Identifying Risk and Protective Factors for Shoulder Pain in Competitive Swimmers: The Role of Stroke Specialty and Competitive Level

Diogo Nunes Sousa ; Eduardo Santos ; Rui Escaleira; Daniel Moedas; Bárbara Campos; Eduardo Malavolta; Hélder Pereira

DOI: 10.70885/hmsj.2025.05.001

Abstract

Background: Competitive swimmers are frequently exposed to overuse injuries. The etiology of overuse injuries is not fully understood but has been associated with training volume and biomechanical/anatomical characteristics of each swimmer.Purpose: To evaluate and identify risk factors associated with shoulder pain and injury in competitive swimmers.Methods: This prospective cohort study was conducted in collaboration with the Portuguese Swimming Federation (FPN) and included swimmers affiliated with the FPN during the 2023–2024 season. A questionnaire was administered to collect demographic and anthropometric data, training habits, injury history, and the presence of shoulder pain.Results: A total of 167 athletes were included. Of those, 116 (69%) reported substantial interfering shoulder pain (SIP) during the 6-month study period, while 51 (31%) reported substantial shoulder injury (SSI). The incidence of SIP varied between 34% and 50%, and that of SSI ranged between 19% and 21%. Master’s swimmers showed a decreased risk of SIP (p=0.008, odds ratio [OR]=0.243) compared with state competitive swimmers. Backstrokers demonstrated a decreased risk of SIP (p=0.003, OR=0.197) compared with swimmers with other stroke specialties. Injury history and distance swam per training (km) proved to be risk factors for the presence of SSI (p=0.007, OR=4.283 and p<0.001, OR=2.224, respectively).Conclusion: Stroke specialty (backstroke) and competitive level (master’s) play protective roles in the development of SIP. History of injury and distance swam per session were risk factors for SSI. There is a pressing need to develop preventive programmes and attentive measurement tools to evaluate shoulder pathologies among swimmers.What this study adds: For the first time, we demonstrated a protective association of backstroke and master’s level swimmers with the presence of short-term shoulder pain. This study also demonstrated that the training volume and a history of shoulder injury are directly associated with the presence of long-term shoulder pain among swimmers.How this study might affect research, practice or policy: This study highlights the pressing need to develop specific preventive programmes and measurement tools for evaluating shoulder pathologies among swimmers.Study design: Prospective cohort studyLevel of evidence: Level IIKeywords: Shoulder Pain; Swimmers; Swimmer's Shoulder; Swimming; Swimming Injuries.https://doi.org/10.70885/hmsj.2025.05.001

References

  1. Mountjoy M, Junge A, Alonso JM, Clarsen B, Pluim BM, Shrier I, et al. Consensus statement on the methodology of injury and illness surveillance in FINA (aquatic sports). British Journal of Sports Medicine. 2016;50(10):590-6. doi: 10.1136/bjsports-2015-095686.
  2. Martins LCX, Paiva JR, Freitas AC, Miguel LB, Maia FRC. Prevalence of pain and associated factors in elite swimmers. Science and Sports. 2014;29(3). doi: 10.1016/j.scispo.2013.08.002.
  3. Wanivenhaus F, Fox AJS, Chaudhury S, Rodeo SA. Epidemiology of Injuries and Prevention Strategies in Competitive Swimmers. Sports Health2012. p. 246-51. DOI: 10.1177/1941738112442132
  4. Kennedy JC, Hawkins R, Krissoff WB. Orthopaedic manifestations of swimming. The American Journal of Sports Medicine. 1978;6(6):309-22. doi: 10.1177/036354657800600602.
  5. Marnie Allegrucci MP, Susan Whitney PPT, James Irrgang MSP. Clinical Implications of secondary Impingement of the Shoulder in Freestyle Swimmers. 1994.
  6. Walker H, Gabbe B, Wajswelner H, Blanch P, Bennell K. Shoulder pain in swimmers: a 12-month prospective cohort study of incidence and risk factors. Physical Therapy in Sport. 2012;13(4):243-9. DOI: 10.1016/j.ptsp.2012.01.001
  7. Feijen S, Tate A, Kuppens K, Claes A, Struyf F. Swim-training volume and shoulder pain across the life span of the competitive swimmer: A systematic review. Journal of Athletic Training: National Athletic Trainers' Association Inc.; 2020. p. 32-41.
  8. Bizzini M, Dvorak J. FIFA 11+: An effective programme to prevent football injuries in various player groups worldwide - A narrative review. British Journal of Sports Medicine: BMJ Publishing Group; 2015. p. 577-9. DOI: 10.1136/bjsports-2014-094449
  9. McMaster WC, Troup J. A survey of interfering shoulder pain in United States competitive swimmers. The American Journal of Sports Medicine. 1993;21(1):67-70. doi: 10.1177/036354659302100112.
  10. Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. Journal of clinical epidemiology. 1996;49(12):1373-9. DOI: 10.1016/S0895‑4356(96)00236‑3
  11. Chowdhury MZI, Turin TC. Variable selection strategies and its importance in clinical prediction modelling. Family medicine and community health. 2020;8(1). DOI: 10.1136/fmch‑2020‑000262
  12. Mansournia MA, Collins GS, Nielsen RO, Nazemipour M, Jewell NP, Altman DG, et al. A checklist for statistical assessment of medical papers (the CHAMP statement): explanation and elaboration. British journal of sports medicine. 2021;55(18):1009-17. DOI: 10.1136/bjsports‑2020‑102921
  13. Sein ML, Walton J, Linklater J, Appleyard R, Kirkbride B, Kuah D, et al. Shoulder pain in elite swimmers: Primarily due to swim-volume-induced supraspinatus tendinopathy. British Journal of Sports Medicine2010. p. 105-13. DOI: 10.1136/bjsm.2008.047282
  14. Krüger PE, Dressler A, Botha M. Incidence of shoulder injuries and related risk factors among master swimmers in South Africa. South Africa African Journal for Physical2012. p. 56-76.
  15. Zemek MJ, Magee DJ. Comparison of glenohumeral joint laxity in elite and recreational swimmers. LWW; 1996. p. 40-7.
  16. Feijen S, Struyf T, Kuppens K, Tate A, Struyf F. Prediction of Shoulder Pain in Youth Competitive Swimmers: The Development and Internal Validation of a Prognostic Prediction Model. American Journal of Sports Medicine. 2021;49(1):154-61. doi: 10.1177/0363546520969913.
  17. Hall JA, Stewart AV, Rogers GR. INTERFERING SHOULDER PAIN INCIDENCE AND MANAGEMENT IN A GROUP OF PROVINCIAL SWIMMERS. 1995.
  18. Miyashita M, Mutoh Y, Richardson AB. Shoulder Pain in Competitive, Age-Group Swimmers'. Medicine and Science in Aquatic Sports Med Sport Sci Basel, Karger1994. p. 218-25.
  19. Bak K, Bue P, Olsson G. Injury patterns in Danish competitive swimming. Ugeskrift for laeger. 1989;151(45):2982-4.
  20. Bak K, Bue P, Olsson G. Injury patterns in Danish competitive swimming. Ugeskrift for laeger. 1989;151(45):2982-4.
  21. Ciullo JV, Stevens GG. Injury Clinic The Prevention and Treatment of Injuries to the Shoulder in Swimming. Sports Medicine1989. p. 182-204.
  22. Weldon EJ, Richardson AB. UPPER EXTREMITY OVERUSE INJURIES IN SWIMMING. John A Burns School of Medicine2001. DOI: 10.1016/S0278‑5919(05)70260‑X
  23. Barry L, Lyons M, McCreesh K, Powell C, Comyns T. The relationship between training load and pain, injury and illness in competitive swimming: A systematic review. Physical Therapy in Sport: Churchill Livingstone; 2021. p. 154-68.
  24. Butler D, Funk L, Mackenzie TA, Herrington LC. Sorting swimmers shoulders: An observational study on swimmers that presented to a shoulder surgeon. International Journal of Shoulder Surgery. 2015;9(3):90-3. doi: 10.4103/0973-6042.161444.
  25. Boettcher C, Halaki M, Holt K, Ginn KA. Is the Normal Shoulder Rotation Strength Ratio Altered in Elite Swimmers? Medicine and Science in Sports and Exercise. 2020;52(3):680-4. doi: 10.1249/MSS.0000000000002177.
  26. Yoma M, Herrington L, Mackenzie T. The Effects Of Differing Density Of Swim-Training Sessions On Shoulder Range Of Motion and Isometric Force Production In National and University Level Swimmers. International Journal of Sports Physical Therapy. 2023;18(2):375-87. doi: 10.26603/001c.72717.
  27. Serenza FS, Oliveira AS, Bedo BLS, Mariano FP, Aquino R, Warner M, et al. Biomechanical analysis of the shoulder of swimmers after a maximal effort test. Physical Therapy in Sport. 2018;30:14-21. doi: 10.1016/j.ptsp.2017.11.002.

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