and an abnormal pattern of motor recruitment. Squats were performed in front of a mirror with the therapist sitting behind the subject placing hands on the buttocks to guide the movement so as to counter the tendency of a lateral shift of the pelvis to the right. This lateral shift together with trunk lateral ¯exion to the left was very pronounced when performing a one leg squat and was taken as indicative of the gluteal weakness. The squat was chosen, as it was an easy exercise for an 11year-old to perform, and it was also easy to guide the movement so as pick up any asymmetry. A further point was that it could also be done at home under the supervision of his mother. The remaining exercises were patterning exercises, as described by Blanch (1997), performed in prone kneeling and prone and side lying with emphasis on transversus abdominus. This phase lasted 3 weeks with three sessions a week and again ended with a session at the pool with the coach. Yet another video was taken and this time a photograph was also taken. As seen in Figure 3, the photograph clearly illustrates the asymmetry in the leg motion and the position of the left hip and leg. At this time the subject was able to perform approximately nine kicks, i.e. about 20 metres before the asymmetry appeared. It appeared as if muscle fatigue and lack of concentration were the main areas responsible for the problem. A kicking drill, which consisted of free style kicking (for gluteal endurance and to pre-fatigue these muscles), followed by breaststroke kicking while holding the body up against the wall to stabilize it and to keep the pelvis level was included in the programme. Phase three consisted of gym work designed to develop endurance in the gluteal muscles especially on the left. It was performed three times a week for 3 weeks and consisted of using the stepper machine and spinning on the bicycle for 10 minutes. This was followed by step up and step down sideways on a step leading with the left leg. Squats in front of a mirror, lunges and push-ups were also undertaken. This was done under the supervision of the physiotherapist and emphasis was placed on quality of movement. These exercises were chosen because they were easy to perform with good form, provided variety and again added a fun element so that the subject, who was quite young, would remain motivated. Manual Therapy (1999) 4(2), 100±106
Fig. 3Ð`Screw' kick clearly illustrated.
The home programme continued and shoulder and hip mobilizations, together with contract-relax stretching of tight muscle, were performed once a week. At re-evaluation after phase three the improvement in stroke and kick was marked. The subject was able to swim 50 metres with a correct stroke at 70% eort. However, when the eort was increased the stroke tended to fall back into the old pattern. The coach felt that the bulk of the programme should now consist of stroke drills under supervision so as to consolidate correct movement patterns. The subject at this stage could feel exactly when the kick was wrong and would then stop. In consultation with the subject's mother it was decided that she would supervize the stroke drills and exercise programme for the next phase of 3 weeks. After this if the technique was well established the coach would work on speed. Speed in competitive swimming is the ultimate goal. Pritchard (1997), however, feels that in a young swimmer the emphasis should be on technique rather than speed. It was unanimously agreed that because of the emotional impact of the regular disquali®cation, the subject would not be entered into a gala until stroke and speed were well consolidated.
RESULTS Twelve weeks after the commencement of the rehabilitation programme the following results were obtained: # 1999 Harcourt Brace & Co. Ltd
The rehabilitation of a competitive swimmer 105
. At the impairment level: observation of posture revealed less winging and tipping of the scapulae. Tightness in the pectoralis minor was graded as moderate on both sides. On performing a push up there was still slight winging of the scapulae but no forward rotation of the shoulder was present on the right side. Rotation of the right arm in 90degree abduction showed no anterior translation of the humeral head. Left hip internal rotation was equal in range to the right hip, as was the strength of the internal and external rotators. The subject was able to perform two sets of 15 repetitions of two legged squats while maintaining a symmetrical movement. On the one-legged squat, eight repetitions were possible on both the left and right sides. . At the functional level: a video of the subject swimming was taken. The coach was present to deliver criticism. The verdict was that the kick was fully acceptable and symmetry was maintained throughout the session. A slight asymmetry of the shoulders was still present. There was a de®nite increase in the subject's postural awareness. DISCUSSION Genadi Touretski (1997), coach of dual Olympic and World Sprint Champion Alexander Popov, when commenting on Alex stated `when he ®rst started swimming with me, at the University of Delmartar, I had to tell him to control his posture or he would not be included in the group. Alex's posture is still not perfect, but when he originally came to me his posture was quite bad. It is very important for him to understand that posture is a very, very important thing for all of us, and I would not coach him until he tried to improve it'. Another coach, Bob Pritchard (1997), has stated that `A small loss in swimmers' ¯exibility can change their mechanics and decrease their eciency levels'. He feels that by the time swimmers reach their physiological best, their ¯exibility may be decreased by up to 50% due to microtears and scar tissue formation causing dysfunction. Physiotherapists are also aware of the eects of posture on joints and movement patterns, and it would appear that a close working relationship between coach and physiotherapist may be bene®cial in the quest for good posture amongst athletes. White & Sahrmann (1994) emphasize that the reason a person moves in a certain way should be correctly identi®ed so that those individuals can be taught to restore normal movement. In a muscle system balance approach the relative strength and endurance of muscles is more important than the overall strength that any muscle or group of muscles can develop. They list amongst the priorities of this system an explanation to the subject of the posture # 1999 Harcourt Brace & Co. Ltd
movement faults that are perpetuating the condition. The subject should be taught to be aware of these and to correct them. This is time consuming and requires direct eort and co-operation on behalf of the subject. Constant encouragement and correction in the home, at school and by the coach would help reinforce new patterns of movements. The use of mirrors, supportive taping, videotaping and active stretching are also invaluable tools in the quest for good posture and movement patterns. It would appear that the physiotherapist, working in conjuction with the coach, teachers and family, ful®lling a role of educating, treating and management may play an important role in the attainment of good technique in a sport, and ultimately injury prevention, through the establishment of biomechanically advantageous movement patterns. The subject in this case report achieved an improved movement pattern in his breaststroke through a conscientious approach to his treatment. The stroke will need ongoing attention and constant correction. Once the awareness and physical capabilities are established this task is possibly made a bit easier. The treatment in the case reported was time consuming but very rewarding. Two months after the cessation of treatment, the author was presented with a bronze medal that had been won by the subject in a breaststroke race. CONCLUSION A swimmer swimming 8 kilometres per day performs approximately 5000 strokes. Attention given to good posture and body alignment from an early age may contribute towards the development of good joint mechanics and good movement patterns. Good movement patterns may in turn translate into good technique, better performances and possibly injury prevention. In this way the competitive life span of the athlete may be lengthened. It would appear that the physiotherapist, working in conjuction with coach and others involved in the daily activities of the subjects, may play an eective and important role in the achievement of these ideals as shown in this case report. References Blanch P 1997 The Swimming Machine, (Make the Most of Every Stroke by Being Flexible and Strong). Australian Swimming Inc. Briggs C, Sandor SM, Kenihan M 1995 The knee. In: Xuluaga M, Briggs C, Carlisle J et al. (Eds) Sports Physiotherapy Applied Science and Practice. Churchill Livingstone, South Melbourne, ch 29, pp 541±586 Costill D, Maglischo E, Richardson AB 1992 Swimming. Blackwell Scienti®c, Oxford. Manual Therapy (1999) 4(2), 100±106
106 Manual Therapy Federation Internationale De Natation Amateur 1996±1998 Constitution and Rules. 138 Edited by FINA Oce Janda V 1994 Muscles and motor control in cervicogenic disorders: Assessment and management. In: Grant R (Ed) Physical Therapy of the Cervical and Thoracic Spine. Churchill Livingstone, Edinburgh Kendall FP, McCreary EK, Provance PG 1993 Muscles: testing and function, 4th Edn. Posture and Pain. Williams and Wilkin, Baltimore, 109 Maitland GD 1986. Vertebral Manipulation, 5th Edn. Butterworths, London Mulligan BR 1996 Mobilizations with movement (MWMS) for the hip joint to restore internal rotation and ¯exion. Journal of Manual and Manipulative Therapy 1: 118±126
Manual Therapy (1999) 4(2), 100±106
Pritchard B 1997 The new swim paradigm. In: The Australian Institute of Sport International Swim Seminar Proceedings Section 2: 131±142. RWM Publishing (Pty) Ltd Sahrmann SA 1988 Diagnosis by the physical therapist ± a prerequisite for treatment: a special communication. Physical Therapy 68: 1703±1706 Touretski G 1997 Preparation of Olympic champion Alexander Popov. In: The Australian Institute of Sport International Swim Seminar Proceedings. Section 2: 85±89. RWM Publishing (Pty) Ltd White SG, Sahrmann SA 1994 A movement system balance approach to management of musculoskeletal pain. In: Grant R Physical Therapy of the Cervical and Thoracic Spine. Churchill Livingstone, Edinburgh
# 1999 Harcourt Brace & Co. Ltd
Case report
The rehabilitation of a competitive swimmer with an asymmetrical breaststroke movement pattern P. A. Carson Private Practitioner, Bloemfontein, South Africa
SUMMARY. This case study describes the treatment and management of an 11-year-old competitive swimmer who was repeatedly disquali®ed from races because of an asymmetrical movement pattern, otherwise called stroke. The treatment was based on the impairments found during the physical examination that were considered relevant to the physical dysfunction resulting in the asymmetrical stroke. This gave rise to the hypothesis that muscle imbalances around the right shoulder and left hip, together with a relative restriction of motion in these joints, were resulting in the transmission of forces up and down the kinetic chain and that these were contributing factors to the asymmetrical breaststroke stroke. An eclectic approach was used in the analysis, and the subsequent treatment and management, of the problem. To achieve the goal of a symmetrical stroke, the muscle balance/imbalance approaches of Janda (1994), Sahrmann (1988) and Kendall et al. (1993) were used. The joint impairments were treated with techniques described by Maitland (1986) and Mulligan (1996), while the exercise programme included the core/stabilizing approach presented by Blanch (1997). The treatment period consisted of four phases of 3 weeks each. The result indicates that early identi®cation and treatment of muscle imbalance syndromes and relative joint restrictions by the physiotherapist and coach working together may be useful in establishing good movement patterns and technique for competitive swimmers.
kick. A scissors, ¯utter or downward dolphin kick is not permitted'. Briggs et al. (1995) in their analysis of the breaststroke kick describes the kick as follows: `the hips are ®rst abducted with the knee internally rotated. The hips are then actively internally rotated and the knees forcibly extended with the feet externally rotated during the propulsive phase'. Costill et al. (1992) describe the kick as the most intricate part of the stroke. Janda (1994) is of the opinion that the tendency for some muscles to develop tightness, and others inhibition or weakness, is not random and results in systematic dysfunction associated with muscle imbalance patterns. In the shoulder±neck complex, muscles prone to tightness are pectoralis major and minor, upper trapezius, levator scapulae and sternocleidomastoid. The small neck extensors, temporalis, digastric and masseter are also involved. Muscles that tend to develop weakness and inhibition are the lower stabilizers of the scapula (serratus anterior, rhomboids, middle and lower trapezius, deep neck ¯exors
INTRODUCTION AND BACKGROUND The ruling body of competitive swimming is Federation Internationale de Natation Amateur (FINA) (1996±1998). It is this body that lays down the rules for stroke techniques. Failure to comply with these rules results in disquali®cation. The subject was disquali®ed for a raised right shoulder and dropped left hip, or in swimming terms, a `screw kick'. A recent rule change allows shoulder asymmetry but as regards the kick, Rule SW 7.4 and 7.5 of the FINA handbook states that `all movements of the legs shall be simultaneous and in the same horizontal plane without alternating movement. The feet must be turned outwards during the propulsive part of the
Petro A. Carson, BSc (Physiotherapy) (Wits), BA (Unisa), PO Box 13685, Noordstad, 9302, Bloemfontein, South Africa. Physiotherapist in private practice. Presently studying for MPhil (Sports Physiotherapy) at the Sports Science Institute of University of Cape Town. This case study was submitted as part of the requirements for the MPhil. 100
The rehabilitation of a competitive swimmer 101
supra and mylohyoid). The nature of the breaststroke arm movement is conducive to reinforcing these patterns if attention is not paid to correct technique and appropriate stretching. The pelvic-hip complex is characterized by the imbalance between shortened and tight hip ¯exors and lumbar erector spinae and weakened gluteal and abdominal muscles. Poor posture and long hours of sitting on school benches as well as sitting in front of the television or computer may reinforce these patterns. Janda (1994) is of the opinion that muscle imbalance in children, in contrast to that of adults, usually starts in the upper part of the body. The reason for this is unknown, but it is presumed that comparatively weak neck muscles support the large and heavy head of the child. The fact that the centre of gravity of the child's head is located forward but is gradually shifted backwards into a well-balanced position during growth exacerbates the problem. Kendall et al. (1993) point out that while it is important to observe and recognize postural deviations in the growing individual, it is equally important to realize that children are not expected to conform to the adult standard of alignment. White & Sahrmann (1994), however, suggest that in accordance with Wolf's law, incorrect postural alignment and/or faulty force transmission through the musculoskeletal system lead to maladaptation of the components of that system. The correction of kinetics at an early age would contribute to the normal development of bones and joints. Their `Movement System Balance Theory' proposes that the relative length of soft tissues including antagonistic muscles, capsule, ligaments, tendons and nerves, determines the posture of joints. This theory suggests that the body will take the line of least resistance and that movement will occur in the more ¯exible areas. Blanch (1997) is of the opinion that to create a `perfect human machine' where major motions occur at the large joints (i.e. hip and shoulders) without compensating movements along the thoracic and lumbar spine requires core strength and/or stability. This stability would require optimum range of motion in the limbs and that the musculature of the trunk should be able to maintain the trunk position while applying and receiving force. The major force producing muscles originate from the trunk and insert on the limbs, e.g. latissimus dorsi and gluteus maximus. The subject of this case report was an all round sportsman who played hockey, golf and squash as well as swimming. He started swimming at 7 years of age and gained provincial colours holding six provincial records in his age group in the freestyle, backstroke and breaststroke events. Recently he had been disquali®ed in the breaststroke events as a result of an asymmetrical kick. As this had usually occurred # 1999 Harcourt Brace & Co. Ltd
after having won the event, it was extremely distressing for the subject and he no longer wished to swim breaststroke, which was previously his best stroke. His parents had been told that he had scoliosis. PHYSICAL EXAMINATION The subject was right hand dominant. Observation from posterior, anterior and lateral aspects revealed a slight thoraco lumbar scoliosis convex to the right, plus a slightly raised left shoulder. Both scapulae were abducted with winging and tipping evident. The shoulders were rounded, especially the right side. The pelvis was slightly tilted anteriorly. The gluteal folds were level with the bulk on the left appearing slightly smaller than the right. This was con®rmed on palpation. Both feet were slightly pronated (Fig. 1). Manual muscle testing with the muscles in the shortened position, as described by Kendall et al. (1993), revealed weakness/inhibition of the serratus anterior, as well as middle and lower ®bres of trapezius on the right side when compared with the
Fig. 1ÐPosterior view illustrating winging and tipping of scapulae. Manual Therapy (1999) 4(2), 100±106
102 Manual Therapy
left. When testing the upper ®bres of trapezius on the right, the subject rotated his shoulder forward when resistance was applied. This did not occur on the left side. Latissimus dorsi testing on the right elicited a strong contraction of the upper ®bres of trapezius on the right as well. There was a bilateral weakness of the rhomboids. Passive range of motion testing, as described by Kendall et al. (1993), revealed tightness in the pectoralis minor bilaterally with the subject lying supine with knees bent and arms at the side. This was recorded as marked on both sides but especially on the right. The right upper ®bres of trapezius and levator scapulae were tight. With the subject supine, it was possible to demonstrate anterior translation of the right humeral head but not the left with medial rotation of the shoulder while the arm was in 90 degrees of abduction. This was taken as a possible tightness of the joint capsule as well as the overlying muscles. Observation of the push up, as advocated by Janda (1994), revealed bilateral winging of the scapulae with a tendency of the right shoulder to rotate forward and elevate, indicating serratus anterior weakness. In the pelvic-hip complex the left gluteus medius, maximus and tensor fascia lata were all weaker than the right side. The left hip internal and external rotators were also weaker on the left side. When performing a squat the pelvis shifted laterally to distribute the weight over the right leg. This was accompanied by trunk lateral ¯exion to the left. Passive range of motion was measured with a goniometer and followed the procedure used by Blanch (1977) in his `Screening of Swimmers'. Hamstring and sciatic nerve ¯exibility was measured using the Straight Leg Raise (SLR), a good range being an angle with the horizontal of greater than 70 degrees. The subject had a range of 65 degrees on the left and 68 degrees on the right. Hip internal rotation was measured in prone lying with both knees ¯exed to 90 degrees and kept together in contact with the bench. The right side was normal at 45 degrees while the left side was restricted at 30 degrees. Tibial external rotation, the other important component of the stroke, was normal. A video of the subject swimming breaststroke was taken as a functional demonstration. This was also used as a baseline for re-evaluation at a functional level. It was also used in stroke analysis and helped in the process of relating the relevant impairments found to the dysfunction. TREATMENT Sahrmann (1988) advocates that, because a medical diagnosis is insucient, diagnostic categories should Manual Therapy (1999) 4(2), 100±106
be developed by physiotherapists. In her opinion the diagnosis by the physiotherapist is the term that names the primary dysfunction towards which treatment by the therapist is directed. This dysfunction is identi®ed by history taking, symptoms and signs, examination and tests the therapist performs or requests. Taking into account various views (Sahrmann 1988; Kendall et al. 1993; Janda 1994; White & Sahrmann 1994; Blanch 1997) and assessing the evidence of the examination as well as the videotape, the following hypothesis was formed: a muscle/soft tissue imbalance around the neck±shoulder complex was altering the instantaneous axis of rotation of this joint and was contributing to the shoulder dysfunction while the decreased range of internal rotation in the left hip and the associated muscle imbalance was resulting in the transmission of forces up the kinetic chain to the gluteal muscles and lumbar spine resulting in fatigue of these muscles and lumbar extension. All these factors were contributing to the abnormal movement pattern. This was explained to the subject and his mother, and a proposed treatment plan was outlined. They were told that the treatment would be time consuming and demanding, requiring active participation on behalf of both of them. The help of the swimming coach would also have to be enlisted. The proposed treatment plan was accepted by both, and treatment commenced. The long-term goal was to restore function enabling the subject to swim a breaststroke race without being disquali®ed. To achieve this, a time period of approximately 3 months was anticipated. The immediate goal was to work on the impairments that had been assessed as relevant and to gain the symmetry needed between left and right sides. Swimming demands that the swimmer is able to perform forceful repetitive motions at the extremes of range while maintaining a stable trunk and to achieve this the following treatment strategy was instituted: 1. Joint mobilizations of the right shoulder and left hip. The joint mobilizations for the shoulder consisted of antero-posterior pressures as described by Maitland (1986). These were performed as IV++ with the arm at the side as well as in 90 degrees of abduction and external rotation. The aim of this was to restore glide in the joint and possibly to stretch the posterior capsule and in an attempt to change the instantaneous axis of rotation of the joint, which is aected by the length and mobility of the soft tissues crossing the joint. Hip joint mobilizations were performed by using a belt and applying lateral traction to the hip joint while performing internal rotation as described by Mulligan (1996). As advocated by him, three sets of 10 pain free repetitions into resistance were performed. This did not quite result in # 1999 Harcourt Brace & Co. Ltd
The rehabilitation of a competitive swimmer 103
2.
3.
4.
5.
6.
7.
performing a `miracle' as described by Mulligan (1996) but the increase in range was remarkable. White & Sahrmann (1994) are of the opinion that manual therapy complements the movement system balance approach to patient management in particular the need to mobilize hypomobile joints that are contributing to hypermobility elsewhere or to a faulty movement pattern. Post isometric relaxation techniques for the tight muscles, namely upper ®bres of trapezius, levator scapulae and pectoralis minor. This was followed by active stretching. This involved stretching the scapula elevators by ¯exing the neck towards the chest and laterally to the onset of resistance in these muscles. Active depression and abduction of the ipsilateral scapula accompanied this by contraction of the lower ®bres of trapezius and serratus anterior. Active stretching was also given as part of the home programme. Closed chain and medicine ball exercises concentrating mainly on the shoulder, abdominal muscles (especially transversus abdominus) and hip muscles. The movement system balance theory emphasizes that powerful, rapid movements of the limbs should take place from a stable base, i.e. the scapulo-thoracic joint, cervical and thoracic spine for the upper limb, the lumbar spine and pelvis for the lower limb. The exercises described by Blanch (1997) are designed to achieve this. The sequence involves patterning to lay down an engram for stability, followed by mobility on stability and ®nally loaded mobility on stability. Postural correction and awareness. This was done in front of a mirror and initially taping was used as an aid to help brace weak muscles and increase proprioceptive awareness (Fig. 2). Appropriate postures during activities of daily living were stressed. According to Blanch (1997) being able to maintain good posture while not engaging in sport will reinforce the pattern of using the stabilizers correctly or, alternatively, if the stabilizers are not activated routinely (i.e. during everyday activities) it is usually more dicult to recruit them purely for athletic pursuits. Postero-anterior mobilizations to the cervical and thoracic and lumbar spine. These consisted mainly of large amplitude grade II and III movements to help maintain smooth movement of the spinal joints. Neurodynamic stretches. These were carried out for both upper and lower limbs to ensure that adverse neural tension would not interfere with the movement patterns. The home exercise programme was demonstrated to the mother who supervized it. This consisted of Theraband exercises for hip internal rotation in the functional position of prone lying and shoulder external rotation (loaded mobility on
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Fig. 2ÐTaping to provide support and proprioception.
stability), plus closed chain hip, shoulder and abdominal exercises using a Physio Ball as described by Blanch (1997), passive stretching by sitting in the `frog position' required by breaststroke (initially this could only be accomplished by using two pillows between the legs), manual stretching of pectoralis minor by the subject's mother. Activities such as skipping and moving along in a wheelbarrow-type position whilst being held by the legs were encouraged. These were considered fun activities and were also used to aid co-ordination by encouraging reciprocal movements. This phase of treatment consisted of three sessions a week for 3 weeks. At the end of the period a session with the coach at the pool was held at which time a video was taken. Stroke assessment revealed that the shoulder position was much better and that the subject was able to perform one or two `correct' kicks but then lapsed back into the habitual pattern. On Manual Therapy (1999) 4(2), 100±106
104 Manual Therapy
advice from the coach the next phase of 2 weeks concentrated on the pelvic area. The subject watched the video and this helped in the visualization of the stroke movement. During phase two of the rehabilitation programme full range of internal rotation at the hip was achieved. Treatment was focussed on quality of movement in the pelvic area and the strengthening of the left gluteal muscle which on manual palpation had a much smaller bulk than on the right side and an abnormal pattern of motor recruitment. Squats were performed in front of a mirror with the therapist sitting behind the subject placing hands on the buttocks to guide the movement so as to counter the tendency of a lateral shift of the pelvis to the right. This lateral shift together with trunk lateral ¯exion to the left was very pronounced when performing a one leg squat and was taken as indicative of the gluteal weakness. The squat was chosen, as it was an easy exercise for an 11year-old to perform, and it was also easy to guide the movement so as pick up any asymmetry. A further point was that it could also be done at home under the supervision of his mother. The remaining exercises were patterning exercises, as described by Blanch (1997), performed in prone kneeling and prone and side lying with emphasis on transversus abdominus. This phase lasted 3 weeks with three sessions a week and again ended with a session at the pool with the coach. Yet another video was taken and this time a photograph was also taken. As seen in Figure 3, the photograph clearly illustrates the asymmetry in the leg motion and the position of the left hip and leg. At this time the subject was able to perform approximately nine kicks, i.e. about 20 metres before the asymmetry appeared. It appeared as if muscle fatigue and lack of concentration were the main areas responsible for the problem. A kicking drill, which consisted of free style kicking (for gluteal endurance and to pre-fatigue these muscles), followed by breaststroke kicking while holding the body up against the wall to stabilize it and to keep the pelvis level was included in the programme. Phase three consisted of gym work designed to develop endurance in the gluteal muscles especially on the left. It was performed three times a week for 3 weeks and consisted of using the stepper machine and spinning on the bicycle for 10 minutes. This was followed by step up and step down sideways on a step leading with the left leg. Squats in front of a mirror, lunges and push-ups were also undertaken. This was done under the supervision of the physiotherapist and emphasis was placed on quality of movement. These exercises were chosen because they were easy to perform with good form, provided variety and again added a fun element so that the subject, who was quite young, would remain motivated. Manual Therapy (1999) 4(2), 100±106
Fig. 3Ð`Screw' kick clearly illustrated.
The home programme continued and shoulder and hip mobilizations, together with contract-relax stretching of tight muscle, were performed once a week. At re-evaluation after phase three the improvement in stroke and kick was marked. The subject was able to swim 50 metres with a correct stroke at 70% eort. However, when the eort was increased the stroke tended to fall back into the old pattern. The coach felt that the bulk of the programme should now consist of stroke drills under supervision so as to consolidate correct movement patterns. The subject at this stage could feel exactly when the kick was wrong and would then stop. In consultation with the subject's mother it was decided that she would supervize the stroke drills and exercise programme for the next phase of 3 weeks. After this if the technique was well established the coach would work on speed. Speed in competitive swimming is the ultimate goal. Pritchard (1997), however, feels that in a young swimmer the emphasis should be on technique rather than speed. It was unanimously agreed that because of the emotional impact of the regular disquali®cation, the subject would not be entered into a gala until stroke and speed were well consolidated.
RESULTS Twelve weeks after the commencement of the rehabilitation programme the following results were obtained: # 1999 Harcourt Brace & Co. Ltd
The rehabilitation of a competitive swimmer 105
. At the impairment level: observation of posture revealed less winging and tipping of the scapulae. Tightness in the pectoralis minor was graded as moderate on both sides. On performing a push up there was still slight winging of the scapulae but no forward rotation of the shoulder was present on the right side. Rotation of the right arm in 90degree abduction showed no anterior translation of the humeral head. Left hip internal rotation was equal in range to the right hip, as was the strength of the internal and external rotators. The subject was able to perform two sets of 15 repetitions of two legged squats while maintaining a symmetrical movement. On the one-legged squat, eight repetitions were possible on both the left and right sides. . At the functional level: a video of the subject swimming was taken. The coach was present to deliver criticism. The verdict was that the kick was fully acceptable and symmetry was maintained throughout the session. A slight asymmetry of the shoulders was still present. There was a de®nite increase in the subject's postural awareness. DISCUSSION Genadi Touretski (1997), coach of dual Olympic and World Sprint Champion Alexander Popov, when commenting on Alex stated `when he ®rst started swimming with me, at the University of Delmartar, I had to tell him to control his posture or he would not be included in the group. Alex's posture is still not perfect, but when he originally came to me his posture was quite bad. It is very important for him to understand that posture is a very, very important thing for all of us, and I would not coach him until he tried to improve it'. Another coach, Bob Pritchard (1997), has stated that `A small loss in swimmers' ¯exibility can change their mechanics and decrease their eciency levels'. He feels that by the time swimmers reach their physiological best, their ¯exibility may be decreased by up to 50% due to microtears and scar tissue formation causing dysfunction. Physiotherapists are also aware of the eects of posture on joints and movement patterns, and it would appear that a close working relationship between coach and physiotherapist may be bene®cial in the quest for good posture amongst athletes. White & Sahrmann (1994) emphasize that the reason a person moves in a certain way should be correctly identi®ed so that those individuals can be taught to restore normal movement. In a muscle system balance approach the relative strength and endurance of muscles is more important than the overall strength that any muscle or group of muscles can develop. They list amongst the priorities of this system an explanation to the subject of the posture # 1999 Harcourt Brace & Co. Ltd
movement faults that are perpetuating the condition. The subject should be taught to be aware of these and to correct them. This is time consuming and requires direct eort and co-operation on behalf of the subject. Constant encouragement and correction in the home, at school and by the coach would help reinforce new patterns of movements. The use of mirrors, supportive taping, videotaping and active stretching are also invaluable tools in the quest for good posture and movement patterns. It would appear that the physiotherapist, working in conjuction with the coach, teachers and family, ful®lling a role of educating, treating and management may play an important role in the attainment of good technique in a sport, and ultimately injury prevention, through the establishment of biomechanically advantageous movement patterns. The subject in this case report achieved an improved movement pattern in his breaststroke through a conscientious approach to his treatment. The stroke will need ongoing attention and constant correction. Once the awareness and physical capabilities are established this task is possibly made a bit easier. The treatment in the case reported was time consuming but very rewarding. Two months after the cessation of treatment, the author was presented with a bronze medal that had been won by the subject in a breaststroke race. CONCLUSION A swimmer swimming 8 kilometres per day performs approximately 5000 strokes. Attention given to good posture and body alignment from an early age may contribute towards the development of good joint mechanics and good movement patterns. Good movement patterns may in turn translate into good technique, better performances and possibly injury prevention. In this way the competitive life span of the athlete may be lengthened. It would appear that the physiotherapist, working in conjuction with coach and others involved in the daily activities of the subjects, may play an eective and important role in the achievement of these ideals as shown in this case report. References Blanch P 1997 The Swimming Machine, (Make the Most of Every Stroke by Being Flexible and Strong). Australian Swimming Inc. Briggs C, Sandor SM, Kenihan M 1995 The knee. In: Xuluaga M, Briggs C, Carlisle J et al. (Eds) Sports Physiotherapy Applied Science and Practice. Churchill Livingstone, South Melbourne, ch 29, pp 541±586 Costill D, Maglischo E, Richardson AB 1992 Swimming. Blackwell Scienti®c, Oxford. Manual Therapy (1999) 4(2), 100±106
106 Manual Therapy Federation Internationale De Natation Amateur 1996±1998 Constitution and Rules. 138 Edited by FINA Oce Janda V 1994 Muscles and motor control in cervicogenic disorders: Assessment and management. In: Grant R (Ed) Physical Therapy of the Cervical and Thoracic Spine. Churchill Livingstone, Edinburgh Kendall FP, McCreary EK, Provance PG 1993 Muscles: testing and function, 4th Edn. Posture and Pain. Williams and Wilkin, Baltimore, 109 Maitland GD 1986. Vertebral Manipulation, 5th Edn. Butterworths, London Mulligan BR 1996 Mobilizations with movement (MWMS) for the hip joint to restore internal rotation and ¯exion. Journal of Manual and Manipulative Therapy 1: 118±126
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Pritchard B 1997 The new swim paradigm. In: The Australian Institute of Sport International Swim Seminar Proceedings Section 2: 131±142. RWM Publishing (Pty) Ltd Sahrmann SA 1988 Diagnosis by the physical therapist ± a prerequisite for treatment: a special communication. Physical Therapy 68: 1703±1706 Touretski G 1997 Preparation of Olympic champion Alexander Popov. In: The Australian Institute of Sport International Swim Seminar Proceedings. Section 2: 85±89. RWM Publishing (Pty) Ltd White SG, Sahrmann SA 1994 A movement system balance approach to management of musculoskeletal pain. In: Grant R Physical Therapy of the Cervical and Thoracic Spine. Churchill Livingstone, Edinburgh
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