News Release 

'Swimmer's shoulder,' common in more than three-quarters of swimmers

Research shows that painful swimmer's shoulder may be due to heavy training load and a 'no pain, no gain' work ethic

American Academy of Pediatrics

NEW ORLEANS - The painful overuse injury called swimmer's shoulder, common in competitive swimmers, may be caused by excessive swimming distance during training along with a culture in competitive swimming that sublimates pain, according to new research being presented at the American Academy of Pediatrics (AAP) 2019 National Conference & Exhibition.

The research abstract, "No Pain, No Gain: Normalizing Attitudes Associated with Shoulder Pain in Adolescent Swimmers," will be presented 11 a.m.-2:45 p.m. Saturday, Oct. 26, in room 386-387 at Ernest N. Morial Convention Center during the American Academy of Pediatrics (AAP) 2019 National Conference & Exhibition in New Orleans.

A related research abstract by the Stanford group, "Below the Surface: Analyzing the Role of Practice Features on Swimmer's Shoulder in Adolescents," and two other posters on swim injuries will be presented during the same session, and the author will give a podium presentation on swim shoulder starting at 2:45 p.m.

The research team surveyed high school and youth club competitive swimmers and found that many children were suffering with shoulder pain, which seemed linked to the distance they swam each day. Simultaneously, swimmers almost universally felt pain was necessary to succeed. The research found that swim clubs were more associated with pain than high school teams, in part because those club workouts were longer in time and distance swum.

"This research showed that pain was normalized for both high school and club swimmers," said study author Eli Cahan. "Additionally, we found that nearly half of the athletes in our study know peers who use medication to address swim-related injuries, so we worry about the exposure to medications especially in the context of the opioid epidemic."

Researchers surveyed 150 youth ages 13-18 and found that 76.7% of swimmers reported experiencing shoulder pain within the last 12 months, and 66.0% agree that "mild shoulder pain should be tolerated" if they want to become successful swimmers and 61% that "taking time off from swimming is not ideal." Fifty percent reported knowing a competitor who used pain medication.

The research also shows clear links between distances swum and pain. Of those who report no shoulder pain, median practice distances ranged from 1,568-3,513 yards, while those who reported pain swam between 2,001-6,322 yards per practice.

Eli Cahan will present this research on Saturday, Oct. 26, in rooms 386-387 of the Ernest N. Morial Convention Center.

In addition, Cahan will be among highlighted abstract authors will give brief presentations and be available for interviews during a press conference and luncheon on Saturday, Oct. 26, starting at 12:30 p.m. in rooms 208-209 (Press Office) of the Ernest N. Morial Convention Center. During the meeting, you may reach AAP media relations staff in the National Conference Press Room at 504-670-5406.

Please note: only the abstract is being presented at the meeting. In some cases, the researcher may have more data available to share with media, or may be preparing a longer article for submission to a journal. For tables and images that accompany this abstract, please contact AAP media relations.

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The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. For more information, visit http://www.aap.org. Reporters can access the meeting program and other relevant meeting information through the AAP meeting website at http://www.aapexperience.org/

Abstract Title: Below the Surface: Analyzing the Role of Practice Features on Swimmer's Shoulder in Adolescents

Eli Cahan, presenting author

Introduction: "Swimmer's shoulder" is the colloquial phrase describing pain and injury in the anterolateral region of the shoulder, formerly referred to as supraspinatus impingement syndrome (1). Reported by 40-91% of adolescent competitive swimmers, the presumptive pathophysiology resembles that of other overuse injuries involving microtrauma to the local soft tissue, as the shoulder accounts for 90% of propulsive force in certain strokes (such as the forward crawl) (2, 3). The relative influence of "in-pool" risk factors such as training load, training volume, stroke specialty, and drill equipment use have demonstrated mixed associations with shoulder pain (4). We are not aware of any study addressing risk factors between club and high school (HS) swimmers. To best inform practice regulations, we analyzed the impact of in-pool practice features across club and HS athletes. Methods: Athletes (ages 13-18) were recruited via an online survey (Qualtrics) across California through coaches listed in the California Interscholastic Federation (CIF) Swimming database. The questionnaire surveyed demographics, sports participation, practice programs, medication, injury reporting and detection, and psychosocial beliefs about swimmer's shoulder. To be eligible, the athlete had to have participated in competitive swimming within the last 12 months. Descriptive statistics including medians, frequencies, and percentages were reported. Results The median frequency of practice is 5 days per week for both HS and club teams. The middle 50% of club practices ranged from 2 to 2.5 hours, which was significantly higher than HS practices (1.5 to 2 hours) (p < 0.001). Additionally, club practices were significantly longer in median yardage per practice compared to HS practices (4,012.5 yards or 160.5 lengths vs. 2,538.0 yards or 101.52 lengths, p < 0.001) (Table 1). There were no significant differences in shoulder pain prevalence across stroke specialties (breaststroke, butterfly, crawl, backstroke and individual medley) (p = 0.580). The median distance swam per practice was significantly higher for swimmers with shoulder pain (3,589 vs. 2,503 yards, p = 0.008) (Figure 1). Length of swimming career, amount of time swimming per year, percentage of practice time pulling with a buoy, and percentage of practice time pulling with both a buoy and paddles were not significantly different between groups (p = 0.236, p = 0.260, p = 0.161, p = 0.295, and p = 0.719, respectively). Conclusions: Practice characteristics differ between HS swim teams and club swim teams. Both hold practices with similar frequency, but club practices are significantly longer in duration and length. Shoulder pain is significantly associated with median swimming distance but not with stroke type or specialized practice drills. To best tailor injury prevention programs for adolescent swimmers, programs must consider overall distance swum across strokes and drills rather than in specific scenarios alone.

Abstract Title: No Pain, No Gain: Normalizing Attitudes Associated with Shoulder Pain in Adolescent Swimmers

Eli Cahan, presenting author

Introduction: "Swimmer's shoulder" is the colloquial phrase describing pain and injury in the anterolateral region of the shoulder and is reported by 40-91% of adolescent competitive swimmers (1-3). Early detection of shoulder pain is beneficial to long-term health of athletes across similar sports requiring repetitive overhead shoulder motions as shoulder pain can signal imminent overuse injury (4). However, prior studies indicate that 86% of athletes implicitly or explicitly endorse swimming through practice pain, and 84% express reluctance towards the idea of taking time off (5). Such normalization is likely derived from theories that relate attitudes towards pain to external circumstances and social mores (6, 7). As such, we sought to better understand adolescent competitive swimmers' outlooks and perceptions related to shoulder pain. In doing so, injury prevention protocols can be better designed to address behavioral elements contributing to the ubiquity, and potential delay in treatment, of swimmer's shoulder. Methods: Questionnaires were developed for swimmers (ages 13-18). Information regarding demographics, practice programs, medication, injury reporting and detection, and psychosocial beliefs about swimmer's shoulder was solicited. The surveys were distributed electronically to coaches listed in the California Interscholastic Federation (CIF) Swimming database. Surveys were subsequently distributed to swimmers after receiving parental consent as necessary. Results Of the 150 participants, 76.7% of swimmers reported experiencing shoulder pain within the last 12 months. Agreement with statements concerning shoulder pain perception between swimmers with and without shoulder pain is represented in Figure 1. Swimmers generally agree with the statement "shoulder pain is normal among competitive swimmers," although the difference between those with and without shoulder pain was insignificant (p = 0.083) (Figure 1). Swimmers who only swim on a seasonal high school team and swimmers who swim on both club and high school teams did not significantly differ in their agreement to the same statement (4.0 vs. 4.1, p = 0.455). The majority of swimmers agree that "mild shoulder pain should be tolerated" if they want to become successful swimmers (66.0%) and that "taking time off from swimming is not ideal" if they want to become successful swimmers (61.0%) (Figure 2). Conclusion As noted in previous research, it is common for swimmers to normalize swimmer shoulder pain (5). Regardless of swim organization type (high school vs. high school and club), the surveyed cohort generally perceived shoulder pain as normal, suggesting that both elite and non-elite swimmers normalize pain. Furthermore, perceptions of the normality of shoulder pain did not differ significantly between swimmers with shoulder pain and swimmers without shoulder pain, suggesting that normalization of shoulder pain can contribute to the development of shoulder pain. Understanding perceptions towards shoulder pain will allow coaches, trainers, and parents to optimize injury prevention and treatment of swimmer's shoulder.

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