Swimming After Shoulder Reconstruction

author : AMSSM

comments : 0

How to regain enough range of motion to swim freestyle after a shoulder injury or surgery

Question from BT Member MMauldwin

"I underwent nine major surgeries in as many months back in 2009 when retiring from Special Forces. One of those include the complete reconstruction of my right shoulder. The shoulder was initially scoped to remove a Morph II but it was determined that one of my ligaments and the upper head of the bicep were hanging on by a litteral thread.

I have fully recovered from the surgery, yet I have a limited range of motion when reaching above my head with my right arm. I continue to do stretches behind my back and across my chest but the shoulder does not seem to respond with any increased range of motion.

This hinders my swimming and I am preparing to begin my training schedule for an upcoming IM next year. Any suggestions on what I should do to compensate or stretch out this three year old issue would greatly be appreciated. Especially since I can only do Freestyle for about 50m then I shift to Breaststroke. It's not the fastest, but I am consistent with it."
-- Michael

Answer from Jeffrey B. Kreher, MD, FAAP
Member AMSSM

Hi Michael,
Great question and thank you for your service. 

However, there are a couple unanswered questions here ...

(1) Why can you swim freestyle only for 50 meters at a time?  (I am assuming that you alternate 50 meters freestyle / 50 meters breaststroke from your question.)

• Is there fatigue?
• Is there pain?
• How long can you carry on with the alternating pattern?

The fact that you can come back to the freestyle after 50 meters of breaststroke is very reassuring. 

Your body and shoulder are trainable and with a proper buildup in distance and/or decrease in rest time between 50 meter freestyle swims you should be able to increase your freestyle distance.  If it is pain that limits you after 50 meters of freestyle, then the pain generator must be addressed.  Seek the advice of a local Sports Medicine Specialist to examine and determine the pain generator and plan of management so you can build to longer distances of freestyle. 

It is very likely that the smaller muscles of your back need strengthening and endurance training.  By smaller muscles I am referring to your “scapular (shoulder blade) stabilizers,” or muscles that help conserve your power during the stroke and decrease pinching of the rotator cuff tendons with the swim stroke.   I believe you can make the greatest gains by focusing on good physical therapy of small muscles in your back.

Simply by increasing your swim volume you should acquire some stretching about your shoulder.  However, the loss of motion about your shoulder could also be something we call GIRD, or glenohumeral (or shoulder) internal rotation deficiency.   This can be stretched by something called a “sleeper stretch” to improve your internal rotation. 

In a “sleeper stretch” you lay on your side and your upper arm (of side being laid on) is level with your shoulder on the ground/table and forearm/hand point up at 12 o’clock (toward the ceiling).  You then use your opposite hand to weight your stretched side down toward 3 o’clock.  HOWEVER, you should be very cautious of internal rotation and adduction which can happen with poor swim form and reaching across your body (adduction) and catching the water (internal rotation) – this is the position of instability with a shoulder reconstruction. 

(By the way, there is nothing wrong with alternating freestyle and breaststroke if you feel more comfortable with such a swimming strategy.)

(2) What is causing the limitation of motion? 

• Is it a limitation of the construct/shoulder replacement? 
• Is there a different bony or mechanical obstruction? 
• Is it soft tissue restriction?  (Was there a capsular reconstruction?)

This question can be answered by a qualified Orthopedic shoulder specialist with knowledge of your current reconstruction, examination (and knowledge of your rotator cuff status) and review of imaging studies. 

I am assuming that there has been no failure of the shoulder replacement, which may not be correct.  However, if the limitation is the result of a mechanical obstruction, not much can be done to overcome your limited motion (short of another surgery). 

You should obtain assurance that there is no loosening of the construct and document if there is instability present.  However, if the limitation is only from capsular restriction (less likely), an appropriately trained physical therapist (usually with manual skills) can help regain motion.  You may also consider a sports chiropractor – especially if advanced with Active Release Techniques (trademarked).

Jeffrey B. Kreher, MD, FAAP
Pediatric Musculoskeletal & Sports Medicine Specialist
Assistant, Department of Orthopaedic Surgery
Division of Pediatrics Orthopaedics
Assistant Professor, Department of Pediatrics
Massachusetts General Hospital for Children
Instructor, Harvard Medical School
Boston, Massachusetts

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date: February 6, 2012