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Fundamental shoulder strengthening exercises for competitive swimmers
Written by Behnam Liaghat, recognized specialist by the International Federation of Sports Physical Therapy, based in Denmark at the University of Southern Denmark. Email: email@example.com
Following my recent blog about identifying joint hypermobility in swimmers, in this blog I will go through some of the top shoulder exercises for the competitive or elite swimmer to develop fundamental strength and neuromuscular control of the rotator cuff and scapular stabilizers.
In our recent research about young competitive swimmers with joint hypermobility (Liaghat et al., 2018), we found that swimmers with inherent shoulder joint hypermobility displayed reduced internal rotation strength and a tendency to poor activation of the scapular muscles. Another interesting finding was that swimmers with joint hypermobility not only display reduced absolute internal rotation strength, but these swimmers are weaker through the entire range of shoulder rotation. The suggested dry-land exercises in this blog can be designed to be beneficial for both hypermobile and non-hypermobile swimmers with few adjustments in range of motion, i.e. by increasing shoulder rotation to be as close as possible to the individual end range.
What are the benefits?
The four exercises specifically aim at improving shoulder retraction (refers to moving the scapula towards the spine), internal rotation and external rotations strength. To avoid injuries, it is important to target muscles on both sides of the shoulder to achieve a balanced intermuscular function. This is the rationale for including exercises for both internal and external rotation movements. Adequate strength in these movements has, besides injury prevention purposes, a positive effect on swimming stroke performance.
Some general guidelines for these exercises include performing them without producing any pain or discomfort and slowly through the entire range (approximately 6-8 seconds per repetition) to engage all important muscles. As there are no golden standard number of repetitions, you may want your swimmers to start with 3 x 30 seconds for the first 2-4 weeks and then move on to 3 x 8-12 repetitions with heavier resistance. Depending on the load applied and experienced level of muscle soreness, the exercises can be performed 3-5 times weekly. Make sure your swimmers breathe in a relaxed manner and engage the whole kinetic chain in all exercises.
When introducing these exercises to your swimmers, be certain that they can control the shoulder so excessive movement of the tip of the shoulder in either upward (towards the ear), backward or forward directions is avoided. In principle, reducing resistance and/or decreasing the range of movement may be applied to increase quality of shoulder control.
Active release of muscles before you start
Before instructing swimmers in performing these exercises, it is recommended to do some active release of the posterior rotator cuff muscles by standing against a wall with the arms perpendicular to the trunk and putting a pressure to the mid-point of the scapula with a lacrosse ball to target the infraspinatus area (Fig. 1). From here the swimmer can simply roll on the ball and add a shoulder external and internal rotation movement for up to two minutes to release tight and sore muscles (Fig. 2 A-C). The active self-release can be performed in supine for adding more pressure.
Now let us move on to the top dry-land exercises for fundamental shoulder strength
Exercise 1: Prone 1-arm diagonal lift
Either lie on the floor or on a gym ball supporting with your feet and one arm. Apply resistance with an elastic band. Slightly retract and depress your shoulder before lifting your arm with a 45 degrees angle away from the trunk´s midline. While lifting the arm, a maximum external rotation is performed in the arm so the thumb points towards the ceiling.
Level down by lifting the arm perpendicular to the trunk’s midline.
Level up by adding a back extension in the movement or lifting the opposite leg.
Exercise 2: Supine internal rotation 1
Either lie on the floor or on a gym ball supporting with your feet. Apply resistance with an elastic band. Slightly retract and depress your shoulder before turning one arm at a time internally as far as possible without losing shoulder control (e.g. protracting the shoulder towards the ceiling).
Level up by adding oscillation (fast movements back and forth) through the movement.
Exercise 3: Supine internal rotation 2
Description: Either lie on the floor or on a gym ball supporting with your feet. Apply resistance with dumbbells. Slightly retract and depress your shoulder before slowly turning one arm at a time externally in cranial direction and then back to vertical position in the underarm without losing shoulder control (e.g. avoid pushing the shoulder towards the ceiling).
Level up by adding more load and increasing range of external rotation.
Exercise 4: Prone external rotation
Lie on a gym ball supporting with your feet and one arm. Apply resistance with a dumbbell. Slightly retract and depress your shoulder before externally rotation your arm with the upper arm perpendicular to the trunk.
Level up by adding more load and increasing range of external rotation.
Every swimming coach should be familiar with these top shoulder exercises and include them in some content as part of the dry-land routines for injury prevention and for enhancing swimming stroke performance.
A special thanks to the Danish swimmers Matilde Lerche Schrøder and Line Virkelyst Johansen for giving their photo consents.
Liaghat, B., Juul-Kristensen, B., Frydendal, T., Marie Larsen, C., Søgaard, K., & Ilkka Tapio Salo, A. (2018). Competitive swimmers with hypermobility have strength and fatigue deficits in shoulder medial rotation. Journal of Electromyography & Kinesiology, 39, 1-7. DOI: 10.1016/j.jelekin.2018.01.003
Written by Behnam Liaghat, recognized specialist by the International Federation of Sports Physical Therapy, based in Denmark at the University of Southern Denmark.
With hypermobility, it is really a balance for the swimmer between taking advantage of the condition by reducing drag and avoiding excessive motion that may potentially damage the joint. I propose that you may easily acquire the knowledge to test many of your swimmers for generalized joint hypermobility, including shoulder hypermobility, within 1-2 minutes.
In our recent research study on young competitive swimmers, the main findings were that healthy swimmers with hypermobility in the shoulder had a decreased strength and a larger fatigue development. In addition, more experimental data indicated a poorer stability of the shoulder blade. As a swimming coach, you can prescribe exercises to target these deficits and help your swimmers take advantage of their joint hypermobility. Generalized joint hypermobility is evaluated with the 9-point Beighton scale, which requires the performance of five maneuvers, four passive bilateral and one active unilateral performance:
Passive dorsiflexion and hyperextension of the fifth MCP joint beyond 90°
Passive apposition of the thumb to the flexor aspect of the forearm
Hyperextension of the elbow beyond 10°
hyperextension of the knee beyond 10°
Active forward flexion of the trunk with the knees fully extended so that the palms of the hands rest flat on the floor
Each positive test scores one point, with cut-off values of more than 5/9 being indicative of the presence of generalized joint hypermobility. These cut-off values may vary, and some authors suggest lower cut-off values (e.g. 4/9) for males.
Since the shoulder is not represented in the Beighton scale, you may use a shoulder external rotation (positive score more than 90°) with the upper arm in neutral along the side of the body.
In case further investigation is required of the musculoskeletal condition of the swimmer or in case the swimmer experiences pain, please refer to a sports physiotherapist, who can perform additional tests and examination.
For more detail on this topic, please read the freely available research paper by Liaghat et al. (2018): “Competitive swimmers with hypermobility have strength and fatigue deficits in shoulder medial rotation”. https://authors.elsevier.com/a/1WU8g3kurobLDS
1. Please introduce yourself to the readers (how you started in the profession, education, credentials, experience, etc.).
My name is Lucas Wymore, and I am an orthopedic surgeon specializing in sports medicine. I attended Notre Dame for college where I swam for the Irish. I went to medical school at Texas A&M University, completed my orthopedic residency at the University of North Carolina at Chapel Hill and a sports medicine fellowship with the San Diego Sports Medicine and Arthroscopy fellowship. I became interested in sports medicine while in high school. I loved sports, and because of swimming, I had a desire to remain involved in the sport and work with athletes as a career.
2. You recently published an article on subject active swimmer responses based on their shoulder. What do we know about the accuracy of subjective responses ?
We know with any survey study, there are some inherent limitations. Recall bias can change people’s responses due to memory of past events. Some athletes may wish to underreport their symptoms if they fear that they may lose playing time. In order to decrease this bias, our study was to be completed based on shoulder symptoms at the present time, in an effort to minimize recall bias. Privacy was assured so that athletes would be more comfortable answering as truthfully as possible.
3. What did you choose the KJOC and did you consider any other subjective questionnaires ?
The KJOC score was selected because it is validated for overhead athletes. It is specific for function and performance in the athlete, which will pick up differences that may be missed in other scores. Many studies have used this questionnaire for a variety of shoulder and elbow research in athletes. There are other shoulder scores in the orthopedic literature, but these focus on activities of daily living. For example, the Disabilities of Arm, Shoulder, and Hand (DASH) ask questions including difficulty with preparing meals or washing one’s hair because of shoulder pain. In many athletes, they may have a debilitating shoulder problem and are completely disabled for sport, but can still have a nearly perfect DASH score. The KJOC score evaluates function and performance specifically for athletes to find these differences.
4 . What exactly did your study look at and why is this a point of interest ?
Our study was designed to define a baseline KJOC score for active swimmers. We wanted to take a group of swimmers that were actively competing in the sport at a high level, and determine a numerical value for their shoulder function. This had been done previously with baseball pitchers. Our goal was to provide similar data to the swimming community that can be useful for comparison both with future research and clinical evaluation.
5. What were the results of your study ?
The study showed that swimmers had a surprisingly low baseline KJOC score. The mean score for all participating athletes was 79.0 out of a possible 100. For swimmers competing without shoulder trouble, the mean score was 84.4, those with shoulder trouble was 53.9. We found swimmers competing for 11 years or longer had a significantly lower score than those swimming for 10 years or less, 72.0 vs 86.4, respectively. We have no other swimming data like this for comparison. However, other studies looking at baseball pitchers show a baseline score of 94.8 (Kraeutler et al, Journal of Shoulder Elbow Surgery, 2013.) That study concluded that scores for healthy pitchers should be greater than 90. Our study showed a baseline score less than 80.
6. What were the practical implications for coaches and swimmers from your study ?
This data can be useful when evaluating swimmers with complaints of swim shoulder pain. The survey is very simple to use and can be completed in under 5 minutes. Physicians and athletic trainers can now compare their athlete’s score to our baseline scores to help guide treatment.
7. Do you think the results would be different if you had older, elite or untrained swimmers?
Yes, I think the results would have been different. We focused only on NCAA swimmers, which gives a consistent age and skill level. Older studies show that youth or age group swimmers have less incidence of swim shoulder pain than older swimmers. Most research shows that the more elite swimmers have a higher incidence of shoulder trouble. I think that generalizing our results to all swimmers- competitive or recreational, youth or masters, is difficult and should be done with caution.
8. There has recently been research on perceptions of swim shoulder pain in swimmers (mainly by Hibberd), what are your views on the perception of swim shoulder pain in the sport of swimming?
Dr. Hibberd has published some excellent research in swimming. Her recent article on perception of swim shoulder pain gives a scientific insight to the culture of the sport. I think that in swimming, shoulder pain is considered part of the sport in ways not seen in other overhead athletes. Pitchers are shut down if they develop shoulder pain. Swimmers tend to accept it as normal. I think our data shows this. Athletes who define themselves as competing without shoulder trouble have an average score of 84.4- still lower than what is considered the cutoff for a healthy pitcher.
9. I’m often asked, especially in maturing young swimmers, how can you tell the difference between pain and soreness, how do you respond to that question?
It can definitely be difficult to define. In general, I think of soreness as the body’s physiological response to intense athletic activity. It is generally milder discomfort, resolves on its own, and should not interfere with sport. Pain from injury tends to be more severe and consistent in location and nature. Pain that forces alteration in technique, or causes a noticeable decline in performance in both training and competition is more concerning.
10. There has been more of a shift towards high intensity swimming training with a lower volume, do you feel this training approach reduces shoulder stress ?
I think that the “swimmers shoulder” is a cumulative effect of the miles on the shoulders. Swimming is still an inexact science- both with training and medicine. I think that less miles reduces shoulder stress. The true test will be if it improves performance as well as decreases shoulder problems.
11. If a swimmer has pain in their shoulder, what course of action do you suggest?
I would first recommend a short period of rest (3 days rest to minimize deconditioning,) ice, and anti inflammatory medications. Then a gradual return into the pool, with a focus on warm up. Pain that was persistent and more debilitating warrants work up with a careful exam of the shoulder, X-rays, and possibly an MRI if there was concern for a soft tissue structural problem, such as a tear of the labrum or rotator cuff.
12. What research or projects are you currently working on or should we look from you in the future?
I would like to design a study that determines prevention strategies to decrease shoulder problems in swimmers. In our study, the question “How difficult is it to get loose or warm up before practice?” had the lowest score, a mean of 6.4 out of 10. I think that investigating warm up is an area that may help the athletes decrease shoulder problems.
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