Introduction
A group of researchers at The Oho State University conducted a systematic review for the current available evidence on Injury Screens for swimmers as of October 2018. Twenty-one articles were included in the review. I will attach a link to the article for more detailed background questions. My focus will be clinical pearls gleamed from the article to improve treatment of swimmer's and prevent shoulder, low back, and knee injuries.
Relevant Objective Clinical Assessment and Screening Tools
Upper Extremity
A total of 17 studies included were included in this review discussed shoulder pain and injury. The specific tests and measured varied between articles, but a few common terminology appear universally. Shoulder external rotation (ER) range of motion (ROM) shoulder ER and internal rotation (IR) strength, endurance and associated ER:IR ratio, scapular control and mobility, glenohumeral instability, and shoulder complex muscle extensibility were all referenced in more than one study as constructs aimed at being investigated.
Current evidence exists that supports the relationship between Shoulder IR and ER ROM and relationship to shoulder injuries in swimmer. This review describes two additional relationships for shoulder pain that are worth while explaining. The first is in regards to impaired muscle length of both the pectoralis minor and latissimus dorsi with shoulder pain due to their effect on force couplings of the shoulder. The second major reported associations is within impaired scapular upward rotation with humeral elevation and shoulder pain. If you want to learn more about scapulothoracic rhythm and swimmers, please refer to our previous post here.
After undergoing statistical comparison between studies, moderate quality of evidence exists to support the relationship between shoulder ER:IR strength and ratio as a predictor of shoulder injuries. One of the articles proposed a cut-off score of >1.08 as a predictor for shoulder injuries.
Generalized joint mobility of >7 has been correlated with significant strength and endurance changes in shoulder IR. With this said, the review states that there is currently limited research to suggest that increased joint hyper-mobility increases your risk of shoulder related injuries in elite swimmers. This is largely related to difficulties in measuring joint mobility and the large majority of swimmers falling into some level of hyper-mobility to begin with.
More conflicting results were discussed regarding the relationship between scapular dyskinesia and shoulder injury/pain in swimmers.
There are two patient reported outcomes that are aimed at identifying risk of injury in swimmers: The Swimmer Functional Pain Scale and the Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow score (KJOC).
Stroke specification is reported to have an association between at-risk body regions. Freestyle and backstroke specialization have an increased risk of shoulder injuries, both specifics about age of specialization and percentages of training s not outlines.
Lower Extremity
A total of 3 nonrandomized controlled trials were included in this review. One of the three studies examined hip IR as a predictor of knee pain in breastroke specialist and found a limited relationship.
Asymmetry in quad/hamstring strength of >10% was found to have a weakness relationship between lower level injuries in elite swimmers. At this time, there is not sufficient evidence to use this in isolation for prediction of lower extremity injuries.
Spine
A single cross-sectional study was included that was aimed at risk factors for spinal injuries in elite adolescent swimmers. The study included 329 swimmers. The use of plumbline assessment for lumbar hyper-lordosis and thoracic hyper-kyphosis was described as having low quality evidence to associate with low back pain in swimmers.
Summary
Based on the above review and other available clinical commentary, and previous systematic review were referenced to make a comprehensive screening tool for elite adolescence swimmers. The constructs that were included are outline below from a figure adapted from Schlueter, Pintar, Wayman, Hartel & Briggs, 2020. This systematic review added to the work on Hill et al that included shoulder IR/ER strength, pectroalis length, and scapular kinematics, strengths and dyskinesias currently lack sufficient evidence. Current research does support a relationship between shoulder pain and Shoulder ER:IR endurance rations and GH rotational mobility. This is a significant step forward in our understanding and creation of a complete injury prevention and screening tool for swimmers.
* Image adapted from (Schlueter, Pintar, Wayman, Hartel & Briggs, 2020)
References:
1. Schlueter, K., Pintar, J., Wayman, K., Hartel, L., & Briggs, M. (2020). Clinical Evaluation Techniques for Injury Risk Assessment in Elite Swimmers: A Systematic Review. Sports Health: A Multidisciplinary Approach, 13(1), 57-64. doi: 10.1177/1941738120920518
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