Biomechanics and Medicine in Swimming XI

Figure 1. MRI findings of the left Shoulder
Figure 2. Checked taping on rotator cuff muscles by using a 4-mm wide
non-elastic tape
Aquatic rehabilitation at the pool side during training camp commenced
on the 17 th day after injury (6 visits total). Joint mobilization of
posterior capsule and mobilization with movements (MWMS) in active
flexion-abduction-external rotation with the humeral head posteroinferior
gliding (Mulligan, 2004) were applied on the 17 th and 18 th day.
Stretching rotator cuff muscles, taping at supraspinatus, infraspinatus,
and teres minor (fig. 2), and education of scapula and humeral head
positioning were also performed. In this period, the humeral head still
deviated anteriorly, and a painful arc occurred during elevation of the
arm. Joint mobility testing indicated limitation of posterior glide of the
humeral head because of the tight posterior capsule. Therefore, joint mobilization
was applied and MWMS was used to try to correct dynamic
alignment and to avoid impingement of the supraspinatus tendon during
elevation. After correction of humeral head position, checked taping
was applied on the rotator cuff muscles by using a 4-mm wide non-elastic
tape to maintain the correct position. Self MWMS was also taught
to keep good position of the humeral head on the glenoid during elevation
of the arm. On the 21 st day, the PT programs were supplemented
with MWMS with a 300-g weight (using 300 mL of water in a plastic
bottle) and proprioceptive neuromuscular facilitation (PNF) (Myers and
Lephart, 2000). At this time, elevation of the arm during front dive did
not cause shoulder pain; however, rapid elevation and elevation during
back dive caused pain. Therefore, MWMS with a light weight and PNF
were applied to improve proprioceptive stimulation for motor learning.
From the 23 rd to the 26 th day, MWMS with a 500-g weight was used,
chaPter6.medicineandwatersafety
and soft-tissue mobilization such as transverse friction massage (TFM)
(Cyriax and Cyriax, 1993) and functional massage (Evjenth and Hamberg,
1984) were added. The reason for increasing the weight during
MWMS was to increase proprioceptive stimulation for motor learning.
Palpation indicated muscle spasm of the rotator cuff muscles, especially
subscapularis. Reaction to the palpation at the supraspinatus tendon indicated
that the tendinitis would improve in the recovery stage. Therefore,
soft-tissue mobilization was applied in these muscles.
dIscussIon
Rehabilitation in this case study involved immobilization during the
acute stage (2 weeks), followed by stability exercises for the glenohumeral
joint and scapula, and finally movement toward a functional approach.
The rehabilitation program commenced the 5 th day after injury;
the affected area needed to be rested and other areas trained to keep
good condition. On the 13 th day, the immobilizing brace was detached,
and passive treatments for limited range of motion (ROM), stabilizing
exercises for the affected glenohumeral joint, and scapulothoracic
exercises were applied. At this stage, the PT program commenced stabilization
exercises for the glenohumeral joint to prevent impingement
of the rotator cuff. In addition, concentric and eccentric exercises for the
rotator cuff were included to induce optimal muscle recruitment during
overhead activities of the arm. The scapula plays an important role in
facilitating adequate shoulder function to produce efficient movement.
The scapular muscles must be dynamically positioned in the glenoid so
that efficient glenohumeral movement can occur; therefore, the scapular
muscles should be trained optimally.
Being in the subacute stage during the first day of the aquatic rehabilitation,
the subject complained slightly of resting pain after elevating
the arm and had positive sign of painful arc. Maneuvers of MWMS
applied posteroinferior force on the humeral head and mechanically
avoided impingement of supraspinous tendon under the coracoacromial
arch during active elevation of the arm. MWMS with a light weight
(Mulligan, 2004) and PNF facilitated proprioception to gain good motor
control of arm movements (Myers and Lephart, 2000). Self MWMS
with a light weight was used to gain proper movement patterns of the
arm during abduction and adduction. The checked taping was not strong
enough to mechanically restrict anterior movement of the humeral
head; however, the tape stimulated skin and muscles as light compression
during anterior deviation of the humeral head. The tape also stimulated
receptors of the skin and the proprioceptors during movements.
Although he did not complain of shoulder pain during diving on the
day before competition and the day of competition, he was still in the
recovery stage. It was evident that he had learned the correct movements
of the glenohumeral joint and scapulothoracic junction. Because
divers hold extremely elevated positions of the glenohumeral joints and
shoulder girdle during the water-entry stage, they can avoid impingement
at the middle and final range of elevation by using an appropriate
movement pattern and congruous articular position during movements.
This rehabilitation program for diving is very sports specific; however,
the program could be applied to some sports with a throwing stage, such
as wind-up and cocking.
conclusIon
The rehabilitation program for a diving-related shoulder injury was
as follows: (1) during the immobilization stage, general conditioning
exercises, such as stretching and strength training of the neck, trunk,
and extremities (not including the affected left arm), were applied; (2)
after the immobilization stage, joint mobility was addressed, especially
posterior capsule and short and tight muscles, then rotator cuff muscles
and scapula muscles were strengthened; and (3) an appropriate movement
pattern and congruous articular position were achieved during
movements by MWMS, PNF, and motor learning.
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