Member Case Study: Shoulder Pain - Type II Acromioin

author : AMSSM

comments : 0

I've had shoulder problems since the very beginning of tri training. I did see an ortho who took x-rays and said I have a type II acromioin. I'd love to know some stretches to help my flexibility.

Member Question from Keyone
I've had shoulder problems since the very beginning of tri training. I know it's related to my spending long hours on a computer and that has caused a tightness somewhere in my shoulder joint. I do have an ergonomic keyboard tray and sometimes move my mouse over to the left instead of right (it's there now, actually).

The weird thing is, if I don't swim enough, I get pain. If I swim too much, I get pain. So, I have to swim just the right amount to keep my shoulder issues to a nominal irritation level with no pain.

I did see an ortho who took x-rays and said I have a type II acromioin. He referred me to a PT and I went to her for a while. She gave me some exercises to do. I went to her for about three weeks, and continued the exercise regime for about six weeks. It didn't really help, so I stopped.

Like I said above, my pain is manageable if I swim the right amount. I'm more interested in how this affects my swimming form. I know the lack of flexibility in my shoulder affects my swim stroke, and breathing rhythm and it's much harder for me to breathe to my left than my right. When I breathe to my right, even though it feels better, my arm goes down too deep into the water and I am twisting my head funny (I had videos taken). I'm pretty sure this is because of lack of flexibility. I'd love to know some stretches to help increase my flexibility in my shoulders and improve my stroke.

I know this is probably too vague or complex, but thought I'd shout it out anyway! Thanks!

PS: This issue limits my future to compete in an Ironman - I just don't think I could do enough swim training!

Answer from Marjie Delo, MD

Member AMSSM

Your question is a bit vague, but hopefully this will be helpful. You are probably experiencing pain from shoulder impingement. There are multiple types of shoulder impingement that can occur during swimming: subacromial, intraarticular (in the shoulder joint), and subcoracoid. From long hours at a desk, you most likely have significant pectoralis tightness. This and your type II acromion are risk factors for subacromial impingement. This occurs when the rotator cuff rubs against the acromion (the bone on top of your shoulder) during the swim stroke.

Mechanics of the swim stroke as well as muscular fatigue can also contribute to impingement. Swimmers who have a large amount of internal rotation during the pulling phase, have delayed initiation of external rotation during the recovery phase, or have decreased upward scapula (shoulder blade) rotation have a higher incidence of impingement. You are already increasing your roll (I'm assuming towards the painful side), which will decrease impingement. You can also use less internal rotation during the recovery phase, and perform hand entry more lateral to the midline.

The next factor is muscular fatigue. The repetitive nature of swimming leads to fatigue around the shoulder, shoulder blade, and upper back. The two muscles that are active throughout the entire swim stroke are the serratus anterior (responsible for scapula rotation) and subscapularis. These, along with the lower trapezius and rhomboid, are the most important muscles to train for endurance and strength. While you are working on strengthening, you can avoid further fatigue by avoiding hand paddles or pulling sets. Fins can be used also to decrease upper body stress.

In your situation, stretching of the pec muscles is crucial. You likely also have tightness in the upper trapezius and levator scapulae (neck muscles) from sitting at a desk, and these may be contributing to your neck twisting as well as poor scapular mobility. I would also focus on stretching these muscles, and consider deep tissue massage. Taping of the scapula may help you with proprioceptive awareness (awareness of where the shoulder blade should be in relation to the ribcage). Many swimmers have tightness in the posterior capsule (rear lining of the shoulder joint) which can respond to stretches. You should ask your therapist or orthopedist if posterior capsular stretches are indicated.
 

Hope this helps, and good luck with your training!

Marjie Delo, MD
Mercy Sports Medicine & Rehabilitation Center 
 

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date: October 15, 2008