Manual Therapy 16 (2011) 510e515

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Manual Therapy
journal homepage: www.elsevier.com/math

Case report

Swimmers shoulder in young athlete: Rehabilitation with emphasis on manual

therapy and stabilization of shoulder complex
Gabriel Peixoto Leo Almeida a, *, Vivian Lima De Souza a, Gisele Barbosa a, Marcelo Bannwart Santos a,
Michele Forgiarini Saccol a, b, Moiss Cohen a
a

Centro de Traumatologia do Esporte (CETE), Departamento de Ortopedia e Traumatologia, Universidade Federal de So Paulo, Escola Paulista de Medicina, Rua Emba,
n 73, Vila Clementino, Cep: 04039-060, So Paulo, SP, Brazil
Departamento de Fisioterapia, Universidade Federal de So Carlos, So Carlos, SP, Brazil

a r t i c l e i n f o
Article history:
Received 19 October 2010
Received in revised form
21 December 2010
Accepted 22 December 2010
Keywords:
Swimming
Musculoskeletal disorders
Manual therapy
Exercise

1. Introduction
Competitive swimmers swim 10e14 km per day six to seven days
per week, which corresponds to 2500 rotations of the shoulder per
day. The combination of these repetitive movements with a large
range of motion of the joint makes the shoulder more prone to injury
in this sport (Stocker et al.,1995; Pink and Tibone, 2000; Weldon and
Richardson, 2001; Lynch et al., 2010). Wolf et al. (2009) investigated
a university swim team over ve seasons and found that 71% of the
athletes became injured in this period, with the shoulder accounting
for 35.4% of all injuries. Another study involving young highperformance athletes reports that 91% of the 80 athletes analyzed
had shoulder pain (Sein et al., 2010).
Swimmers shoulder was rst described by Kennedy and
Hawkins (1974), who dened the condition as a painful presentation due to repetitive impingement of the shoulder in swimmers.
Swimmers shoulder does not have an established clinical diagnosis,
but rather is a syndrome that may be due to subacromial impingement, tendinopathy of the rotator cuff and long portion of the biceps
brachii, shoulder instability, labral tear or acromion-clavicle injury
* Corresponding author. Rua Onofre Sampaio Cavalcante, n 381, Cidade dos Funcionrios, Cep: 60834-450; Fortaleza, CE, Brazil. Tel.: 55 11 87708340/55 11 55395090;
fax: 55 11 55395090.
E-mail address: gabriel_alm@hotmail.com (G.P. Leo Almeida).
1356-689X/$ e see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2010.12.012

(Bak and Fauno, 1997; Jones, 1999; Sein et al., 2010). Treatment for
swimmers shoulder is generally conservative (Allegrucci et al.,
1994; Russ, 1998) and the main goals are to reduce the pain,
control the inammatory process, strengthen, stretch and improve
the stability of the glenohumeral joint, correct posture and return
the athlete to the sport at the pre-injury level (Kenal and Knapp,
1996; Weldon and Richardson, 2001).
This paper describes a rehabilitation protocol with an emphasis
on manual therapy and strengthening of the stabilizing muscles of
the shoulder complex in a young competitive swimmer.
2. History
A 10-year-old female competitive swimmer with a training
frequency of six times a week 3 h a day and three years experience
practicing the sport reported feeling strong pain in the anterior
region of the left (dominant) shoulder during a practice session, but
was able to nish the session. However, she was unable to practice
the following day due to debilitating pain in the shoulder (Fig. 1).
The physician solicited radiographs of the shoulder, which were
normal. Magnetic resonance imaging revealed Bigliani type 1
acromion (Mayerhoefer et al., 2009) and a T2 hypersignal in the
supraspinatus tendon, leading to the diagnosis of supraspinatus
tendinopathy.

G.P. Leo Almeida et al. / Manual Therapy 16 (2011) 510e515

511

trapezius, levator scapula, sternocleido-mastoid, scalene, rhomboid, coracobrachial, subscapular, supraspinal, pectoralis minor,
biceps (long portion) and suboccipital muscles.
3.3. Range of motion and muscle strength of shoulder
The range of motion (ROM) was determined using a universal
goniometer for the movements of exion, extension, abduction and
medial and lateral rotation with 90 of shoulder abduction, which
were all preserved in comparison to the contralateral limb, but the
patient reported pain at the end of each movement (Hayes et al.,
2001). The muscle strength test was executed based on Kendall
et al. (2005). The injured shoulder (left) exhibited muscle strength
decit in comparison to the right shoulder for the movements of
exion, extension, abduction and lateral rotation (grade 4/5),
whereas the movements of adduction and internal rotation exhibited normal muscle strength (grade 5/5).
3.4. Specic tests

Fig. 1. Body chart illustrating pain presentation.

3. Examination
3.1. Pain level and functional capacity
The score on the visual analog pain scale (VAPS) was 9.5
(0 absence of pain; 10 maximal pain). The result of the initial
Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire
was 26.6 points and 68.75 points on the sports and music activities
module (0 no pain and disability; 100 worst pain and disability)
(Orfale et al., 2005).
3.2. Inspection and palpation
The head leaned forward and the shoulders were protracted
(Kendall et al., 2005), with a Kibler type III scapula, in which
excessive migration of the upper angle of the scapula occurs during
movement with greater than 90 of exion (Kibler and Sciascia,
2010). Bone palpation revealed pain in the acromioclavicular
joint, coracoid process, greater tuberosity of the humerus, upper
and lower angle of the scapula and cervical spine at C5eC6eC7.
Palpation of the musculature revealed pain in the upper and mid

The patient reported pain during the Neer impingement test (Neer,
1983) and HawkinseKennedy test (Hawkins and Kennedy, 1980). The
tests used to evaluate stability were anterior apprehension (anterior
instability) (Rowe and Zarins, 1981), Jerk test (posteroinferior instability) (Blasier et al., 1997) and sulcus sign (inferior instability) (Neer
and Foster, 1980), all of which were negative. The Upper Limb
Tension Test 1 (ULTT1) specic for the median nerve was used to test
neural tension (Elvey, 1985; Butler, 2000). The test is considered
positive if it reproduces pain, a bilateral difference greater than 10 of
extension of the elbow and an increase in symptoms with the
contralateral inclination of the cervical spine (Wainner et al., 2003). In
the present case, the test reproduced the anterior pain in the patients
shoulder and a worsening during contralateral inclination.
4. Intervention and results
The rehabilitation protocol was divided into four phases, totaling
24 sessions of physical therapy with a frequency of three times
a week (Allegrucci et al., 1994). The initial goal was to reduce the
symptoms, thus manual therapy techniques at cervical and thoracic
spine, glenohumeral joint and neural tissue were performed. After
this phase, exercises to increase strength, stability and functional
capacity were performed, followed a gradual return to sport. At the
end of each session the patient was reassessed in all the initial
examination criteria and the level of pain was reviewed (Graph 1).
Also, at the end of each week the Dash questionnaire and the
optional module (Graph 2) were re-checked.

Visual Analog Pain Scale

8
7
6
5
4
3
2
1
0

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Session
Graph 1. Visual analog pain scale over the sessions.

512

G.P. Leo Almeida et al. / Manual Therapy 16 (2011) 510e515

60
50

Scores

40
30
20
10
0
1

Weeks
DASH

Optional Module

Graph 2. Disabilities of the arm, shoulder and hand questionnaire and sports/music activities module over the weeks.

4.1. Phase I (1st to 4th session)

Initially, myofascial release and trigger point inhibition were
performed (Vernon and Schneider, 2009). The shoulder mobilization techniques were executed obeying Maitlands principles
(Hengeveld and Banks, 2005), with Grade II anterior, posterior and
inferior mobilization of the shoulder, progressing to Grade III in the
second session. At levels C5eC6eC7 of the cervical spine, Grade II
posteroanterior mobilization was performed. All Maitland mobilizations were executed in three 30-s sets. For the mobilization of the
upper thoracic spine (T2eT5), the technique of natural apophyseal
glides (NAGS) reverse of the Mulligan concept was executed in three
1-min sets (Exelby, 2002; Vicenzino et al., 2007). Neural mobilization was performed in the same position as that of the evaluation,
but within a range that did not exacerbate the pain. Oscillatory
movements of the wrist were performed in exioneextension in

three 1-min sets (Butler, 2000). In the second session, isometric

strengthening work was begun for the rotator cuff and posterior
depression of the scapula, strengthening increased according to the
capacity to perform the exercise without pain (Table 1). As criteria
for the progress of Phase II, the patient reported the absence of pain
in the anterior region of the shoulder, the absence of pain upon bone
palpation, complete ROM with pain in the upper trapezius only at
the end of the range from exion to abduction and a score of 5 points
on the VAPS.
4.2. Phase II (5th to 13th session)
Exercises for the strengthening of the dynamic stabilizers of the
scapulothoracic and glenohumeral joints, stretching, core stability
exercises (Fig. 2), proprioception and aerobic conditioning were
emphasized. The sessions began with contraction techniques,

Table 1
Exercise program based on progress phases.
Sets  Repetitions
Phase I
Isometric exercises
Shoulder
Internal rotation
External rotation
Scapula
Posterior depression
Exercises with elastics
Internal rotation
External rotation
Elevation of shoulder to scapula plane
Scapular muscle exercises
Prone Extension
Horizontal abduction with external rotation
Push-upplus
PNF
Functional diagonal
Primitive diagonal
Device oscillatory (bodyblade)
Flexion
Abduction
Rhythmic stabilization
90 of shoulder exion
Position from 90 to 90
Core stability exercises
Elbow-Toe
Back bridge
Side bridge
Plyometrics
Trampoline
Thera-band (rotations)

Phase II

Phase III

Phase IV

3  12
3  12
3  12  0.5 kg

3  15
3  15
3  15  0.5 kg

3  25
3  25
3  15  1 kg

3  30s  0.5 kg
3  30s  0.5 kg
3  10 (cot)

3  40s  0.5 kg
3  40s  0.5 kg
3  12 (oor)

3  40s  1 kg
3  40s  1 kg
3  15 (oor)

3  12  0.5 kg
3  12  0.5 kg

3  15  0.5 kg
3  15  0.5 kg

3  10
3  10

3  12
3  12

3  15 s
3  15 s

3  30 s
3  30 s

2  30 s
2  30 s
2  30 s

3  40 s
3  40 s
3  40 s

3  30 s
3  30 s

3  40 s
3  40 s

3  10  8 s
3  10  8 s
3  10  8 s

2  20 s
2  20 s

G.P. Leo Almeida et al. / Manual Therapy 16 (2011) 510e515

513

Fig. 2. Exercises performed for this case report: (A) back bridge, (B) side bridge, (C) elbow-toe, (D) prone extension, (E) horizontal abduction with external rotation, (F) position from
90 e90 with bodyblade, (G) abduction with bodyblade, (H) exion with bodyblade.

followed by stretching (contractionerelaxation) (Sharman et al.,

2006), with three sets of four repetitions for the sternocleidomastoid, scalene and pectoralis minor muscles (Kluemper et al.,
2006). This was followed by stretching of the anterior and posterior capsule of the shoulder (Weldon and Richardson, 2001). This
phase began with strengthening of the musculature of the scapula,
shoulder and stabilizers of the hip and trunk (Table 1) (Weldon and
Richardson, 2001; Cools et al., 2007). In this phase, the athlete was
allowed only to train the lower limbs for swimming. When necessary, manual therapy techniques described above (Phase I) were
employed to reduce the pain symptoms which the patient presented
with. To progress to Phase III, the patient exhibited a complete painfree ROM, a score of 3 points on the VAPS, normal muscle strength for
all movements (Grade 5/5) and a negative ULTT1.

4.3. Phase III (14th to 20th session)

There was progression in the strengthening exercises and
plyometric exercises were added (Table 1) on a trampoline and
with thera-band exercise bands, diagonal exercises of proprioceptive neuromuscular facilitation (PNF) (Allegrucci et al., 1994;
Carson, 1999) and exercises using an oscillatory device commonly
known as a Bodyblade (Fig. 2). Stretching was maintained with the
same sets and repetitions. Functional swim movement training was
performed, in which the patient was positioned in ventral decubitus on the exercise ball and an elastic band attached to a back rest
placed in front of her and was instructed to execute upper arm
movements in four swimming styles (Allegrucci et al., 1994). The
patient was allowed to perform half of her swimming training
routine, but instructed not to perform specic exercises that
required only the use of the upper limbs. At the end of this phase
and as criteria for the progress of Phase IV, the patient reported no
shoulder pain, but a sensation of discomfort with sporadic nonspecic movements, impingement tests (Neer and HawkinseKennedy) did not generate any pain and score of 0 points on the VAPS.

4.4. Phase IV (21st to 24th session)

This phase involved the return to the sport, for which communication with the coach and/or physical trainer was fundamental in
order to draft a specic program for the athletes gradual return.
The stretching, plyometric, sensory-motor and functional exercises
remained in this phase. Information was provided for the prevention for future injuries, such as stretching of the anterior and
posterior capsule of the shoulder and strengthening of the rotator
cuff and stabilizers of the scapula.
At the end of rehabilitation, the athlete was able to return to her
sport activities at the pre-injury level. In the follow-up evaluation,
she exhibited complete ROM with an absence of pain in all shoulder
movements, an absence of pain during bone and muscle palpation
and normal muscle strength for all movements (Grade 5/5). The
impingement tests (Neer and HawkinseKennedy) and ULTT1 did
not generate any pain and there was signicant improvement
regarding the scores of the overall DASH questionnaire, the sport
and musical activities module and the VAPS (Table 2).
5. Discussion
The results in this case report demonstrate improvement in pain
and disability following a manual therapy management and exercise
program addressing strengthening of the stabilizing muscles of the
shoulder complex. The treatment strategy was based on normalizing impairments of the cervical and thoracic spine, glenohumeral

Table 2
Pain and functional capacity of shoulder before and after rehabilitation protocol.

DASH questionnaire (0e100)

Sports and music activities module (0e100)
VAPS (0e10)

Initial

Final

26.6
68.75
9.5

5
6.25
0

DASH Disabilities of the arm, shoulder and hand; VAPS Visual Analog Pain Scale.

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G.P. Leo Almeida et al. / Manual Therapy 16 (2011) 510e515

joint and upper limb neural tissue. However, due to the multimodal
intervention, a direct relationship between the intervention and the
improvements cannot be conclusively established by this type of
report.
The positive results achieved in the present case are consistent
with those reported in other studies demonstrating the benets of
manual therapy for shoulder disorders (Bang and Deyle, 2000;
Bergman et al., 2010). Bang and Deyle (2000) found that manual
therapy combined with specic exercises for patients with
shoulder impingement syndrome achieved better results in comparison to a group submitted to specic exercises alone. Bergman
et al. (2010) compared a group submitted to standard conservative treatment involving orientation, anti-inammatory agents,
analgesics, exercise and massage to a group who received both
standard conservative treatment and manual therapy and found
lesser pain severity and better mobility of the shoulder and neck in
the latter group.
In the initial evaluation, the neural tension test indicated substantial mechanosensitivity of the neural tissue, which may be an important factor of shoulder pain, regardless of sport and daily activities
(Coppieters et al., 2003). Manual therapy techniques were performed
to address the neural tissue mechanosensitivity believed to contribute
to the patients symptoms. Manual therapy techniques were also used
to treat the articular component thus creating a multimodal approach.
Allison et al. (2002) didnt nd any difference in the level of pain and
functional capacity on patients that presented with cervico-brachial
pain syndrome treated with neural or articular techniques. In a case
study, Haddick (2007) report an improvement in functional capacity
and ROM of the shoulder following manual therapy performed on
a patient with shoulder pain due to problems with the cervical spine
and neural tissue.
A number of hypotheses have been raised to explain the reduced
pain and improved function achieved with manual therapy, such as
inhibition of the afferent pathway of pain through the stimulation
of mechanoreceptors, activation of the descending pain inhibitory
system, possible corrections of joint position problems, excitation
of the sympathetic system and non-opioid hypalgesia (Coppieters
et al., 2003; Vicenzino et al., 2007; Bergman et al., 2010; Jowsey
and Perry, 2010).
Shoulder strengthening exercises for swimmers are mainly
directed at the stabilizers of this joint, as muscle imbalance in the
scapulo-humeral musculature is believed to be an important
contributing factor to injuries among swimmers (Allegrucci et al.,
1994; Johnson et al., 2003; ODonnell et al., 2005). A number of
studies report the effects of exercise on postural correction in
swimmers. Kluemper et al. (2006) and Lynch et al. (2010) demonstrated that strengthening exercises combined with stretching are
capable of improving posture in swimmers with regard to the
forward lean of the head and protraction of the shoulders.
Manual therapy is mainly based on the individuality and
overall status of the patient and does not merely consider the
pathological condition. Thus, the favorable results are limited to
the case study described and cannot be considered a pattern for
swimmers shoulder. Further studies are needed to clarify the
effects of manual therapy on shoulder pain and disability more
consistently.
6. Conclusion
Manual therapy techniques for the shoulder, lower cervical
spine and upper thoracic spine in combination with specic exercises for the stabilizers of the shoulder were effective in improving
pain and functional capacity in the present case, allowing the
patients return to competitive swimming at the pre-injury level.

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