The Effects Of Differing Density Of Swim-Training Sessions On Shoulder Range Of Motion and Isometric Force Production In National and University Level Swimmers.

Background: Well-developed physical qualities (i.e., greater load capacity) in athletes can provide protection against injuries. Although higher competitive level swimmers have more developed physical qualities, no studies have investigated how physical qualities of the shoulder respond to a swim-training session in different competitive levels. Purpose: To compare baseline shoulder external rotation range of motion (ER ROM) and isometric peak torque of the shoulder internal rotators (IR) and external rotators (ER) between national and university level swimmers with differing training volumes. To compare the post-swim changes of these physical qualities between groups. Study design: Cross-sectional. Methods: Ten male swimmers (age= 18.7 ± 1.2 years) were divided into high-load (N= 5 national-level, weekly swim-volume= 37.0 ± 2.7 km) and low-load groups (N= 5 university-level, weekly swim-volume= 6.8 ± 1.8 km). For each group, shoulder active ER ROM and isometric peak torque of the shoulder IR and ER were measured before and immediately after a high-intensity swim-training session (for each group, the hardest swim-session of the week was analyzed). The results were evaluated by the level of significance (p-value), effect size, and whether changes exceeded the measurement error. Results: University-level swimmers had lower baseline ER torque (p= 0.006; d= 2.55) and IR torque (p= 0.011; d= 2.42) than national-level swimmers. For post-swim analysis, ER ROM decreased more in university swimmers (change= -6.3° to -8.4°; d= 0.75-1.05) than national counterparts (change= -1.9° to -5.7°; d= 0.43-0.95). Greater drops in rotation torque were found in university swimmers (IR change= -15% to -21.0%; d= 0.83-1.66; ER change= -9.0% to -17.0%; d= 1.14-1.28) compared to national swimmers (IR change= -10.0% to -13.0%; d= 0.61-0.91; ER change= -3.7% to -9.1%; d= 0.50-0.96). The average change of all tests in university swimmers exceeded the minimal detectable change (MDC), whereas in national level swimmers some tests exceeded the MDC. Despite this, only post-swim ER torque in the dominant side (p= 0.003; d= 1.18) was significantly lower in university swimmers (possibly due to the small sample size). Conclusions: University swimmers have less baseline shoulder external and internal rotator torque and had greater drops of all shoulder physical qualities after a swim-training session, which may have implications for injury risk. However, due to the sample size, the results have to be interpreted with caution. Level of evidence: 3.

The Effect of Exercise Therapy Interventions on Shoulder Pain and Musculoskeletal Risk Factors for Shoulder Pain in Competitive Swimmers: A Scoping Review.

CONTEXT: Shoulder pain is the main cause of missed or modified training in competitive swimmers. Exercise therapy can improve the outcomes, yet uncertainty exists regarding the characteristics of these interventions. OBJECTIVES: The primary aim was to describe the evidence base relating to the effectiveness of exercise therapy interventions on shoulder pain and shoulder musculoskeletal risk factors for shoulder pain in swimmers. The secondary aim was to identify gaps in the literature and provide recommendations for future research and practice. EVIDENCE ACQUISITION: A scoping review methodology was applied through the search of MEDLINE, PubMed, Scopus, Web of Science, and CINAHL databases. The authors included any research studies (except clinical commentaries and conference papers) that assess the effect of exercise therapy on shoulder pain and musculoskeletal risk factors for shoulder pain in swimmers. The literature was critically appraised using the Modified Down and Black checklist. EVIDENCE SYNTHESIS: From 452 papers identified, 14 studies were included in this review. An exercise program of 6 to 8 weeks, including strengthening exercises (shoulder external rotator and scapula retractor muscles) and stretches (pectoral muscles), can decrease the incidence of shoulder pain in swimmers. Furthermore, a combination of exercises and stretches with manual therapy techniques can help to decrease shoulder pain in injured swimmers. Regarding risk factors, a strengthening program of more than 12 weeks increased shoulder external rotation peak force, endurance, and external rotation/internal rotation ratio; however, this was not associated to decreases in pain. Finally, open kinetic chain exercises and a dry-land program are superior to close kinetic exercises and water training for improving shoulder external rotation strength and endurance. CONCLUSIONS: Exercise therapy has positive effects on reducing the incidence of shoulder pain, the management of shoulder pain, and improving shoulder musculoskeletal risk factors in competitive swimmers. However, due to methodological limitations of the studies, caution must be used when applying these results in practice. Future research should focus on high-quality randomized controlled trials for prevention and management of shoulder pain in swimmers.

Cumulative Effects of a Week's Training Loads on Shoulder Physical Qualities and Wellness in Competitive Swimmers.

BACKGROUND: Competitive swimmers are exposed to high training loads, which can contribute to the development of shoulder pain. There is a lack of research investigating the interactions between the accumulation of training loads and factors associated to shoulder pain in swimmers. PURPOSE: The primary objective was to analyze the changes in shoulder physical qualities and wellness factors over a week of training in competitive swimmers. A secondary objective was to compare the changes in these variables between different swim-training volumes performed during the week. DESIGN: Cross-sectional. METHODS: Thirty-one national and regional-level swimmers were included (18 females, 13 males; age= 15.5 ± 2.2 years). Active shoulder external rotation (ER) range of motion (ROM), shoulder-rotation isometric torque, and wellness factors using the Hooper questionnaire were measured twice over the week: a baseline measurement (before Monday´s training session) and a follow-up during the week. Participants were divided into a high-volume group (HVG) and low-volume group (LVG) based on the day follow-up was performed. HVL (n= 15) was tested at the end of the training week (after Saturday´s session) and LVG (n= 16) during the week (after Thursday or Friday´s session). Rating of perceived exertion (RPE) of the whole week was recorded after the follow-up session. RESULTS: At follow-up, the LVG averaged a volume of 26.2 ± 2.2 km, whereas the HVG averaged a volume of 37.5 ± 3.7 km. LVG and HVG participants decreased active shoulder ER ROM on dominant (p= 0.002; p= 0.006) and nondominant sides (p= 0.001; p= 0.004), displayed increased muscular soreness (p= 0.001; p= 0.007) and worsened overall wellness (p< 0.001; p= 0.010). Fatigue (p= 0.008) and poor sleep quality were increased (p= 0.023) in HVG, but not in LVG. There were no changes in shoulder-rotation torque and stress in any group. Regarding between-groups differences, only weekly RPE was higher (p= 0.004) in HVG. CONCLUSIONS: The accumulation of training loads over the week negatively affect physical and wellness factors. Greater swim-volumes were associated with an increase perception of training loads. The regular monitoring of multiple factors to assess swimmers' response to training might be necessary. LEVEL OF EVIDENCE: 3.

Training Intensity and Shoulder Musculoskeletal Physical Quality Responses in Competitive Swimmers.

CONTEXT: Shoulder pain is the main cause of missed or modified training in competitive swimmers. Shoulder musculoskeletal maladaptations occur to some extent as a consequence of training loads during swimming that may increase the risk of shoulder injury. Further evidence is needed to understand the training intensities at which these maladaptations occur. OBJECTIVE: To determine the acute effect of training intensity on the shoulder musculoskeletal physical qualities associated with shoulder injury in competitive swimmers. DESIGN: Cross-sectional study. SETTING: Indoor swimming pool. PATIENTS OR OTHER PARTICIPANTS: Sixteen asymptomatic national- and regional-level swimmers (7 females, 9 males; age = 14.6 ± 3.9 years, height = 160.5 ± 12.7 cm, mass = 55.3 ± 12.5 kg). MAIN OUTCOME MEASURE(S): Bilateral active shoulder-rotation range of motion (ROM), joint position sense, latissimus dorsi length, combined elevation test, and shoulder-rotation isometric peak torque and handgrip peak force normalized to body weight were measured before and immediately after low- and high-intensity swim-training sessions. The intensity of the sessions was determined by the distance swum over or at the pace threshold and confirmed by the swimmer's rating of perceived exertion. RESULTS: After the high-intensity training session, shoulder external-rotation ROM (dominant side: P < .001, change = -7.8°; d = 1.10; nondominant side: P = .002, change = -6.5°, d = 1.02), internal-rotator isometric peak torque (dominant side: P < .001, change = -11.4%, d = 0.42; nondominant side: P = .03, change = -6.6%, d = 0.20), and external-rotator isometric peak torque (dominant side: P = .004, change = -8.7%, d = 0.27; nondominant side: P = .02, change = -7.6%, d = 0.25) were reduced. No changes were found in any of the outcome measures after the low-intensity session. CONCLUSIONS: Shoulder active external-rotation ROM and rotation isometric peak torque were decreased immediately after a high-intensity training session, possibly increasing the risk of injury during subsequent training. Monitoring these variables may help practitioners adjust and manage training loads to decrease the risk of shoulder injury.

Surgery for the fractured clavicle: factors predicting nonunion.

BACKGROUND: This study identifies the reasons for failure after plate osteosynthesis of midshaft clavicle fractures, complication rates, and time to radiographic union. METHODS: A retrospective review of 84 consecutive patients who had undergone surgical fixation for a midshaft clavicle fracture was performed. RESULTS: There were 82 patients who were included for analysis and operated on by 11 different surgeons using a mixture of locking (63%) and nonlocking (37%) plates. The rate of osteosynthesis failure was 12.2%. A logistical regression analysis found that failure of osteosynthesis had no relationship to type of plate used (P = .82), gender (P = .42), number of proximal (P = .96) or distal (P = .63) screws to the fracture, or length of plate (P = .42). Smoking was found to be the only risk factor (P = .02) that increased failure rates after midshaft clavicle osteosynthesis. CONCLUSION: Smoking was the only identifiable risk factor to increase failure rates in clavicle osteosynthesis. Preoperative counseling can identify those at increased risk of implant failure and can help improve clinical results by implementing a smoking cessation plan.

Low-grade infections in nonarthroplasty shoulder surgery.

BACKGROUND: Recent studies have identified the diagnostic challenge of low-grade infections after shoulder arthroplasty surgery. Infections after nonarthroplasty procedures have not been reported. This study assessed patient-related risk factors, outcomes, and clinical presentation of low-grade infection after open and arthroscopic nonarthroplasty shoulder surgery. METHODS: The cases of 35 patients presenting with suspected low-grade infection were reviewed. Biopsy specimens taken at revision surgery were cultured in the sterile environment of a class II laminar flow cabinet and incubated for a minimum of 14 days at a specialist orthopedic microbiology laboratory. Patient-related factors (age, occupation, injection), index surgery, and infection characteristics (onset of symptoms, duration to diagnosis, treatment) were analyzed. RESULTS: Positive cultures were identified in 21 cases (60.0%), of which 15 were male patients (71%). Of all patients with low-grade infection, 47.6% were male patients between 16 and 35 years of age. Propionibacterium acnes and coagulase-negative staphylococcus were the most common organisms isolated (81.1% [n = 17] and 23.8% [n = 5], respectively). Of 14 negative culture cases, 9 were treated with early empirical antibiotics (64.3%); 7 patients reported symptomatic improvement (77.8%). Of 5 patients treated with late empirical antibiotics, 4 stated improvement. Patients presented with symptoms akin to resistant postoperative frozen shoulder (persistent pain and stiffness, unresponsive to usual treatments). CONCLUSION: Young male patients are at greatest risk for low-grade infections after arthroscopic and open nonarthroplasty shoulder surgery. P. acnes was the most prevalent organism. Patients presented with classic postoperative frozen shoulder symptoms, resistant to usual treatments. Interestingly, 78.6% of patients with negative cultures responded positively to empirical treatment.

The Effects of Rigid Scapular Taping on Acromiohumeral Distance in Healthy Shoulders: An Observational Study.

CONTEXT: Compromise to the acromiohumeral distance (AHD) has been reported in subjects with subacromial impingement syndrome when compared with healthy subjects. In clinical practice, patients are taped with the intention of altering scapular position and influencing the AHD. However, research to determine the effects of taping on AHD is exiguous. OBJECTIVES: To evaluate the effect of ridged taping techniques to increase posterior scapular tilt and upward scapular rotation on the AHD. DESIGN: 1-group pretest/posttest repeated-measures design. SETTING: Human performance laboratory. PARTICIPANTS: 20 asymptomatic participants (10 male and 10 female) age 27 y (SD 8.0 y). INTERVENTION: Ridged tapping of the scapula into posterior tilt and upward scapular rotation. MAIN OUTCOME MEASURE: Ultrasound measurement of the AHD. RESULTS: AHD increased significantly after rigid tape application to the scapula (P < .003) in healthy shoulders in 60° of passive arm abduction. CONCLUSION: Taping techniques applied to the scapula had an immediate effect of increasing the AHD in healthy shoulders in 60° of passive arm abduction. Results suggest that taping for increasing posterior scapular tilt and increasing scapular upward rotation can influence the AHD and is a useful adjunct to rehabilitation in patients with subacromial impingement syndrome.

Shoulder injuries in adolescent rugby players.

BACKGROUND: Rugby is a high-intensity contact sport, frequently causing shoulder injuries. Between the ages of 12 years to 18 years, academy and county level players are being selected for professional contracts, making this is a critical stage of their career. The present study aimed to describe the patterns of injury in adolescent rugby players with shoulder injuries. METHODS: Academy and county level rugby players in the target age group, over a 7-year period, were included in the present study. Data collected included the mechanism of injury, position and level of play, radiology and surgical findings, and recurrence rate at a minimum of 2 years post-surgery. RESULTS: One hundred and sixty-nine cases adhered to the inclusion criteria, with most cases involving two or more pathologies in the shoulder (54%). Forwards sustained more shoulder injuries than backs, incurring more labral injuries. By contrast, backs had a higher incidence of bony pathology. The mechanism of injury frequently correlated with player positions. There was a 21% injury recurrence rate, with forwards (7%) and higher level academy players (11%) most likely to suffer a recurrence. CONCLUSIONS: Shoulder injury patterns in this important group of adolescent contact athletes are complex, with recurrence rates being higher than those in older rugby players.

Relationship between extrinsic factors and the acromio-humeral distance.

BACKGROUND: Maintenance of the subacromial space is important in impingement syndromes. Research exploring the correlation between biomechanical factors and the subacromial space would be beneficial. OBJECTIVES: To establish if relationship exists between the independent variables of scapular rotation, shoulder internal rotation, shoulder external rotation, total arc of shoulder rotation, pectoralis minor length, thoracic curve, and shoulder activity level with the dependant variables: AHD in neutral, AHD in 60° arm abduction, and percentage reduction in AHD. DESIGN: Controlled laboratory study. METHOD: Data from 72 male control shoulders (24.28years STD 6.81 years) and 186 elite sportsmen's shoulders (25.19 STD 5.17 years) were included in the analysis. The independent variables were quantified and real time ultrasound was used to measure the dependant variable acromio-humeral distance. RESULTS: Shoulder internal rotation and pectoralis minor length, explained 8% and 6% respectively of variance in acromio-humeral distance in neutral. Pectoralis minor length accounted for 4% of variance in 60° arm abduction. Total arc of rotation, shoulder external rotation range, and shoulder activity levels explained 9%, 15%, and 16%-29% of variance respectively in percentage reduction in acromio-humeral distance during arm abduction to 60°. CONCLUSION: Pectorals minor length, shoulder rotation ranges, total arc of shoulder rotation, and shoulder activity levels were found to have weak to moderate relationships with acromio-humeral distance. Existence and strength of relationship was population specific and dependent on arm position. Relationships only accounted for small variances in AHD indicating that in addition to these factors there are other factors involved in determining AHD.

Inter-rater Reliability of Real-Time Ultrasound to Measure Acromiohumeral Distance.

BACKGROUND: Real-time ultrasound (RTUS) has been suggested as a reliable measure of acromiohumeral distance. However, to date, no vigorous assessment and reporting of inter-rater reliability of this method has been performed with the shoulder in a neutral position or with active and passive arm abduction. OBJECTIVE: To assess intrasession inter-rater reliability of using RTUS to measure acromiohumeral distance with the shoulder in a neutral position and with 60° active and passive abduction. STUDY DESIGN: Inter-rater intrasession reliability of repeated measures. SETTING: Human performance laboratory. PARTICIPANTS: Twenty persons (12 male and 8 female) with an average age of 29.86 years (standard deviation, 7.8). METHOD: In an inter-rater, intrasession study, RTUS was used to measure the acromiohumeral distance with the shoulder in a neutral position and with 60° of both active and passive abduction. MAIN OUTCOME MEASURE: Acromiohumeral distance. RESULTS: Intraclass correlation coefficient (ICC)2.1 scores ranged between 0.65-0.88 (standard error of the mean = 0.81-1.2 mm and minimal detectable differences with 95% confidence = 2.2-2.3 mm) for inter-rater intrasession reliability. CONCLUSION: RTUS was found to have fair to good inter-rater reliability as a tool to measure acromiohumeral distance with the shoulder in a neutral position and with 60° of both active and passive arm abduction.

Sorting swimmers shoulders: An observational study on swimmers that presented to a shoulder surgeon.

CONTEXT: It is common for swimmers to suffer shoulder injuries resulting in a wealth of research focusing on the causes and types of injury. However, there is a lack of evidence regarding current management for shoulder injuries in swimmers. AIMS: To investigate the diagnosis, subsequent management, and the return to swimming outcomes for swimmers presenting to an orthopedic practice. SETTINGS AND DESIGN: Retrospective cohort study of competitive swimmers presenting to an orthopedic practice. MATERIALS AND METHODS: The diagnosis, subsequent management, and the return to swimming outcomes were analyzed for 14 swimmers whose injuries were managed by a shoulder surgeon. STATISTICAL ANALYSIS USED: Descriptive analysis. RESULTS: No significant association was identified between swimming stroke and type of injury. The majority of swimmers had good scapula rhythm, with no visible dyskinesis, including those with impingement. Swimmers with impingement did not require arthroscopy, and with nonoperative management had a mean time to return to swimming of 1.6 months. All labral tears required arthroscopic labral repair, with these swimmers having a mean time of 2.9 months postsurgery to return to swimming. CONCLUSION: The study demonstrated that an accurate diagnosis, and appropriate choice of nonoperative and surgical treatments lead to reassuring outcomes for swimmers suffering from shoulder injuries.

An evidence-based review of current perceptions with regard to the subacromial space in shoulder impingement syndromes: Is it important and what influences it?

BACKGROUND: Reduction of the subacromial space as a mechanism in the etiology of shoulder impingement syndromes is debated. Although a reduction in this space is associated with shoulder impingement syndromes, it is unclear if this observation is cause or consequence. METHOD: The purposes of this descriptive review are to provide a broad perspective on the current perceptions with regard to the pathology and pathomechanics of subacromial and internal impingement syndromes, consider the role of the subacromial space in impingement syndromes, describe the intrinsic and extrinsic mechanisms considered to influence the subacromial space, and critique the level of evidence supporting these concepts. FINDING: Based on the current evidence, the hypothesis that a reduction in subacromial space is an extrinsic cause of impingement syndromes is not conclusively established and the evidence permits no conclusion. INTERPRETATION: If maintenance of the subacromial space is important in impingement syndromes regardless of whether it is a cause or consequence, research exploring the correlation between biomechanical factors and the subacromial space, using the later as the outcome measure, would be beneficial.

Acromiohumeral Distance During Neuromuscular Electrical Stimulation of the Lower Trapezius and Serratus Anterior Muscles in Healthy Participants.

CONTEXT: Compromise to the acromiohumeral distance has been reported in participants with subacromial impingement syndrome compared with healthy participants. In clinical practice, patients with subacromial shoulder impingement are given strengthening programs targeting the lower trapezius (LT) and serratus anterior (SA) muscles to increase scapular posterior tilt and upward rotation. We are the first to use neuromuscular electrical stimulation to stimulate these muscle groups and evaluate how the muscle contraction affects the acromiohumeral distance. OBJECTIVE: To investigate if electrical muscle stimulation of the LT and SA muscles, both separately and simultaneously, increases the acromiohumeral distance and to identify which muscle-group contraction or combination most influences the acromiohumeral distance. DESIGN: Controlled laboratory study. SETTING: Human performance laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty participants (10 men and 10 women, age = 26.9 ± 8.0 years, body mass index = 23.8) were screened. INTERVENTION(S): Neuromuscular electrical stimulation of the LT and SA. MAIN OUTCOME MEASURE(S): Ultrasound measurement of the acromiohumeral distance. RESULTS: Acromiohumeral distance increased during contraction via neuromuscular electrical stimulation of the LT muscle (t(19) = -3.89, P = .004), SA muscle (t(19) = -7.67, P = .001), and combined LT and SA muscles (t(19) = -5.09, P = .001). We observed no differences in the increased acromiohumeral distance among the 3 procedures (F(2,57) = 3.109, P = .08). CONCLUSIONS: Our results supported the hypothesis that the muscle force couple around the scapula is important in rehabilitation and scapular control and influences acromiohumeral distance.

Reinterpretation of O'Brien test in posterior labral tears of the shoulder.

BACKGROUND: Injuries to the posterior labrum are less common and more difficult to diagnose compared to anterior labral pathology. This may be in part due to difficulties in preoperative diagnosis. Posterior labral injuries cause abnormal loading of the rotator cuff with subsequent weakness. Examination using the O'Briens test tightens the posterior capsule and posteriorly translates the humeral head, stressing the labrum resulting in pain and weakness. METHOD: A retrospective study. RESULTS: Of 74 patients diagnosed with a posterior labral tear at arthroscopy 55 had subjective weakness on performing a O'Briens test, a sensitivity of 83% and a positive predictive value (PPV) of 90%. CONCLUSION: Multiple tests have been described for posterior labral pathology and none of these, on their own, have a high sensitivity rate. Posterior labral injuries can often be missed on magnetic resonance imaging scanning and also at surgery if not specifically looked for. Using a sign of clinically demonstrated weakness when performing the O'Briens test, and hence reinterpretation of the test, is sensitive, with a high PPV for posterior labral pathology and can help guide further treatment.