Swimming is a popular activity for fitness, recreation, and competition. However, it places the shoulder in repetitive end-range positions that are subject to high loads. It is therefore not surprising that shoulder pain is common in swimmers. The shoulders are the primary force generators responsible for propulsion through the water. Competitive swimmers can perform thousands of stroke cycles during a single training session, exposing the shoulder to substantial cumulative loads over time. In a recent survey of competitive swimmers, shoulder pain was common, with over 50% of older teenage swimmers reporting shoulder pain that had interfered with training or competition at some stage (Stirling et al., 2024).
Efficient swimming technique plays an important role in reducing the demands placed on the shoulder. Good body position and effective stroke mechanics help reduce resistance through the water and improve efficiency, meaning less stress is placed on the shoulder muscles and tendons with each stroke. When shoulder pain does occur, it is most commonly experienced during the propulsive pull-through phase of the stroke, when the shoulder is generating force to move the swimmer through the water. Symptoms may also occur during the recovery phase, although this tends to be less common.
What is swimmer’s shoulder?
Swimmer’s shoulder is a broad term used to describe shoulder pain arising from the repetitive overhead demands of swimming. Rather than representing a single diagnosis, it encompasses a range of conditions affecting the muscles, tendons and soft tissues around the shoulder. The structures traditionally associated with swimmer’s shoulder include the supraspinatus tendon, subscapularis tendon, subacromial bursa, and the long head of the biceps tendon. These structures are subjected to repetitive loading throughout the swimming stroke and are therefore commonly considered when assessing shoulder pain in swimmers.
Imaging studies have identified a range of structural changes in swimmers, including supraspinatus and subscapularis tendinopathy, superior labrum anterior-to-posterior (SLAP) tears, and acromioclavicular joint changes. Importantly, many of these findings are also present in swimmers who report no pain or functional limitations. Therefore, structural pathology identified on imaging does not necessarily explain a swimmer’s symptoms, and imaging findings should always be interpreted alongside a thorough clinical assessment (Holt et al., 2022).
Why do swimmers develop shoulder pain?
One of the most common contributors to swimmer’s shoulder is a change in training load. The shoulder adapts well to the demands of swimming when progression occurs gradually; however, problems can arise when the load placed on the shoulder exceeds its capacity to adapt.
When shoulder pain develops, it is important to consider whether there have been any recent changes to training or preparation, including:
- Training volume
- Training frequency
- Training intensity or speed
- Stroke focus
- Swimming technique
- Use of equipment
- Gym-based strength and conditioning programmes
- Return from a period of reduced training
Often, shoulder pain does not arise as a result of a single factor, but rather from the cumulative effect of multiple changes occurring over a relatively short period. A thorough review of a swimmer’s recent training history is therefore an important component of assessment and management. Recovery should also be considered alongside training load, as insufficient recovery between sessions may reduce the shoulder’s ability to adapt to the demands of training.
What does a physiotherapy assessment involve?
A physiotherapy assessment is valuable for identifying mobility and strength limitations that may affect stroke efficiency, performance, and shoulder loading. Swimming is a highly technical sport that requires specific physical characteristics to achieve an efficient stroke. Restrictions in one area of the body can result in compensations elsewhere, potentially increasing the demands placed on the shoulder.
Areas commonly assessed include:
- Thoracic and shoulder mobility – which contribute to key swimming positions such as streamline. Adequate thoracic rotation may also allow the swimmer to achieve arm recovery with less reliance on excessive horizontal extension at the shoulder.
- Hip mobility, particularly hip extension – which assists swimmers in maintaining an efficient body position in the water and may reduce the need for excessive extension through the lower back.
- Shoulder strength, particularly the muscles responsible for shoulder extension, internal rotation, and external rotation – which contribute to propulsion during the pull-through phase and control of the arm during recovery.
Identifying deficits in mobility or strength may help explain inefficient stroke mechanics and increased demands on the shoulder.
Injury prevention
The research regarding injury prevention in swimmers remains equivocal. Nevertheless, it is reasonable to focus on factors that improve swimming efficiency and the body’s capacity to tolerate load. This includes developing the mobility required to achieve efficient stroke mechanics, refining technique to minimise unnecessary resistance through the water, building strength throughout the shoulder and kinetic chain to generate propulsion, and carefully managing training loads over time.
Load management remains an important consideration. Monitoring changes in training volume, frequency, speed, stroke focus, gym-based training, and the use of equipment may help reduce the likelihood of the shoulder being exposed to loads beyond its capacity.
Gym-based strength and conditioning programmes can assist swimmers in developing the strength qualities required for performance and achieving normative strength benchmarks. Regular mobility exercises can also help swimmers attain and maintain the positions required for an efficient stroke, particularly at the shoulder, thoracic spine, and hips.
While no injury prevention strategy can completely eliminate risk, swimmers who combine efficient technique, appropriate mobility, adequate strength and sensible progression of training loads are likely to reduce unnecessary stress on the shoulder while simultaneously optimising swimming performance.
References
Holt, K., Delbridge, A., Josey, L., Dhupelia, S., Livingston, G. C., Jr., Waddington, G., & Boettcher, C. (2022). Subscapularis tendinopathy is highly prevalent in elite swimmer’s shoulders: An MRI study. Journal of Science and Medicine in Sport, 25(9), 720-725. https://doi.org/10.1016/j.jsams.2022.06.010
Pink, M. M., & Tibone, J. E. (2000). The painful shoulder in the swimming athlete. Orthopedic Clinics of North America, 31(2), 247-261.
Stirling, B. D., Sum, J. C., Baek, L., Michener, L. A., Barrack, A. J., & Tate, A. R. (2024). Shoulder pain in competitive swimmers: A multi-site survey study. International Journal of Sports Physical Therapy, 19(8), 965-975. https://doi.org/10.26603/001c.121114