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Swimmers and Divers,How Does Surgical
Intervention Change?
Ben Rubin, M.D.Orthopaedic Specialty Institute
Orange, CA
Is There a Difference in the Surgical Treatment of Shoulders in Swimmers
and Divers?
Swimmers vs. Divers
• Kinematics• Body characteristics• Mechanisms of injury• Observed pathology• Surgical correction
Diving Kinematics
• Phases– Approach – open chain– Press – open chain– Flight – open chain– Entry – closed chain
• Arm position
Diving Kinematics
• Arm position
Swimming Kinematics
• Phases– Catch – closed chain
• Hand entry• Catch
– Pull through – closed • Insweep• Finish
– Recovery – open chain• Arm position
Body Characteristics
• Postural dysfunction
Body Characteristics
• Postural dysfunction• Scapular dyskinesis
– Proximally derived– Distally derived
Body Characteristics
• Postural dysfunction
• Scapular dyskinesis
• Joint laxity
Body Characteristics
• Postural dysfunction• Scapular dyskinesis• Joint laxity• Aerobic fitness
Body Characteristics
• Postural dysfunction• Scapular dyskinesis• Joint laxity• Aerobic fitness• Training schedule
Mechanisms of Injury
• Always try to correlate symptoms with mechanics of sport
• Diving– Pain with front throw or back throw– Circling– Entry
• Swimming– Catch, pull through, recovery
Entry Statistics
• Velocity– 1 meter 18.75 mph– 10 meter 36.8 mph
• Force at impact– 2.0 – 2.4 Gs
• Submerged 128-140 msec
• 53% decrease in velocity• All without a splash
Mechanisms of Injury
• Diving– Macrotrauma
• Dislocation, subluxation• Occasional RCT with dislocation
– Microtrauma• Repetitive subluxation (assoc. RCT)• MDL becoming instability• Scapular dyskinesis (proximal vs. distal)• “Overuse” – capsule and/or cuff strain
– Usually associated with laxity/instability
Mechanisms of Injury
• Swimming– Microtrauma
•MDL becoming instability•Scapular dyskinesis (scapulothoracic
weakness or imbalance)•“Overuse” – capsule and/or cuff strain
– Macrotrauma•Injuries out of the water
Shoulder Pathology
• When evaluating the shoulders of young athletes, be careful not to describe symptoms (biceps and/or cuff tendinitis, “impingement syndrome”, etc.)
• Make a core diagnosis which explains the symptoms
• Primary SAI is extremely rare in swimmers and divers
Shoulder Pathology in Divers
• Labral tears and detachments– SLAP lesions (ant, post, combined)
Shoulder Pathology in Divers
• Labral tears and detachments– Bankart lesions (ant, post, both)– Hill Sachs lesion
Shoulder Pathology in Divers
• Labral tears and detachments– ALPSA lesion
Shoulder Pathology in Divers
• Capsule attenuation– Unidirectional
instability– MDL with UDI– MDI– Rotator interval
lesion– HAGL lesion
• MGHL deficiency (congenital)
Shoulder Pathology in Divers
• Rotator cuff tears– Partial thickness
• PASTA lesions• Tensile failure
– Full thickness (rare)
• Internal impingement (rare)
Shoulder Pathology in Swimmers
• Capsule attenuation– MDL unidirectional instability– Unidirectional and MDI may be a
continuum– Rotator interval
• MGHL deficiency• GIRD• Tensile injury to cuff
Correction of Pathology
• Evaluate and modify technique prn• Correct scapular dyskinesis if
proximally derived• Teach scapular positioning if
distally derived– Program must be sport specific
• EUA (always compare sides)• Diagnostic arthroscopy
Surgical Correction
• Suture capsulorrhaphy• Rotator interval plication prn
Surgical Correction
• Bankart repair with suture capsulorrhaphy
Surgical Correction
• SLAP repair
Surgical Correction
• Rotator cuff repair or debridement
Surgical Correction
• Reexamine under anesthesia– Insure stability without compromising
ROM required for sport– Refine rehabilitation based on postop
ROM and stability
Rehabilitation
• Core based functional rehabilitation which is sport specific
THANKSFOR
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