physiotherapy assessment of swimmers€¦ · physiotherapy assessment of swimmers swimming in...

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Cameron Elliott B.App.Sc (Physio)

Cameron Elliott

PHYSIOTHERAPY ASSESSMENT OF

SWIMMERS

SWIMMING IN AUSTRALIA

• Over 160,000 adults participate in organised swimming and with female

participation rates (59.5%) higher than males (40.5%)

• Second in popularity as a recreational sporting activity only to walking.

• More than half of these people swim more than once a week and the likely

hood of swimmers to participate in other sports is higher than almost any

other sport.

- Australian Bureau of Statistics 2007

SWIMMING FAST • Although fitness and strength are important parts of making a good swimmer, good

technique and an ability to move smoothly through water is what often defines a great

swimmer from a good swimmer.

• Using their hands/ arms as anchors swimmers propel themselves forward by ‘grabbing’

onto the water like an anchor and pulling/pushing themselves over that anchor.

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SNAPSHOT OF SWIMMING HISTORY • The study of the mechanics of swimming was

revolutionized by Counsilman (1971) with his experiment which lead to the theory that propulsion in swimming was achieved using force generation principles that are similar to the effects of a hydrofoil. i.e. as the hand moves through the water, the water over the back of the hand and arm would flow faster than the water on the underside of the hand/ forearm causing a pressure differential between these two areas- creating a ‘lift’ of the hand/forearm that creates a form of anchor in the water while the bodies muscles pull the body over this anchor.

SNAPSHOT OF SWIMMING HISTORY

• The theories of lift forces at the hand being the most influential cause behind

swimming have come under criticism over the last fifteen years. Now Newton's

second and third law are usually held as the underlying forces responsible for

forward motion in swimming; in short a body in motion will accelerate in proportion to

the forces placed upon it. (Blanch 2004)

Forces on a swimmer:

• Propulsion force: Produced by the swimmer to move forward.

• Drag force: Produced by the swimmers interaction with the water, slows the swimmer.

• Weight: Forces of gravity pushing the swimmer into the water, can increase drag force.

• Buoyancy: (Bernoulli's principle) keeps the swimmer afloat, can be used to reduce drag.

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FORCES ACTING ON A SWIMMER GREATEST PROPULSION FORCE

REDUCING DRAG

• The swimmer attempts to

minimize drag by trying to

maintain as streamlined

position of the body as

possible. This position allows

them to try to combat the

effects of drag by interrupting

the least amount of water flow

as possible

FACTORS THAT MAY DECREASE

STREAMLINED POSITION.

• Poor technique - (Eg: lifting head to breathe)

• Poor flexibility - Shoulder internal rotation

- Thoracic spine extension and rotation

- Combined hip Internal rotation and knee

external rotation (breastroke)

• Poor motor patterning (co-ordination) (eg: pectoral dominant pull

through)

• Poor strength - Shoulder stabilizers

- Abdominal stabilizers

- Hip stabilizers

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MUSCULAR SYSTEMS MUSCULAR SYSTEMS

WHICH SWIMMER HAS

APPROPRIATE STABILITY? ASSESSMENT: CLINICAL AND POOL BASED

• Pool:

Observation: done on pool deck from all angles (Hint: Height can be an advantage)

Video analysis: useful for underwater observation

• Clinical:

General musculoskeletal testing can be useful but is not

always functional.

Specific swimming screening tests a useful addition to

a general screening

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CLINICAL IDEAS • Like all activity, the swimming stroke is an integration of the whole kinetic chain. If any

one ‘link’ in this chain does not perform effectively then another joint/ link in the chain will compensate in its movement patterns.

• Flexibility is a key component to the elite swimmers body (eg: large amounts of internal rotation to gain the ‘high elbow’ in swimming). It can be tricky at times to know how much is too much but some ideas are offered in the talk.

• Pathology cannot be ignored (eg: does shoulder

impingement pain result from irritated soft tissue

structures (sub-acromial bursitis) or are other

tendonopathies/ partial tears present?

• Posterior capsule tightness commonly accepted to

be a large contributor to shoulder overload injuries.

Very common in swimming.

ABDUCTION WITH INTERNAL

ROTATION • A measure of the swimmers ability to achieve and maintain a high elbow throughout a

stroke cycle

• Best if done by two testers

• Patient seated and facing away from the examiner

• Abduct arms of swimmer while their elbows stay at 90˚ flexion

• Test both shoulders to avoid lateral flexion of spine

• Result of between 150˚ and 170˚ seems to be acceptable

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ABDUCTION WITH INTERNAL

ROTATION THORACIC ROTATION • Test for rotation movement through the body

• Patient seated (tall), hands clasped together and in line with the sternum

• Patient asked to rotate while keeping shoulder/arm/hand position unchanged.

• Result of 60˚ to 90˚ seems to be acceptable

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THORACIC ROTATION THORACIC ROTATION

GLENO-HUMERAL INTERNAL

ROTATION • Prone:

• Patient prone with arm hanging off edge of table, elbow flexed to 90˚

• Support upper arm with one hand and other hand is used to retract and stabilise shoulder girdle and hold. (This must be maintained at all times)

• Swimmer asked to rotate arm so hand moves toward/ away from the physiotherapist ‘ as far as you can’

• Second person measures the line of the ulnar against vertical

• An ideal measurement would be 40˚ to 50˚ of internal rotation

• Supine:

• Patient supine with arm off edge of bed, elbow flexed to 90˚ and humerus supported

• Similar cues to above, therapist can use hands to stabilise shoulder girdle and prevent protraction of the shoulder during test


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ROTATION


ROTATION


ROTATION HUMERAL TORSION PREVIEW ONLY


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COMBINED ELEVATION • Test of thoracic spine extension, shoulder elevation and the ability to draw the shoulders

behind the body

• Patient lies prone and in ‘Streamline’ position (elbows locked straight and thumbs held

together)

• Patient asked to lift arms as high as they can wile keeping their body in contact with the

bed.

• Between 5˚ and 15˚ degrees seems acceptable

COMBINED ELEVATION

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COMBINED HIP INTERNAL ROTATION

AND TIBIAL EXTERNAL ROTATION

• Test mainly for breastroke swimmers.

• Hips are tested in prone with knees together and legs allowed to fall apart, measure the

line of the tibia compared to the vertical.

• Knees are tested with athlete sitting with hips and knees at 90˚ of bend. Ankle should be

plantargrade (on floor is useful). Keep knees and ankles together and turn both feet out.

The angle between the 2 positions is marked by a measurement form the centre of the

heel fat pad through the 2nd toe.

• As a usual rule the addition of these results should be approx. 90˚

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AND TIBIAL EXTERNAL ROTATION


AND TIBIAL EXTERNAL ROTATION HIP EXTENSION

• Swimmer lies prone

• One examiner holds leg with 90˚ of knee flexion

• Examiner lifts leg slowly until movement is detected in the lumbar spine or in the pelvis

• Second examiner measures line of femur compared to horizontal

• 20˚ to 30˚ of extension seems to be ideal

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ANKLE PLANTAR FLEXION

• Ask swimmer to point their toes and the angle between the line of the leg and the line of

the toes is measured.

• Greater than 160˚ is ideal

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ANKLE PLANTAR FLEXION STRENGTH IMBALANCE

• Commonly found, usual pattern is a strength deficit in ER’s compared to IR’s

• Clinically strength can be measured as a ‘break’ test to gain a MVC value (with

dynamometer) however repeat tests may show an early fatigue (Beach et al 1992)

• Strength ratio of Internal: External → 1.5:1 (Whiteley 2010)

• May not be present in the painful swimmers shoulder – if so pay particular attention the

results of the previously mentioned tests when clinically reasoning.

REFERENCES

• Humeral Torsion in the Throwing Arm of Handball Players, Hans-Gerd Pieper, MD,

PhD, Presented at the 2nd World Congress on Sports Trauma/22nd annual meeting of the

AOSSM, Lake Buena Vista, Florida, June 1996.

• Blanch, P (2004) Conservative management of shoulder pain in swimming Physical

Therapy in Sport 5:109-124

• Whiteley R, Ginn K et al (2009) Sports Participation and Humeral Torsion Journal of

Orthopaedic and Sports Physical Therapy 39(4):256-263

• Trakis J, McHugh M et al (2008) Muscle strength and range of motion in adolescent

pitchers with throwing-related pain: implications for injury prevention The American

Journal of Sports Medicine 36(11):2173-2178

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