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A Delicate Balance in Aquatic
Sports – The Shoulder
Dr. Cees-Rein van den Hooogenband (NED)
Chairman, FINA Sports Medicine Committee
Dr. Jim Miller (USA), FINA Sports Medicine
Committee

Why Aquatic
Athletes?

Application to Aquatic Sports
Synchronized swimming – throws, lifts,
landings/impact; overuse
Diving – impact forces, increased with errant
entry
Water Polo – impact from contact; throwing
motion; overuse
Swimming – classic overuse, exacerbated by joint
instability
Open water swimming – extreme overuse (races
of 5K to 25K or more); impact from contact

How Much
Shoulder Load?
Upper extremity
provides up to 90% of the
propulsive power in
swimming.
60-85% of all elite level
swimmers will have a
painful shoulder
requiring a layoff of a
week or more.
……and then there are
the other aquatic
disciplines which are far
more than just rotations.

Math is Compelling
Rotations
10,000 – 30,000
meters/day
35 rotations (or more) per
50 meters
Over 50,000 - 120,000
rotations per week!!!
This does not account for
lifts, boost and sculling,
throwing, landings

Technique is Critical

Balance
Aquatic sports and
imbalance – stimulating
some muscle groups
while destabilizing others
(e.g. front vs. back
stabilizers and posture)
Training duration and
intensity lead to fatigue
and small stabilizer
failure

Muscle Balance
Front to Back
Left to Right
Small to Large
Firing Sequence
Balance
Is this balance?

Static Stabilizers
Boney Static Stabilizers Tendon Static Stabilizers

Dynamic Shoulder Stabilizers
Extrinsic Muscle Stabilizers Intrinsic Muscle Stabilizers

Stabilizers - Dynamic
All in “force
couple” balance

Force Couple Breakdown
Fatigue of
smaller stabilizers
needed to center
humeral head
Result: forward
and upward
movement of
humeral head

Factors Contributing to Failure
• Genetics
Multi-axial instability
Static Stabilizer
abnormalities
• Technique
• Core Failure
• Sudden Change in
Training Program
• Trauma

Trauma

Trauma

Trauma

Quality Assessment of
Diagnostic Accuracy
Studies(QUADAS)

Assessment of Instability
Apprehension Test
Sensitivity:60%
Specificity:95%

Apprehension Test

Assessment of Instability
Relocation Test
Sensitivity:70%
Specificity:95%%

Relocation Test

Assessment of Instability
Anterior Release Test
Sensitivity:90%
Specificity:90%

Anterior Release Test

Traumatic Shoulder
Operative
treatment
after first
trauma?
Dislocation

Recurrent Shoulder Dislocation(or
Subluxation)
Unidirectional or Multidirectional?

Specialist (Orthopaedic)
Assessment of Instability
Radiographic tools:
MRI/CT scan

Stretching
Is all stretching good?
What are you
stretching??
NO!

Stretching Principles
In case of recurrent subluxation or instability
NO STRETCHING!
Warm up before training or competition is
enough!
In the case of the stable shoulder, do not
CREATE the instability!

Common, but “Bad” Stretches

FINA Shoulder Project
Goal: Provide a video presentation that outlines
simple exercises which will have an impact on
reducing the alarming prevalence of shoulder injuries
in the aquatic sports
Organization: Three main groupings of exercises –
Core, Scapula, and Rotator Cuff – featuring 4
exercises each
Exercises chosen to minimize use of required
equipment

Core Exercise #1 - Quadraped
• Lifting opposite arm and leg simultaneously
• Builds up to holding position for at least 30
seconds
• Each side repeated for 3-6 times.
• Balance ball introduces additional level of core
firing
• Stabilizes core in a free floating environment -
linking

Quadraped

Core Exercise #2 – Dead Bug
• Basic version – Athlete lying on back with
arms under upper hips and lower back; back
pressed against hands to flatten back
• Athlete lifts both legs off of ground and
performs tight flutter kicking
• Building up to a 30 second; 3-6 repetitions

• Advanced version – athlete raises one arm and
contralateral (opposite) leg or one arm and
ipsilateral (same) leg
o Opposite leg – focus is on cross-linking
o Same side leg – focus is on line stabilization
• Builds strength and balance linking ipsilateral
and contralateral sides

Core Exercise #3 – Side Plank Raises
•Involves lifting of hips from side plank position to
form straight line with body
• Core should be engaged at all times to maintain
proper body alignment.
• For advanced version, extend non-supporting arm to
form T
•Repeat the exercise at least 3-6 times holding for 30
seconds – rest – and then go to the other side
•Strength and balance

Side Plank Raises

Core Exercise #4 – Chair pelvic tilt with
three-way crunch
•Athlete lays on back with lower legs resting on chair
•Uses inner abs to flatten lower back and press it into
ground (pelvic tilt)
•Then performs 3 crunches: middle, left and right,
holding each for 2 seconds; maintain pelvic tilt
•Power development combined with rotation – ideal
for aquatic sports

Scapular Exercise #1 – Scapular Push-Up
• Athlete in ‘push-up’ position on hands and feet or hands and
knees, shoulder blades relaxed
• Glide scapulae toward each other posteriorly in squeezing
motion (note swimsuit straps to show location of the
scapulae)
• Works strength as well as symmetry of motion

Scapular exercise #2 – Hitch hiker
•Athlete lies face down with arms at 90 degrees to body
•Arms are raised directly off of surface and up, while
squeezing scapulae together (note swimsuit straps again)
•Up to 20 repetitions per set; 3-6 sets
•Works linking and endurance – can identify asymetry

Scapular Exercise #3 – Isolated Shrug
•Athlete lifts weight on one side, using scapula to glide over ribs to lift
and lower weight
•Build up to 20 repetitions per side, 3-6 sets, with attention to correct
form throughout
Isolation of scapula for strengthening and sequencing

Scapular Exercise #4 – Swimmer
•Seated on a balance ball or chair and leaning
forward, holding light ball or weight

•Athlete brings arms behind body and back and perform 3-5 quick
oscillation raises
•Then returns arms to starting position

•Athlete then drops arms down through legs with shoulder internal
rotation (you should feel a slight stretch) and extend legs for hamstring
stretch (for only 2-3 seconds)
•Return to starting position and repeat sequence.
•Complex motions with focus on scapular linking in a fashion that
builds endurance and balance

Rotator Cuff Exercise #1 – Ball on the
Wall
• Athlete rolls ball on wall in all directions, with
straight arm
• 30 seconds duration, 3-6 sets
• Accomplishes firing of multiple rotator cuff muscles
• If one shoulder fatigues more quickly than other,
maintain ‘good shoulder’ at low repeat count until
weaker shoulder catches up; important for
symmetrical stroke development

Rotator Cuff Exercise #2 – Shake It Up
•Water bottle is only equipment needed – size and amount of
fluid can vary as strength develops
•With forward shoulder flexion and elbow at 90 degree bend,
athlete rocks water bottle back and forth quickly along same
plane as upper arm
•30 seconds duration, 6-10 sets per arm
•Rotator cuff endurance and firing sequence
along with isolation

Rotator exercise #3 – Internal and External
Rotation
•Surgical tubing or thick elastic cords work well, with weight
rack as alternative
•Athlete stands with side to the cords or weight machine,
with elbow tight to waist
•Shoulder and hand rotated inward for internal rotation
•Shoulder and hand rotated outward for outward rotation
•Classic internal and external
rotator strengthening and
balance

Rotator Cuff Exercise #4 – Drop and Catch
• Equipment – lightweight object that fits into hand
•Athlete holds small weight, roll of tape or a water of bottle
with arm extended straight
• While keeping arm in the 90 degree forward extension and
15 degree horizontal adduction, drop and catch the object,
with quick oscillations within six inch vertical distance
• Maintain good posture with scapulae squeezed down and
back.
•3-6 sets of 20 repetitions.
•Rotator cuff conditioning and firing sequencing
•

Thank you for your
Attention.
Questions?
Dr. Cees-Rein van den Hooogenband (NED)
Chairman, FINA Sports Medicine Committee
Dr. James W. Miller
FINA Sports Medicine Committee