Swimmers and Divers, How Does Surgical Intervention Change?

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Swimmers and Divers,How Does Surgical
Intervention Change?

• Ben Rubin, M.D.
• Orthopaedic Specialty Institute
• Orange, CA

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Is There a Difference in the Surgical Treatment
of Shoulders in Swimmers and Divers?
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Swimmers vs. Divers

• Kinematics
• Body characteristics
• Mechanisms of injury
• Observed pathology
• Surgical correction

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Diving Kinematics

• Phases
• Approach open chain
• Press open chain
• Flight open chain
• Entry closed chain
• Arm position

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Diving Kinematics

• Arm position

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Swimming Kinematics

• Phases
• Catch closed chain
• Hand entry
• Catch
• Pull through closed
• Insweep
• Finish
• Recovery open chain
• Arm position

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Body Characteristics

• Postural dysfunction

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Body Characteristics

• Postural dysfunction
• Scapular dyskinesis
• Proximally derived
• Distally derived

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Body Characteristics

• Postural dysfunction
• Scapular dyskinesis
• Joint laxity

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Body Characteristics

• Postural dysfunction
• Scapular dyskinesis
• Joint laxity
• Aerobic fitness

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Body Characteristics

• Postural dysfunction
• Scapular dyskinesis
• Joint laxity
• Aerobic fitness
• Training schedule

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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

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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

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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

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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

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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

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Shoulder Pathology in Divers

• Labral tears and detachments
• SLAP lesions (ant, post, combined)

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Shoulder Pathology in Divers

• Labral tears and detachments
• Bankart lesions (ant, post, both)
• Hill Sachs lesion

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Shoulder Pathology in Divers

• Labral tears and detachments
• ALPSA lesion

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Shoulder Pathology in Divers

• Capsule attenuation
• Unidirectional instability
• MDL with UDI
• MDI
• Rotator interval lesion
• HAGL lesion
• MGHL deficiency (congenital)

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Shoulder Pathology in Divers

• Rotator cuff tears
• Partial thickness
• PASTA lesions
• Tensile failure
• Full thickness (rare)
• Internal impingement (rare)

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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

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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

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Surgical Correction

• Suture capsulorrhaphy
• Rotator interval plication prn

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Surgical Correction

• Bankart repair with suture capsulorrhaphy

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Surgical Correction

• SLAP repair

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Surgical Correction

• Rotator cuff repair or debridement

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Surgical Correction

• Reexamine under anesthesia
• Insure stability without compromising ROM
  required for sport
• Refine rehabilitation based on postop ROM and
  stability

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Rehabilitation

• Core based functional rehabilitation which is
  sport specific

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