From Biomechanics to Clinical Translation: Mechanism Research

and Prevention and Treatment Strategies for Shoulder Injuries of

Swimmers

Chunxiao Zhang

Clinical Medical College, Tianjin Medical University, Tianjin, 300450, China

Keywords: Swimmer's Shoulder, Shoulder Biomechanics, Physical Therapy.

Abstract: Recent years, competitive swimming has developed rapidly, and shoulder injuries among swimmers have

become a key issue affecting their athletic performance and career development. This paper orderly combs

through the biomechanics of the shoulder, analyzes common types and mechanisms of shoulder injuries, such

as rotator cuff tendinitis, subacromial impingement syndrome, biceps brachii long-head tendinitis, and labral

injuries. It also explores how to effectively treat shoulder injuries using physical therapy techniques without

affecting the competitive ability of swimmers. Research shows that repetitive abduction and external rotation

leading to overloading of the rotator cuff is the core mechanism of injury. This paper emphasizes the

optimization of technical movements through biomechanical analysis to reduce the incidence of shoulder

injuries among swimmers, this paper focuses on the targeted strengthening of the rotator cuff muscles and the

development of coordinated training programs for related muscle groups, aiming to provide a theoretical basis

and practical guidance.

1 INTRODUCTION

As people pay more and more attention to their

physical health and develop the habit of daily

exercise, swimming is considered a sport with

relatively little physical damage due to its non -

weight - bearing characteristics. However, for

competitive swimmers, swimming can still cause

some physical injuries. Especially in the current

context, swimming occupies an important position in

international competitions such as the Olympic

Games and World Championships. The increasing

emphasis on professional swimming training has

promoted the global development of swimming and

the improvement of competitive levels. Some sports

injuries may follow as a result.

Previous studies have shown that the most

common injury among swimming athletes is shoulder

joint injury (Tan, Z. Z., 2019). Between 9% and 26%

of swimmers report current shoulder pain, and 38% to

67% of swimmers state that they have had shoulder

pain symptoms in the past (McMaster, W. C., 1993).

Moreover, the likelihood of shoulder discomfort in

athletes increases with the increase in the time of

participating in competitions and training (McMaster,

W. C., 1993). Even 47% of people say that they

regularly take painkillers to control shoulder joint

pain (Hibberd, E. E., 2013). In response to the

shoulder joint pain of swimmers, in 1974, Kennedy

and Hawkins proposed a broad term "swimmer's

shoulder" to summarize the repeated shoulder

abduction and forward flexion movements among

swimmers cause the impingement of the

supraspinatus tendon under the coracoacromial arch

(De Martino, I., 2018). As the research becomes more

profound, "swimmer's shoulder" has turned into a

term that can signify multiple shoulder conditions,

including but not limited to injury types such as

rotator cuff tendinitis, subacromial impingement

syndrome, long head of biceps tendinitis, and labral

injury (De Martino, I., 2018; Tovin B. J., 2006).

In the field of competitive sports, swimming

athletes have extremely high daily training intensity

and exercise frequency. High-frequency overhead

movements increase the likelihood of shoulder

injuries. And daily training is an indispensable and

important part of maintaining athletes' competitive

state. Once they stop training due to injury or

impaired competitive ability, it will not only affect the

athletes' personal performance and development but

Zhang, C.

From Biomechanics to Clinical Translation: Mechanism Research and Prevention and Treatment Strategies for Shoulder Injuries of Swimmers.

DOI: 10.5220/0014493800004933

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 1st International Conference on Biomedical Engineering and Food Science (BEFS 2025), pages 385-390

ISBN: 978-989-758-789-4

385

also cause losses to the team and others. Therefore,

although high-intensity swimming training can lead

to shoulder injuries, swimming athletes still cannot

reduce their training volume, which will form a

vicious cycle. How to enable swimming athletes to

reduce shoulder joint injuries and pain while ensuring

their competitive state has become an issue.

At present, physical therapy techniques have

shown that certain potential in the treatment of sports

injuries. So far, the academic community still lacks

systematic and comprehensive research and summary

on the specific application effects, optimal usage

methods, and possible risks of physical therapy

among swimming athletes. Therefore, this article

intends to summarize the causes and types of shoulder

injuries in swimming athletes, and explore how to use

physical therapy techniques scientifically, safely, and

effectively on the premise of not delaying the athletes'

daily training and not affecting the swimmers'

competitive level, so as to help athletes maintain a

good state during treatment of injuries and reduce the

negative impact on their careers.

2 THE BIOMECHANICAL BASIS

OF THE SHOULDER IN

SWIMMING

Under different swimming strokes, the shoulder

joint's anatomical structure is the basis for its

biomechanical functions, which include a variety of

biomechanical properties. In terms of skeletal

structure, the humerus, scapula, and clavicle jointly

form the shoulder joint. The proximal humerus and

the glenoid cavity of the scapula constitute the

glenohumeral joint, a ball-and-socket joint with an

extremely wide range of motion. It diversifies the

types of joint movements of the arm.

During freestyle swimming, the arm stroke is

divided into four stages: entry, catch, pull, and exit.

The shoulder extends forward, abducts, and internally

rotates during the entry stage and the first part of the

push stage, placing the humeral head beneath the

anterior acromion and the coracoacromial ligament.

Especially when the muscles are fatigued, the

likelihood of impacting the supraspinatus muscle and

the biceps tendon increases. During the act of

swimming, in the latter portion of freestyle and

butterfly strokes, the arms have to carry out abduction

to get back to the position precisely in front of the

head. If inward rotation or lateral horizontal

abduction occur simultaneously in this time frame,

the humeral head will make contact with the posterior

edge of the acromion. Once the water - pushing phase

is over, the shoulder enters a state of inward

movement and internal rotation (Zhang, Y. J., 2022).

Throughout the process, the shoulder joint exhibits an

exceptionally broad range of motion, with its

movement pathways and muscular force application

patterns undergoing continuous variation throughout

motion. It is necessary not only to generate propulsive

force but also to maintain joint stability.

The scapula serves as a platform for the

attachment of numerous muscles, and its position and

movement have a significant impact on the overall

function of the shoulder. The clavicle is like a bridge,

connecting the upper limb and the trunk, playing an

indispensable role in maintaining the stability of the

shoulder.

The shoulder complex comprises four

interdependent articulations - the glenohumeral,

acromioclavicular, sternoclavicular joints and

scapulothoracic articulation - which function in a

coordinated manner to facilitate optimal joint

mechanics. Owing to the shallow glenoid fossa and

lax joint capsule, high mobility but poor stability is

exhibited by the glenohumeral joint. During shoulder

movements, the acromioclavicular and

sternoclavicular joints fine-tune scapular positioning

to facilitate multidirectional arm motion. Although

not a true synovial joint, the scapulothoracic

articulation assists in scapular elevation, depression,

protraction, and retraction, serving as a critical

stabilizer for normal shoulder kinematics. Repetitive

overloading may lead to laxity of the anterior and

posterior capsuloligamentous structures,

accompanied by anterior joint instability,

impingement-related shoulder problems (Rupp, S.,

1995). In breaststroke and butterfly stroke, distinct

biomechanical demands are observed. Breaststroke

involves short, forceful arm movements characterized

by alternating phases of shoulder abduction,

adduction, and rotation, with coordinated activation

of different muscle groups during propulsion and

recovery. Butterfly stroke requires simultaneous

bilateral arm motion, imposing extreme demands on

shoulder flexibility and muscular endurance, thereby

increasing susceptibility to fatigue and overuse

injuries.

Muscle and musculotendinous components are

pivotal in shoulder biomechanics. The deltoid

muscle, divided into anterior, middle, and posterior

bundles, governs shoulder flexion, abduction, and

extension, respectively. During swimming

movements, these muscles work in coordination. For

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instance, the smooth entry of the arm during the

freestyle stroke's water - entry phase is enabled by the

contraction of the supraspinatus muscle and the

anterior deltoid. In the catch phase, the pectoralis

major and biceps brachii exert force to allow the arm

to grip the water firmly. During the pull phase, the

latissimus dorsi, pectoralis major, and other muscles

contract synergistically to propel the arm to pull

backward in the water. When the arm exits the water,

the posterior deltoid and the rotator cuff muscles

work together to complete the upward lifting motion

of the arm.

In backstroke, due to the body lying on its back,

the movement direction and force application mode

of the shoulder joint are different from those of other

swimming strokes. It is necessary to adapt to the

body's position in the water and overcome the water

resistance.

3 TYPES AND MECHANISMS OF

SHOULDER INJURIES IN

SWIMMERS

3.1 Rotator Cuff Tendinitis

The shoulder's rotator cuff musculature consists of

four key components: the supraspinatus,

infraspinatus, teres minor, and subscapularis. These

muscles collectively form the primary stabilizing

mechanism for glenohumeral joint integrity and

rotational function. Swimming athletes suffer from

muscle strain due to repetitive stroking movements,

resulting in shoulder muscle weakness and poor

stability during shoulder joint movement, which

gradually leads to rotator cuff tendinitis (Meng, N.,

1988). Its early symptoms mainly manifest as obvious

tenderness under the acromion or at the greater

tubercle of the humerus. Swimmers will feel deep

pain during overhead movements, and the pain

gradually intensifies. When continuously performing

overhead movements, due to the friction among the

tendon, ligament, and bone, the inflamed tendon is

temporarily de-swollen, and the pain is relieved,

enabling athletes to continue swimming. However,

after stopping the exercise, when athletes move their

shoulders above their heads, they will experience

throbbing pain in the shoulders again (Meng, N.,

1988). In the high-intensity stroking movements of

freestyle and butterfly strokes, the shoulder joint is

repeatedly abducted and externally rotated, causing

friction between the rotator cuff tendon and the

subacromial space, and long-term accumulation leads

to micro-injuries.

3.2 Subacromial Impingement

Syndrome

In most cases, the structural constriction of the

subacromial space gives rise to subacromial

impingement syndrome. The common symptom is

the soft tissue impingement pain that occurs when the

arm is raised. Compression between the acromion and

the humeral head triggers chronic inflammation,

tendon degeneration, or even tearing (Garving, C.,

2017). During the catch phase of freestyle in

swimming athletes' training, the high elbow catch

requires the shoulder joint to be repeatedly and

excessively abducted. Due to the narrowing of the

subacromial space, the humeral head rubs repeatedly

against the lower surface of the acromion. At the

same time, due to the insufficient stability of the

scapula, the scapula tilts forward, resulting in

abnormal scapular movement, which further reduces

the subacromial space. Therefore, it causes shoulder

swelling, limited mobility, and local tenderness in

swimming athletes. Moreover, due to the repetitive

rotation movements of the shoulder joint, the

incidence of subacromial impingement syndrome

(SIS) in freestyle and butterfly swimmers is

significantly higher than that in other swimming

strokes (Matzkin, E., 2016).

3.3 Biceps Brachii Long-Head

Tendinitis

The shoulder joint capsule provides attachment for

the long head of biceps tendon, which contributes to

joint stability while being prone to tendinitis

development (Fu, J., 2011). Biceps tendonitis is

commonly caused by the rotation of the shoulder joint

beyond its normal range, which makes the biceps

tendon in a subluxation state and causes friction. It

can also often occur due to a sudden excessive stretch

(Meng, N., 1988). When swimming athletes swim,

the highly repetitive abduction and external rotation

movements lead to the intertubercular groove of the

humerus subjects the biceps brachii long - head

tendon to repeated friction or overuse., affecting the

proximal biceps brachii long-head tendinitis and its

attachments to the superior glenoid tubercle and the

labrum. This results in the typical characteristics of

the biceps brachii long-head tendinitis, namely

intermittent anterior or deep shoulder pain, and the

pain intensifies during movement (Chalmers, P. N.,

From Biomechanics to Clinical Translation: Mechanism Research and Prevention and Treatment Strategies for Shoulder Injuries of

Swimmers

387

2016). At the same time, during the stroke, Biceps

brachii long-head tendinitis needs to bear a relatively

large pulling force, which can also lead to

inflammation.

3.4 Labral Injury

The glenoid labrum serves as an anchoring structure

for both the joint capsule and associated shoulder

ligaments. The superior labrum-biceps tendon

complex plays an important role in providing

shoulder stability, especially in resisting torsion and

providing anterior stability (Rodosky, M. W., 1994).

The main clinical manifestations are shoulder joint

pain or instability. During the training process of

swimming athletes, due to the instability of the

shoulder, the movements in the entry stage cause the

labrum to be repeatedly rubbed and stretched. The

excessive external rotation and abduction of the

shoulder joint lead to Superior Labrum Anterior to

Posterior (SLAP) injury in the superior labrum.

4 PHYSICAL THERAPY

STRATEGIES

During swimming, the shoulder joint needs to

perform a large number of complex and high-

intensity movements, such as stroking, entry, and

exit. Shoulder instability leads to excessive stress on

periarticular soft tissues (muscles, tendons,

ligaments). Improving shoulder stability can make

these tissues bear force more evenly and diminish the

probability of sustaining an injury. Meanwhile,

shoulder stability helps to maintain the movement of

the shoulder joint in its normal anatomical position.

Enhancing shoulder stability necessitates

strengthening and improving neuromuscular

coordination of the periarticular musculature.

Therefore, the main purpose of the exercise

therapy for shoulder injuries in swimming athletes is

to enhance the stability of the shoulder joint. Through

targeted strength training, such as weight-bearing

exercises like dumbbell presses and barbell rows, it is

possible to stimulate the growth of shoulder muscles

and thus improve shoulder stability. For example,

after physical therapy, it was observed that the range

of flexion/extension rotation decreased by about 10

degrees, indicating that shoulder stability was

improved and motor control was enhanced (Raffini,

A., 2024).

At the same time, postural correction training

cannot be ignored. Swimming athletes are prone to

developing bad postural habits such as forward

shoulder and hunchback during long-term training.

These habits not only affect athletic performance but

also increase the risk of shoulder injuries. Through

postural correction training, it is possible to help

athletes correct bad postures and improve shoulder

posture and stability. For example, regular backward

shoulder stretching can significantly improve the

range of motion (ROM) of the athletes' shoulders

(Chepeha, J. C., 2018).

Furthermore, dynamic stability training such as

shoulder movement exercises on balance pads can

also be combined to enhance the athletes' shoulder

stability in unstable environments (Nie, D. Y., 2024).

In an attempt to reduce the shoulder pain of

swimmers who got hurt, stretching exercises and

manipulative treatments can be used in combination.

That is, training the external rotators of the shoulder

joint, the scapular retractors, and stretching the

pectoralis major muscles are all helpful in relieving

shoulder pain.

For example, a professional rehabilitation

therapist conducts scapular mobilization treatment.

The therapist drives the patient's shoulder joint

through the movement of their own center of gravity,

enabling the scapula to move in six directions:

downward, upward, protraction, retraction, upward

rotation, and downward rotation, once a day for half

an hour each time. In a clinical study, 28 swimming

athletes were randomly divided into a massage +

scapular mobilization manual therapy group and a

massage group. After 6 weeks of intervention, it was

found that the swimming performance of the athletes

could be improved by approximately 10%, and the

functional score of the shoulder joint increased by

about 19% (Liu, N., 2024).

By using different manual techniques such as

swinging, rolling, sliding, and rotating, it is possible

to achieve the effects of relieving pain, improving

joint mobility, and increasing proprioceptive

feedback. At the same time, electro-acupuncture can

be combined with massage, and electro-acupuncture

can be combined with physical therapy (dry needling

therapy helps to relieve shoulder pain and improve

function by directly stimulating specific muscles and

connective tissues). Some studies have also shown

that it can effectively improve the decrease in

shoulder joint mobility caused by shoulder joint

injuries, the decrease in the strength of the muscles

around the shoulder joint, and alleviate the pain of

shoulder joint injuries (Lei, L., 2024; Sun, R. Z.,

2013).

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Studies have shown that in terms of improving

shoulder external rotation strength and endurance,

open kinetic chain (OKC) training combined with a

land-based program has more advantages than closed

kinetic chain (CKC) training and aquatic training

(Yoma, M., 2022). In addition, combining aquatic

training with open kinetic chain exercises can also

enhance the function of the shoulder’s rotator muscles

that reduce the risk of shoulder injuries in swimmers

(Tavares, N., 2022).

Moreover, elastic band internal rotation and

external rotation exercises are also effective treatment

methods. Use a mini band, wrap it around the wrist,

ensure that the muscles are always in a state of tight

elastic band tension, push the scapula backward,

squeeze the scapula, keep the elbows near the lateral

torso when the hands are separated, contract the

scapula, and repeat 5-8 times to enhance the strength

of the rotator cuff muscles and stabilize the shoulder

joint (Liu, N., 2024).

Owing to its features of causing no damage and

having small toxic and side effects, ultrashort wave

therapy finds wide use in treating various diseases.

Most patients with "swimmer's shoulder" have

symptoms such as inflammation of the shoulder joint,

limited joint mobility, and shoulder joint dysfunction.

Ultrashort wave therapy can effectively improve the

above symptoms. The positive effects of ultrashort

wave therapy on improving "swimmer's shoulder"

include promoting blood circulation, sedation, pain

relief, relieving muscle spasms, and promoting

wound healing (Hu, M. X., 2022).

Shock wave therapy, as an emerging non-invasive

treatment method, has a significant effect in relieving

pain and promoting tissue repair. By effectively

stimulating the nerve ending tissues with high-

intensity shock waves, especially the effective

stimulation of pain nerves, it can promote the

decrease in nerve sensitivity, block nerve conduction,

and rapidly improve the pain symptoms of patients.

In a clinical study, 80 patients with periarthritis of the

shoulder were included and randomly divided into a

control group (conventional rehabilitation treatment,

40 cases) and an observation group (extracorporeal

shock wave combined with conventional

rehabilitation treatment, 40 cases). The treatment

effects and shoulder joint mobility (CMS) scores of

the two groups were compared. The results showed

that the total effective rate (97.5% vs. 77.5%) and

CMS score (59.37 vs. 55.26 points) of the

extracorporeal shock wave combined with

conventional rehabilitation treatment group were

better. Although the subjects were not swimming

athletes, it also shows that the combination of

extracorporeal shock wave and conventional

rehabilitation treatment can significantly improve the

treatment effect (Huang, Q. P., 2024). This treatment

method directly acts on the damaged tissues by using

high-energy sound waves, so as to achieve the

purpose of relieving pain and promoting healing (Fu,

J., 2011).

5 CONCLUSION

Shoulder injuries are quite common among

swimming athletes. More than half of the excellent

swimming athletes have been affected in their

training due to shoulder pain, which has a negative

impact on their athletic careers. The main types of

injuries include rotator cuff tendinitis, subacromial

impingement syndrome, biceps brachii long-head

tendinitis, and labral injury, etc. These are usually

caused by shoulder joint instability and frequent

overhead movements, resulting in shoulder joint pain,

limited joint mobility, and other problems.

Except for relatively severe shoulder injuries that

require surgery, according to the situation of athletes'

shoulder injuries, physical therapies such as exercise

therapy, manual therapy combined with acupuncture,

ultrashort wave, shock wave and other methods can

be selectively used to relieve shoulder joint pain and

improve joint mobility for swimming athletes. This

can minimize the impact of injuries on athletes'

careers. At the same time, it is recommended that

athletes enhance their self-protection awareness and

seek medical treatment in a timely manner after an

injury occurs. In addition, medical staff should

accurately diagnose the shoulder injuries of athletes,

formulate personalized treatment plans considering

the identity of the patient athletes, and adjust the

treatment and rehabilitation plans in a timely manner.

However, due to the limitations of small sample

sizes, limited data, and methodology in current

studies, the quality of many studies on the limitations

and safety of physical therapy for shoulder injuries of

swimming athletes is relatively low, and no strong

evidence can be provided. In the future, more multi-

disciplinary, multi-center, and large-scale high-

quality studies are needed to obtain different data,

integrate and analyze them, and obtain individualized

physical or combined treatment methods to reduce

shoulder injuries, so as to provide more diagnosis and

treatment strategies for clinical practice.

From Biomechanics to Clinical Translation: Mechanism Research and Prevention and Treatment Strategies for Shoulder Injuries of

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